2024 Update on UCL Injuries: Non-Op, Reconstruct, or Repair?

Steven DeFroda M.D., M. Eng

AANA Now May


There is no better sound than the crack of a ball against bat, or the pop of the glove at a baseball diamond on a warm spring day. Similarly, there’s no worse sound than the pop of another kind, that of the star pitcher’s elbow after throwing a fastball. The ulnar collateral ligament (UCL) of the elbow aka the “Tommy John ligament” has gotten increasing media attention in recent years as a significant number of professional and amateur baseball players continue to tear this ligament as players get bigger, faster and stronger. Some have gone as far as to call UCL tears an “epidemic.”  This ligament is the topic of a New York Times best-selling book by prominent baseball journalist Jeff Passan, aptly titled “The Arm: Inside the Billion-Dollar Mystery of the Most Valuable Commodity in Sports.” As we approach the 50-year anniversary of the first UCL reconstruction ever performed by Dr. Frank Jobe on, of course, Tommy John, this tiny ligament has transcended medicine and science, and is firmly at the forefront public knowledge and sports journalism. It has become possibly one of the most well-known injuries, especially amongst baseball enthusiast, players and front offices. While this small stabilizer of the medial elbow does not play a role in day-to-day life, it turns out that it is essential for one major thing: throwing a ball very hard. When treating patients who desire the ability to compete in throwing sports, it is crucial to know how to manage this injury which was once thought to be career ending in baseball. Even today, 50 years later, we continue to evolve our techniques and treatment strategies to provide the best long-term outcomes for athletes, while also considering how to get them back on the field as quickly and safely as possible. Unfortunately, these injuries are just as common as ever, with one study of 5,088 professional pitchers finding that 25% of Major League pitchers and 15% of Minor League pitchers have had UCL reconstruction.1


Like most injuries, treating a UCL tear in 2024 essentially boils down to the main question of operative versus nonoperative. Full thickness, complete UCL tears in elite-level throwers will essentially always be an indication for surgery assuming the athlete wishes to return to sport.  For partial tears there may be nonoperative options in the form of biologics such as platelet-rich plasma, (PRP). Considering nonoperative management of UCL injuries comes down to the same question faced when managing other ligaments (or injuries in general) nonoperatively: will it heal? There are mixed results in the literature regarding PRP for UCL tears. Podesta et al. in 2013 reported on 34 patients with partial UCL injuries undergoing a single PRP injection and reported 30 of them returned in 10-15 weeks.2 Another study looked at nonoperative management of 544 UCL tears in MLB players, 133 had PRP and 411 did not. Overall, 54% returned to play, but 50% of the entire cohort eventually needed surgery. Of note, the non-PRP group returned in 20 weeks, versus 25 for the PRP group.3 While nonoperative treatment may get an athlete back to play quicker, is a 50% failure rate worth the wasted time and delay in ultimate return to play? It may come down to location and severity of tear. A histologic study by Buckley et al. showed that the proximal UCL has a dense blood supply, compared to a relatively hypovascular blood supply distally, potentially indicating that proximal tears may have a better chance at healing with conservative treatment with or without PRP.4This was confirmed via a clinical study by Frangiamore et al. of 32 patients who trialed nonoperative management of a UCL injury. Within this cohort, 11 required surgery and 22 returned to sport without surgery, with 82% of the failures consisting of players with a distal tear, and 81% of the successful nonoperative patients having proximal tears.5 Location and blood supply clearly matters when attempting to manage these injuries without surgery. A recent consensus statement revealed that 90% of surgeons agree that proximal tears can be an indication for trial of conservative treatment.6


Ultimately, however, nonoperative treatment may fail, necessitating surgical intervention. The question then becomes, what is the best surgery to ensure a safe, effective and potentially timely return to the same or better level of play? While the currently accepted gold standard in UCL surgery has been slightly modified since Dr. Jobe performed the first reconstruction 50 years ago, it is still widely accepted that reconstruction with autograft tissue is the gold standard.  Numerous studies have examined surgical approach, graft selection, tunnel configuration and graft fixation strategies, with no overwhelming advantage one way or the other.6 Most surgeons agree that there is no minimum amount of nonoperative treatment prior to surgery (93% agree).6 Additionally, based on the aforementioned consensus statement, surgeons agree that there is no singular ideal graft for UCL reconstruction as long as it is an autograft of adequate size.6 Ultimately it is also widely agreed upon that athletes do overwhelmingly well following UCL reconstruction. Tommy John is the shining example, having won 164 games in the 14 seasons AFTER his surgery, compared with 124 prior to surgery. Large studies reveal similar success. A large patient cohort from Cain et al. in 2010 of 743 UCL reconstructions reported 83% at the same of higher level of play at three years post operatively.7 Erickson et al. reported on 179 pitchers with MLB experience with an 83% return to play also. The downside? An average return time of 20.5 months.8 So we have a successful surgery, with a good return to play, the only negative is it takes a long time to get back on the mound. At a professional level a player’s prime may be short, not to mention the patience of a front office, placing a premium on accelerated return to play. In baseball terms, the UCL reconstruction is definitely a solid base hit, maybe even a double or triple, but can we hit a homerun?


The quest for similar (or better outcomes) with shortened return to play led to further innovation in UCL surgery, cue the internal brace. A surgery which has become popular following its success in high-profile athletes such as Brock Purdy of the NFC champion San Francisco 49ers, it’s a procedure known by name by most high-level baseball athletes, often in the same sentence as UCL and Tommy John. Dugas et al. have performed numerous studies, biomechanical and clinical, comparing internal brace with reconstruction and essentially have shown non-inferiority.9 While repair is not all together a new idea, the ability to augment a primary repair with a high strength, non-absorbable suture that acts as a “seatbelt” may hold the key to healing a native ligament. The question becomes when to attempt a repair and is the risk of a failed repair for an accelerated return to play worth it? Early results of repair are positive, with the right indications (otherwise good tissue quality, avulsion injury, primary injury). A recent systematic review summarizes the current literate on UCL repair with suture augmentation nicely. The review included 4 studies with 510 patients. The overall return-to-play rate ranged from 67 to 93% from a mean time of 6.7 to 17.6 months.10 More important, a low re-rupture rate was reported from 0-3.4%.10 Once again early results are impressive, but it is worth pointing out that not all of those athletes were baseball pitchers, and not all were at the highest level of throwing, where resistance to repetitive elbow valgus stress is paramount.  Patient selection remains key. Ultimately a faster return could backfire if the repair cannot hold up to the rigors of elite-level throwing. What do the experts say? The consensus statement on UCL injuries recently published states that indications for reconstruction over repair include: damage to both the humeral and ulnar UCL attachments, insufficient UCL tissue to support suture, patient preference and tissue deficiency. 6 By comparison, the agreed upon indication for repair is: partial thickness injury, isolated acute distal or proximal avulsion, no chronic ligament changes, patient preference (if both an option).6 As in most surgical procedures, decision making should be a team effort, but it is important to steer the athlete towards intervention with the potential for most success, both in the short and long term. Obviously the 17-year-old pitcher trying to get back for his senior year before he hangs it up for good is different than the 20-year-old with MLB aspirations, and the goals and expected expectations should be weighed accordingly?


So where does that leave us in 2024? We are faced with increasing arm injuries as single sport specialization rises and as pitchers place more and more of a premium on “stuff” i.e. increased velocity and increased movement. While the pitchers have advanced their skillsets, so too have we as surgeons. My current treatment algorithm based on the current literature is as follows (level 6 evidence):


Partial Proximal Tear: Initial trial of nonoperative treatment plus or minus PRP based on patient preference and cost with surgery for failures.


Proximal or distal complete tear: Consider trial of nonoperative management with high risk of failure. Surgery via repair plus internal brace versus reconstruction based on patient preference and activity level, time of season etc.


Midsubstance tear: Reconstruction in high-level throwing athlete

Ultimately a combination of UCL reconstruction plus internal brace could be the best of both worlds. The reconstruction brings the biology while the internal brace brings the time zero strength. This construct is gaining popularity both in the primary and revision setting (and is my current go to in any revision case in a serious athlete). As we continue to improve our surgical precision, techniques and outcomes similar to the pitcher painting the corner with a 99 mile per hour fastball we can continue to battle the UCL epidemic, getting these athletes back to player better, stronger and quicker than ever before.




  1. Conte, S.A., Fleisig, G.S., Dines, J.S., et al. Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players. Am J Sports Med. 2015;43(7):1764-1769. doi:10.1177/0363546515580792
  2. Podesta, L., Crow, S.A., Volkmer, D., Bert, T., Yocum, L.A. Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow With Platelet-Rich Plasma. https://doi.org/101177/0363546513487979. 2013;41(7):1689-1694. doi:10.1177/0363546513487979
  3. Chauhan, A., McQueen, P., Chalmers, P.N., et al. Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis. Am J Sports Med. 2019;47(13):3107-3119. doi:10.1177/0363546519876305
  4. Buckley, P.S., Morris, E.R., Robbins, C.M., et al. Variations in Blood Supply From Proximal to Distal in the Ulnar Collateral Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study. Am J Sports Med. 2019;47(5):1117-1123. doi:10.1177/0363546519831693
  5. Frangiamore, S.J., Lynch, T.S., Vaughn, M.D., et al. Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers. Am J Sports Med. 2017;45(8):1783-1789. doi:10.1177/0363546517699832
  6. Erickson, B.J., Hurley, E.T., Mojica, E.S., et al. Elbow Ulnar Collateral Ligament Tears: A Modified Consensus Statement. Arthroscopy - Journal of Arthroscopic and Related Surgery. 2023;39(5):1161-1171. doi:10.1016/j.arthro.2022.12.033
  7. Cain, E.L., Andrews, J.R., Dugas, J.R., et al. Outcome of Ulnar Collateral Ligament Reconstruction of the Elbow in 1281 Athletes: Results in 743 Athletes with Minimum 2-Year Follow-Up. Am J Sports Med. 2010;38(12):2426-2434. doi:10.1177/0363546510378100
  8. Erickson, B.J., Gupta, A.K., Harris, J.D., et al. Rate of Return to Pitching and Performance After Tommy John Surgery in Major League Baseball Pitchers. Am J Sports Med. 2014;42(3):536-543. doi:10.1177/0363546513510890
  9. Dugas, J.R., Walters, B.L., Beason, D.P., Fleisig, G.S., Chronister, J.E. Biomechanical Comparison of Ulnar Collateral Ligament Repair with Internal Bracing Versus Modified Jobe Reconstruction. American Journal of Sports Medicine. Published online 2016. doi:10.1177/0363546515620390
  10. Jackson, G.R., Jawanda, H., Batra, A., et al. Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Results in Good Clinical Results, a Return-to-Play Rate Between 67% and 93%, and a Postoperative Complication Rate Up to 11.9%: A Systematic Review. Arthrosc Sports Med Rehabil. 2023;5:100761. doi:10.1016/j.asmr.2023.100761
Scroll to top