Tommy John Surgery: Are there alternatives to UCL reconstruction surgery?

Ross A. Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C

Tommy John Surgery – The alternatives to UCL reconstruction surgery

If you are reading this article you are likely a baseball pitcher or a parent of one who needs to explore options for the treatment of a partially torn or ruptured ulnar collateral ligament in the elbow. You have probably spent a great deal of time researching these options. Later in this article, we will present evidence for a non-surgical option for partial tears that may help.

You have seen numerous major league baseball players undergo the infamous “Tommy John Surgery,” surgery. Many with good success, many without good success. The great reality of your situation however is that these Major League Baseball players have a huge medical staff behind them and availability to 24/7 healing technology. This is usually not the treatment follow-up that a 16 or 17-year-old or mid-20s independent or low-level minor league or semi-pro player gets.

How to treat a UCL injury is confusing

Despite all the advantages, many major league players did not have good success with elbow surgery. Below we will explore the research which examines why these players did not return to the level of play they wanted to after the surgery. So where does this leave you?

So you know you are not alone, let’s share some of the thoughts our patients have shared with us over the last 26 years:

A baseball pitcher will often tell us that the pain on the inside of their elbow first became “annoying,” during an “easy lob” warm-up. As the pain progressed, anxiety and worry were enough to get the player to the specialist. Doctors are usually not eager to go right to a surgical procedure in a young athlete because the recovery time is so long. A period of rest is usually suggested, normally a few months. If this suggestion is made during the mid-season, this is unfortunately when the player usually tries to “suck it up,” and keeps pitching and tries to make it to the off-season. Likely doing more damage to the ligament.

The ball player has now rested his elbow for a few months. A gentle program of return to throwing is given. A few sessions, go well. Then you or your son tried to throw full strength, the pain is back. In the player’s mind, they spent a lot of wasted time resting.

For most parents and athletes we see, the first option explored is the: “I don’t want the surgery but don’t see any other way.”

Complete rupture or partial tear. Understanding the difference may get you back on the field faster. Can you even pitch without a UCL?

If you have a complete rupture or “disintegration” of the UCL in your elbow, and you are going to continue to play baseball, surgery is likely the way back. However, you can pitch without a UCL.

New York Met right-hander RA Dickey won the 2012 Cy Young award with a 20-6 mark and 230 K’s. He did this by perfecting his knuckleball and not having a UCL in his pitching arm. Dickey was born without a UCL in his elbow joint. This missing UCL was discovered accidentally by Texas Ranger team doctors from a TEAM USA photo. 

So it is possible to pitch without a UCL. The evidence suggests yes if you are a knuckleballer. The UCL however, does provide what every pitcher wants VELOCITY.

In this next segment, we will discuss Tommy John’s surgery for complete ruptures and inner brace surgeries for partial tears. Later in this article, we will discuss possible non-surgical alternatives and possibly why stem cell therapy DID NOT WORK for some high-profile players and why it did.

The research on the reality of Tommy John and Inner Brace surgeries – Let’s start with Tommy John.

Since the earliest papers on ulnar collateral ligament reconstruction, better known as Tommy John Surgery, doctors have sought to improve the method first developed by Dr. Frank Jobe and first performed on the iconic baseball pitcher Tommy John in 1974.

In a 1986 paper, Dr. Jobe noted his findings in 16 patients.  (1)

In May 2015, nearly 30 years later after the paper cited above, doctors are still trying to improve on the original procedure. In this study from Germany, doctors acknowledged that elbow instability, in this case, that Posterolateral rotatory instability of the elbow is the result of a damaged lateral collateral ligament. The standard surgical technique single-bundle reconstruction of the lateral ulnar collateral ligament still resulted in cases of recurrent instability after reconstruction. In their desire to improve this technique the doctors found they could not find anything better. “this biomechanical study does not confirm the hypothesis that more anatomic reconstruction techniques (surgeries) could reduce the risk of recurrent instability when compared to conventional lateral collateral ligament reconstruction. (2)

Improving surgery success rates in non-pitchers 2018

February 2018, the Journal of Shoulder and Elbow Surgery, (3) doctors at New York University Hospital for Joint Diseases publish these observations that were reflective of the data collected on 35 Major League Baseball positional players who underwent medial ulnar collateral ligament reconstruction.

Look at this:

This is of significant interest to us. Season two worse than season one. How come? The UCL injury was the result of repetitive motion, i.e., throwing a baseball. After two years the player performance significantly diminished. Below we are going to show you the evidence that these surgeries, in many cases, does not succeed because another tissue was damaged

Now let’s look at the pitchers

Tommy John finished his playing career with the New York Yankees at age 46, 15 years after his legendary surgery

Is Tommy John Surgery a successful procedure? Here is the debate and an opinion from the Toronto Blue Jays

In March 2018, in the Journal of Shoulder and Elbow Surgery, (4) Scott Peters, Major League Assistant Physical Therapist with the Toronto Blue Jays lead a study that presented findings on how successful Tommy John surgery was in getting players back to pre-injury level. The researchers of this study examined previously documented cases and found that the evidence for the surgery’s success was based on low-level and high-biased reporting.

These are realities you must explore in understanding the surgery.

Many in the medical community are saying those who had great success with Tommy John Surgery may owe their “coming back stronger,” “more velocity,” simply to the rehabilitation process

Pitchers who have had Tommy John Surgery and had results that may not be as successful as hoped face a new reality, multiple surgeries.  Sports Illustrated ran a story in 2015  “Why 2-3 Tommy John surgeries could be a new reality for some pitchers.”

Some baseball people have begun to question whether the surgery is actually bad for pitchers. In fact, many in the medical community are saying those who had great success with Tommy John Surgery may owe their “coming back stronger,” “more velocity,” simply to the rehabilitation process, these pitchers were forced to take a year or two off, it gave their pitching arms time to heal not only the surgery but micro-tears in the shoulder and wrist.

Below are some stunning statistics in regards to Tommy John Surgery. If you are reading this article as a baseball enthusiast, please allow me to explain to the non-baseball audience these most famous and iconic baseball-related surgical procedures.

The surgical procedure is named for the iconic baseball player, then Los Angeles Dodger Tommy John. In this procedure – a surgical graft procedure – the ulnar collateral ligament is replaced with a tendon from elsewhere in the body (often from the forearm, hamstring, hip, knee, or foot of the patient). The procedure is common among collegiate and professional athletes in several sports, most notably baseball.

Why 2-3 Tommy John surgeries is not a good reality – MLB doctors look for a better way

Major League pitchers who undergo more than one Tommy John Surgery have a low rate of return to MLB play and have shortened careers after the return.

In a presentation lecture at the American Academy of Orthopaedic Surgeons Annual meeting 2014, presenters suggested that pitchers who returned to the Major League Baseball level maintained performance in several statistics such as earned run average and walks/hits per innings pitched; however, pitchers returned with a significantly decreased workload. (5) Study highlights:

In the Journal of Elbow and Shoulder Surgery, the Los Angeles Doctors, Dr. Jobe, and doctors at the Hospital of Special Surgery in New York released these 2016 findings:

Appearing in the American Journal of Orthopedics, Brandon J. Erickson, MD wrote an editorial called The Epidemic of Tommy John Surgery: The Role of the Orthopedic Surgeon. In this editorial, Dr. Erickson discussed the realities of the surgery and rehabilitation period for young athletes and compared them to Major League Baseball pitchers.

Dr. Erickson cited that major leaguers even with an endless supply of rehabilitation facilities, trainers, etc, do not return to pitching competitively and consistently in the majors for more than 15 months after UCL reconstruction. The time commitment and rehabilitation required for these patients are staggering.

This is a reality lost on the parents of these children.

As mentioned above, some parents believe this surgery will help their child throw faster, longer, and more accurately. See below we are going to discuss the role of rest and reconstructive injection techniques.

In January 2018, doctors at the Mayo Clinic and the Hospital for Special Surgery in New York published in the Current Reviews in Musculoskeletal Medicine (7) a summary of recent findings:

A brief introduction to the internal brace procedure more will be discussed below.

The summary conclusion of this research presents today’s reality:

The Tommy John Surgery Epidemic: “elbow injuries are common and usually do not require surgery”

Let’s start looking at the numbers and make some connections.

In a paper from June 2016, the title of the research presentation says it all: “Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review.”(8)

Here we have doctors from the New York University Hospital for Joint Diseases saying some remarkable things which confirm the research listed below.

They also noted that there were disproportionate numbers of patients between 15 and 19 years old. Prime baseball years for those with professional aspirations.

Why the disproportionate number of surgeries?: Because parents believe that the surgery will allow their sons to pitch better – this thinking has been cautioned against in many research findings we will now discuss.

Researchers from Columbia University in New York published their findings suggesting that perhaps the surgery is over-performed and that patient expectation of surgery are not what the surgery does. Listen to what they said:

“Reconstruction of the elbow ulnar collateral ligament, known as Tommy John surgery, is being performed with increasing frequency. . .

They developed a questionnaire to measure an individual’s perception of Tommy John’s surgery. 189 players, 15 coaches, and 31 parents completed questionnaires. Data were calculated and statistical analysis was performed.

The results:

Here is what the researchers concluded:

“This study is the first of its kind to investigate the public perception of Tommy John surgery and has identified an alarming percent of players, coaches, and parents with misperceptions. Efforts should be made in our communities to better educate players, coaches, and parents regarding elbow ulnar collateral ligament injury in youth baseball players.”

In other words, the perceptions of Tommy John’s surgery are very troubling.

The media’s role – glamorizing a surgery – spreading misconceptions

Researchers say that these misconceptions can be traced to media coverage. “The prevalence of medial ulnar collateral ligament (UCL) reconstruction is increasing in professional athletes and the delivery of baseball news by the media exerts a powerful influence on public opinion of the injury and surgery.”

These researchers then asked 516 members of the media a series of questions about the procedure.

Why would these players, parents, and coaches believe this? The misconception of the surgery and how it is reported.  There are studies that suggest incredible recoveries from the surgery. “Ulnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to a previous or higher level of competition in less than 1 year.”(11)

How can you argue with surgical results like that? One doctor did. The doctor who invented the “Tommy John” procedure, Frank Jobe, M.D.

Dr. Jobe suggested that these results or increases in performance are generally due to two factors. The athlete’s increased awareness of training and conditioning and secondly – with increasing pitch load, pitchers velocity decreasing as the ligament becomes worn, frayed, lax. Following the procedure, and the months of downtime, the procedure produces favorable results because they have a new “UCL”

The first is pitchers’ increased attention to conditioning. The second is that in many cases it can take several years for the UCL to deteriorate. Over these years the pitcher’s velocity will gradually decrease. As a result, it is likely that the procedure simply allows the pitcher to throw at the velocity he could before his UCL started to degrade. (12)

Alternative to Tommy John Surgery Repair of the Ulnar Collateral Ligament with Internal Brace Surgery.

Above we touched on briefly the concept of Internal Brace surgery as an option to complete UCL reconstruction. A March 2019 study in The Journal of Orthopaedic and Sports Physical Therapy (131) offers this brief explanation and benefit of the procedure.

In a partial tear situation, doctors are now recommending repairing the ligament, in this case with collagen tape. The benefit of this surgery is the great reduction in surgical recovery time.

Doctors writing in the BMJ (British Medical Journal) Case Reports (14) also report on the benefit of this procedure.

Non-Surgical Alternatives to Tommy John Surgery and Internal Brace Surgery.

In our clinic, we offer regenerative medicine techniques that include Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy. We typically do not offer stem cell therapy to athletes. In fact, we rarely offer this treatment unless the situation of joint degeneration is significant.

Many of the patients we see, and we will estimate that 1 in 10 of our new patients has received a stem cell treatment that failed from another health care provider. Why does this treatment fail? Most times we find inappropriate use, over expectation of what the treatment can do, or simply the treatment is offered as a one-shot wonder treatment. Extensive elbow ligament damage cannot be repaired with a one-shot wonder treatment, realistically speaking. While some professional athletes such as Bartolo Colon reported great results and a resurrected career with stem cell treatment, other like Garret Richards did not and had to have Tommy John Surgery. In this article, we will not discuss the wonders of stem cell therapy. We will discuss a realistic and simple injection technique called Prolotherapy.

The goal of Prolotherapy is to do what the internet brace surgery does but without the surgery.

In the videos below you will see Prolotherapy treatment and PRP treatment.

Prolotherapy is the use of simple dextrose to heal a partially torn ligament. How does it work? If you are a pitcher, as your UCL starts to break down, you lose velocity on your fastball. As the wear-and-tear continues you start feeling pain on the inside of your arm.

In this video Ross Hauser, MD and Prolotherapy clinician student demonstrates Prolotherapy medial elbow treatment

The treatment begins at 1:12 

Fastball Velocity and ligament injury

In this section, we are going to talk about velocity. First, this is how our research team explained Prolotherapy in the journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders. (15)

Prolotherapy has been used in clinical practice for more than 80 years to treat various chronic musculoskeletal conditions. Prolotherapy is a practical and effective therapeutic strategy to treat ligament damage including partial tears and resulting looseness or laxity of the ligament.

Note: This is how you lose velocity.

Note: This is how Prolotherapy may bring velocity back

Prolotherapy is a nonsurgical regenerative injection technique that introduces small amounts of an irritant solution to the site of painful and degenerated tendon insertions (entheses), joints, ligaments, and in adjacent joint spaces during several treatment sessions to promote the growth of normal cells and tissues. Irritant solutions most often contain dextrose (d-glucose), a natural form of glucose normally found in the body. In severe cases, autologous cellular solutions may also be needed, such as platelet-rich plasma (PRP), bone marrow, or adipose tissue (stem cell treatments)

The mechanism of action behind prolotherapy is not completely understood. However, the current theory holds that the injected proliferant mimics the natural healing process of the body by initiating a local inflammatory cascade, which triggers the release of growth factors and collagen deposition.

In other words, the treatment tightens your ligament, braces your ligament by initiating natural collagen deposits on the ligament damage. This restores tension strength.

Using Prolotherapy and PRP injections together

In the Journal of Prolotherapy, we provided this basic definition of how PRP could help.

Research: Is Platelet Rich Plasma a realistic option?

In October 2019, writing in the American Journal of Sports Medicine (16) doctors at the Division of Sports Medicine, Department of Orthopaedic Surgery, at the Scripps Clinic in La Jolla, California wrote that “Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries.”

Here is a summary learning point look at this research – what this research team did was examine existing studies to look for better clues as to whether PRP treatment would work or not.

By itself, according to this study, PRP did not improve Return To Play outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs.”

In other words, there are many reasons PRP will not work. In our clinic, the main reason we see in patients that were not usually touched on in their previous treatments was the lack of treatment to the entire elbow joint structure to strengthen ligaments and other supportive structures and reduce abnormal joint movement and the subsequent strain it places on the UCL.

What is realistic?

For some, surgery will be the only option if there is no UCL present. In other words, the ligament is completely disintegrated and there is nothing to repair. For others, there is a partial UCL that may be repaired either regeneratively with PRP or Prolotherapy or other type injections. As mentioned above, there must be a realistic expectation, not only of the treatment but the pitcher’s ability to rest and rehabilitate the ligament well enough to bring it back to strength.

Do you have questions about your elbow pain? You can get help and information from our Caring Medical Staff.

References for this article

1 Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986 Oct;68(8):1158-63. [Google Scholar]
2 Dargel J, Boomkamp E, Wegmann K, Eysel P, Müller LP, Hackl M. Reconstruction of the lateral ulnar collateral ligament of the elbow: a comparative biomechanical study. Knee Surg Sports Traumatol Arthrosc. 2015 May 10. [Google Scholar]
3 Begly JP, Guss MS, Wolfson TS, Mahure SA, Rokito AS, Jazrawi LM. Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players. Journal of shoulder and elbow surgery. 2018 Feb 1;27(2):282-90.[Google Scholar]
4 Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP. The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis. Journal of shoulder and elbow surgery. 2018 Mar 1;27(3):561-71.
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5 Makhni EC. Lee R, Morrow Z, Gualtieri A, Ahmad CS.  Performance Metrics Before and After Tommy John Surgery in 160 Professional Pitchers AAOS Presentation Abstract
6 Liu JN, Garcia GH, Conte S, ElAttrache N, Altchek DW, Dines JS. Outcomes in revision Tommy John surgery in Major League Baseball pitchers.  J Shoulder Elbow Surg. 2016 Jan;25(1):90-7. doi: 10.1016/j.jse.2015.08.040. [Google Scholar]
Clark NJ, Desai VS, Dines JD, Morrey ME, Camp CL. Nonreconstruction Options for Treating Medial Ulnar Collateral Ligament Injuries of the Elbow in Overhead Athletes. Current reviews in musculoskeletal medicine. 2018 Jan 15:1-7. [Google Scholar]
8 Mahure SA, Mollon B, Shamah SD, Kwon YW, Rokito AS. Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review. J Shoulder Elbow Surg. 2016 Jun;25(6):1005-12. [Google Scholar]
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11. Cain EL Jr, Andrews JR, Dugas JR, Wilk KE, McMichael CS, 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 Dec;38(12):2426-34. Epub 2010 Oct 7. [Google Scholar]
12. Keri, Jonah (2007-09-13). “Interview With Dr. Frank Jobe“.
13 Wilk KE, Arrigo CA, Bagwell MS, Rothermich MA, Dugas JR. Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery. Journal of Orthopaedic & Sports Physical Therapy. 2019 Mar 12(0):1-9. [Google Scholar]
14 Wilson WT, Hopper GP, Byrne PA, MacKay GM. Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up. BMJ Case Reports CP. 2018 Dec 1;11(1):e227113. [Google Scholar]
15  Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]
16. Chauhan A, McQueen P, Chalmers PN, Ciccotti MG, Camp CL, D’Angelo J, Potter HG, Fealy SA, Erickson BJ, Hoenecke HR, Keefe D. Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis. The American journal of sports medicine. 2019 Oct 7:0363546519876305. [Google Scholar]
17 Ross Hauser, MD, Hauser M. Platelet Rich Plasma (PRP) injection technique. Journal of Prolotherapy. 2009;1(3):184.


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