UCL Reconstruction (Tommy John Surgery)

Why this approach — at MOS

UCL reconstruction demands technical precision at every step. The decision about graft source, tunnel placement, fixation method, and ulnar nerve management all affect outcomes. At Maryland Orthopedic Specialists, Dr. Fitzgibbons performs the procedure using anatomic tunnel placement guided by the attachment footprints of the anterior bundle — the primary stabilizing component of the UCL — rather than approximated landmarks.

The palmaris longus autograft is used when available. Autograft tissue incorporates reliably without the disease transmission risk of allograft and has the best track record in the published literature for overhead athletes returning to pre-injury level of play. When the palmaris is absent, the gracilis autograft from the thigh provides comparable length and diameter.

Ulnar nerve management is individualized. Not every patient requires anterior transposition, but the decision is made based on pre-operative ulnar nerve symptoms, intraoperative nerve mobility, and the degree of subluxation observed. Addressing the nerve at the time of reconstruction avoids a second operation if symptoms develop later.

Patients in the Germantown and broader Montgomery County area benefit from Dr. Fitzgibbons's experience managing the full spectrum of elbow pathology in overhead athletes, from diagnosis through post-operative return-to-throw progression. Return to competitive overhead throwing typically occurs at 12–18 months following a structured rehabilitation protocol — this timeline is non-negotiable and is explained clearly at the pre-operative visit.

Who is a candidate?

Indications

• Complete or high-grade partial UCL tear confirmed on MRI (ideally MR arthrogram) with medial elbow instability
• Overhead athletes — most commonly baseball pitchers, but also catchers, infielders, javelin throwers, and gymnasts — who require maximal elbow stability for their sport
• Failed non-surgical treatment over 3–6 months: rest, physical therapy, activity restriction, and PRP injection that has not restored competitive throwing capacity
• Acute UCL rupture in a high-level athlete who requires complete functional restoration
• Symptomatic medial elbow instability in non-throwing patients with functional limitation

Contraindications

• Isolated partial UCL tear without valgus instability in a non-overhead athlete — these often respond to non-surgical treatment
• Young adolescent athletes with open growth plates in whom bone tunnel placement would damage the physis (growth plate protection needed)
• Significant elbow arthritis with joint space loss that will not improve with ligament reconstruction alone
• Active local infection or significant skin compromise over the medial elbow
• Patient unwilling or unable to commit to the 12–18 month rehabilitation process required for return to overhead throwing

Conservative Treatment First

Not every UCL tear requires surgery. Partial tears with intact anterior bundle function and low-grade instability are frequently managed without an operation. The non-surgical protocol begins with complete rest from throwing — typically 6–12 weeks — combined with physical therapy focused on periscapular strengthening, rotator cuff conditioning, and restoration of elbow range of motion. Addressing mechanical deficiencies in the kinetic chain (hip and core weakness, scapular dysfunction, poor mechanics) is critical, as many UCL injuries reflect cumulative load transferred from a mechanically inefficient delivery.

Platelet-rich plasma (PRP) injection has been investigated as an adjunct for partial tears. While the evidence base is still developing, some athletes with properly selected partial tears show functional recovery with PRP and rehabilitation that allows them to return to competitive throwing without surgery. This pathway is appropriate for athletes who lack the time commitment for surgical recovery, whose tear is clearly partial, and whose instability is minimal. When conservative management does not restore competitive throwing capacity or when MRI confirms a complete anterior bundle rupture, reconstruction becomes the appropriate recommendation.

The procedure

What Is UCL Reconstruction of the Elbow?

UCL reconstruction of the elbow — commonly known as Tommy John surgery — replaces a torn ulnar collateral ligament with a tendon graft, restoring medial elbow stability for overhead athletes. The surgery is most common in baseball pitchers and other throwing athletes whose ligament has failed completely and cannot heal on its own.

The ulnar collateral ligament (UCL) is a thick band of tissue on the inner (medial) side of the elbow, connecting the humerus to the ulna. Its anterior bundle is the primary restraint against the outward bending force — called valgus stress — that occurs every time a pitcher releases a baseball, a javelin thrower launches a throw, or a gymnast bears weight through an extended arm. This stress, repeated thousands of times over a career, can gradually stretch and fray the ligament or tear it suddenly in a single maximum-effort throw. When the anterior bundle fails, the elbow becomes unstable under valgus load and the athlete loses the ability to throw at full velocity without pain.

The procedure takes its informal name from Los Angeles Dodgers pitcher Tommy John, who had the first successful UCL reconstruction in 1974 performed by Dr. Frank Jobe — a procedure that resurrected his career. Today, UCL reconstruction is a well-established operation with predictable outcomes in appropriately selected athletes. The goal is not simply to restore the anatomy but to return the athlete to throwing at competitive velocity. Dr. Fitzgibbons evaluates each patient's imaging, throwing history, and rehabilitation compliance to determine whether reconstruction is the appropriate pathway or whether non-surgical management remains an option.

What Happens During UCL Reconstruction?

Setting: UCL reconstruction is performed at an ambulatory surgery center under general anesthesia. The procedure takes 60–90 minutes. You are discharged the same day.

Positioning and setup: You lie on your back with the operative arm positioned on an arm board or brought across the chest. A tourniquet is placed on the upper arm. The medial elbow is marked and the skin is sterilely prepped and draped.

Graft harvest: The palmaris longus tendon — a non-essential forearm tendon — is the most commonly used autograft. It is harvested through small transverse incisions in the forearm using a tendon stripper, leaving no functional deficit. Approximately 15–20% of people do not have a palmaris longus tendon; in those patients, a gracilis tendon from the inner thigh is used as an alternative. Dr. Fitzgibbons evaluates for palmaris presence at the pre-operative visit.

Ligament reconstruction: An incision is made over the medial epicondyle. The flexor-pronator muscle mass is carefully split to expose the UCL. The ulnar nerve, which runs directly behind the medial epicondyle, is identified and protected throughout the procedure. In most cases, the nerve is transposed anteriorly (moved forward out of its groove) to prevent post-operative irritation, though the decision is individualized.

Bone tunnels are drilled in the medial epicondyle of the humerus and in the sublime tubercle of the ulna — the anatomic attachment points of the native ligament. The graft is passed through these tunnels and secured with the elbow in 30 degrees of flexion. Most reconstructions use a docking technique or figure-of-eight configuration, which has demonstrated biomechanical superiority over older single-tunnel methods. Tension is set to recreate the native ligament's restraint without over-tightening. The wound is closed in layers and a splint is applied.

Recovery room: A posterior splint holds the elbow at 90 degrees of flexion. Pain is typically mild to moderate. You are discharged with oral pain medication, ice, and elevation instructions.

Recovery timeline

Frequently Asked Questions