Formally Known as Ulnar Collateral Ligament Reconstruction (UCLR)

By Jennifer Whitlock, RN, MSN, FN 

 Medically reviewed by Yaw Boachie-Adjei, MD

Tommy John surgery involves replacing a damaged ligament in the elbow, called the ulnar collateral ligament (UCL) , with a tendon from somewhere else in the patient's body or from a deceased donor.

The ulnar collateral ligament is a thick band of tissue similar to a very strong rubber band. It works to stabilize and strengthen the elbow and can be injured by tearing, stretching, and dislocation.

UCL injuries most commonly occur among athletes who engage in repetitive throwing or overhead motions such as baseball pitchers, javelin throwers, and volleyball and tennis players.

David Ellis / Getty Images

While non-surgical treatments like anti-inflammatory medications and physical therapy are usually tried first for a UCL injury, in many cases—especially professional or collegiate athletes who want to return to their sport—surgery is ultimately required.1

What Is Tommy John Surgery?

Tommy John surgery is a scheduled operation performed under general anesthesia by an orthopedic surgeon. As an outpatient procedure, patients can expect to go home the same day as their surgery.

During the operation, the surgeon removes the damaged UCL through one or more incisions made on the inside of the elbow joint.

Next, the surgeon drills holes into the bones above and below the elbow. Part of a tendon taken from the patient's forearm, leg, or foot (or less commonly, a donor ) is looped through these holes to replace the UCL.2

Tommy John surgery may be performed in one of two ways, depending on factors like the degree of the injury, the patient's health status, and surgeon preference/experience:

• With open surgery, a large incision is made in the skin of the elbow to access the UCL and remove and replace it.

• With arthroscopic surgery, narrow surgical tools (one of which has a camera attached to it) are inserted through multiple smaller skin incisions to perform the same operation.

Various Surgical Techniques

There are numerous UCL reconstruction surgical techniques that have evolved over the years.3

These techniques generally differ in the way the tendon is threaded through the holes drilled in the upper and lower arm bones.

Two commonly used techniques include:4

• Docking technique: The surgeon attaches sutures to the ends of the tendon graft and then drills holes in the lower and upper arm. The tendon graft is looped through a tunnel created by the holes in the lower arm. The attached sutured ends are then pulled through two tunnels created by the upper arm holes. The two sutures are tied together to hold the tendon graft in place.

• Figure-of-eight technique: The tendon graft is looped through two pairs of holes—two in the upper arm and two in the lower arm—in a figure-eight fashion. The two ends of the tendon are then sutured to the tendon itself.

Who Is Tommy John?

Tommy John is a former Major League Baseball pitcher. In 1974, he became the first to have this procedure done on an elbow—all because his surgeon improvised after realizing the UCL he was about to repair was gone due to wear and tear.

One year after surgery, John returned to pitching professionally and continued until 1989. His successful, unprecedented, and surprising recovery led to the surgery coming to bear his name.5

Contraindications

Certain medical circumstances prevent a patient from being a candidate for Tommy John surgery.

These include:6

• An inability or unwillingness to participate in the rigorous postoperative recovery process

• Significant elbow arthritis

Potential Risks

In addition to the general risks of any surgery (e.g., problems related to anesthesia or infection), Tommy John surgery may pose certain risks, including:6

• Elbow stiffness and/or swelling around the elbow joint (synovitis)

• Ulnar neuropathy which can leave the affected hand numb, tingling, and/or weak

• Avulsion fracture of the medial epicondyle (when a piece/fragment of the bony bump on the inside of your elbow is broken off)

• Stretching or rupture of the graft4

• Pain or numbness at the graft harvest site

Purpose of Tommy John Surgery

Tommy John surgery is done to restore elbow function/stability and alleviate symptoms like pain and weakness. In most cases, the patient's desire to return to their competitive sport is also a key goal.

The surgery is indicated in patients who continue to have significant elbow pain and dysfunction despite undergoing nonsurgical therapies like rest, strengthening exercises, and taking nonsteroidal anti-inflammatory drugs (NSAIDs).

Surgery may be advised sooner if the UCL is found to be ruptured, meaning it has fully torn away from the humerus (a bone in the upper arm) or the ulna (a bone in the forearm). Ligament rupture can be diagnosed with an elbow magnetic resonance imaging (MRI).6

If surgery is scheduled, various pre-operative tests will need to be run for anesthesia clearance.

These tests often include:

• Blood tests, such as complete blood count (CBC) and a coagulation panel

• Electrocardiogram (ECG)

How to Prepare

At your pre-operative appointment, your surgeon will review all of the steps involved in your surgery, including the preparatory process.7

Location

Tommy John surgery is performed in an outpatient surgical center or hospital. 

What to Wear

On the day of your surgery, wear comfortable, loose-fitting clothes, including a large shirt without buttons or zippers that you can pull on and off easily.

Avoid wearing makeup, lotions, deodorant, perfume, or cologne. Leave all valuables, including jewelry, at home.

Food and Drink

Avoid eating after midnight on the eve of surgery.

Clear liquids may be allowed up to two hours prior to your scheduled arrival time.

Medications

You may be asked to stop taking certain medications several days prior to surgery. NSAIDs, for example, are among them, as they increase your risk for bleeding.

Before surgery, tell your doctor all of the drugs you are taking including prescription and over-the-counter medications, dietary supplements, herbal remedies, and recreational drugs.

What to Bring

On the day of your operation, bring your driver's license and insurance card. Also, bring along someone to drive you home after your procedure.

Pre-Op Lifestyle Changes

If applicable, stop smoking as soon as possible prior to surgery. Smoking increases your risk for complications, including breathing and wound healing problems, both during and after the procedure.8

What to Expect on the Day of Surgery

On the day of your surgery, you will arrive at the hospital or surgical center and check-in. You may be asked to show your driver's license and insurance card.

Before the Surgery

After checking in, you will be directed to a surgical holding area. Here, you will change into a hospital gown and grip socks.

A nurse will review your medication list, record your vitals, and place an intravenous (IV) line into a vein in your arm. This IV will be also used for administering fluids and other medications during and after surgery.

Your surgeon will then come to greet you and review the specifics of the operation.

Your anesthesiologist will also come to say hello and discuss the anesthesia process. You may need to sign additional consent forms at this time.

From there, you will walk on your own into the operating room or be wheeled on a gurney.

During the Surgery

Once you are in the operating room, you will be positioned on your back on the operating table with your arm draped. The anesthesiologist will give you inhaled or intravenous medications to put you to sleep.

A breathing (endotracheal) tube will be inserted through your mouth into your windpipe (trachea). This tube is connected to a ventilator which helps your lungs breathe during surgery.

An open Tommy John surgery takes around 60 to 90 minutes and proceeds in the general fashion:4

• Harvesting: The surgeon will make an incision in your forearm, back of your thigh, knee, or foot in order to remove a piece of tendon. Around 15 to 18 centimeters (cm) of the tendon is needed to reconstruct the UCL.9

• Visualization and removal: A three- to four-inch incision will be made on the outside of your elbow. Muscles, tendons, and nerves will be carefully moved out of the way so the surgeon can see and remove the damaged UCL.

• Grafting: Holes will be drilled in the bones above and below the elbow. The harvested tendon graft will be weaved through these holes to essentially recreate the UCL. The tendon graft will then be secured with special sutures or screws.

• Closure: The incisions will be closed with sutures. A sterile bandage will be placed over the surgical site. The elbow will be placed in a special rigid brace.

• Prep for recovery: Anesthesia will be stopped and the breathing tube will be taken out. You will be wheeled into a recovery room.

After the Surgery

You will wake up from the anesthesia in the recovery area. You may feel drowsy and experience elbow pain and nausea. A nurse will administer medication to help ease these symptoms.

Once you are fully awake and alert, and your vitals are stable, you will be discharged home.

As you recover at home, it's important to follow your surgeon's post-operative instructions.

These often include:10

• Take your pain medication, usually an opioid followed by an NSAID, as instructed.

• Ice your arm for 15 to 20 minutes, three to four times a day to help reduce swelling and discomfort.

• Resume your normal diet as tolerated.

• Follow-up with your physical therapist and surgeon (usually within a few days to a week after your surgery).

Keep in mind—your new tendon graft is very fragile during the initial weeks following surgery. You will be given instructions on proper wound care and showering, which you should follow closely.

When to Call Your Surgeon

Call your surgeon right away if any of the following occur:

• Fever

• Pain not relieved with medication

• Persistent numbness of the leg

• Excessive nausea/vomiting

• Redness, swelling, or tenderness in your thigh or calf

• Chest pain or trouble breathing

Recovery

The success of your surgery hinges greatly on the rehabilitation period that follows the operation.

Expect full recovery and return to competitive sports (if applicable) to take up to a year or longer.9

Rehabilitation

You will begin working with a physical therapist less than a week after surgery to help maintain muscle strength in your arm, promote healing, and decrease surgery-related pain and inflammation.

Around one to two weeks after surgery, your surgeon will change your rigid elbow brace to a hinged one. A hinged brace allows for some movement, but stops the elbow joint from going any further once it reaches a certain angle.

At this time, your physical therapist will help you perform gentle exercises to slowly increase your elbow's range of motion.

A month after surgery, you should be able to completely extend your elbow. Upon reaching this milestone, most patients can stop wearing their elbow brace.

At two to four months after surgery, you should regain full range of motion of your elbow joint. You will continue working with your physical therapist every week or every other week to increase your overall strength and endurance.

If you play a competitive sport, your therapist will also guide you through proper mechanics and positions.2

Activity Restrictions

Exercises to keep your heart strong are important during the rehabilitation process.

That said, your surgeon will ask you to avoid running and jumping activities for the first few months after surgery. These activities can put stress on your elbow when landing.

Instead, your surgeon will encourage activities like walking or riding on a stationary bike.2

While you can use your arm for eating, you should not bear weight with your arm until instructed by your surgeon.

Your surgeon will probably give you the OK to drive once you are off all pain medications. You will also need to be comfortable controlling the steering wheel primarily with the arm that was not operated on.

You can also likely return to work or school around three to four days after surgery.10

You should not return to your sport of choice until you are given medical clearance to do so.

Long-Term Care

Tommy John surgery is known for its high rates of complete recovery, allowing patients to return to sports and their normal activities.3

That said, preventing a UCL injury from occurring again (or in the first place) is something that all athletes should take seriously.

To do this, it's important to follow your coach's or sport's formal guidelines on taking breaks, warming up properly, and addressing any elbow symptoms (e.g., pain, swelling, or stiffness) right away.

In addition, athletes should expect to continue working with their doctor, athletic trainer, or physical therapist for at least 18 months after surgery, even after they have returned to their sport.2

Such intensive rehabilitation helps ensure that the athlete is continuing to use proper body mechanics and maintain adequate shoulder and core strength and flexibility. These measures are all important for preventing a re-injury of the UCL.

Possible Future Surgeries

Another surgery may be required if the UCL re-tears and/or if a complication from surgery develops.

With a second Tommy John surgery, the rate of return to competitive sports is lower compared to the rate of return after the first surgery. Specifically, among Major League Baseball pitchers, the rate of return to pitching after a second Tommy John surgery ranges from 42% to 78%.11

Sources

Massachusettes General Hospital. Tommy John surgery.

University of Wisconsin Sports Medicine. Rehabilitation Guidelines for Elbow Ulnar Collateral Ligament (UCL) Reconstruction.

Jensen AR, LaPrade MD, Turner TW, Dines JS, Camp CL. The History and Evolution of Elbow Medial Ulnar Collateral Ligament Reconstruction: from Tommy John to 2020. Curr Rev Musculoskelet Med. 2020 Jun; 13(3): 349–360. doi:10.1007/s12178-020-09618-y

Johns Hopkins Medicine. Tommy John Surgery (Ulnar Collateral Ligament Reconstruction).

Landers C. Why is it called Tommy John surgery? Major League Baseball.

Erickson BJ, Harris JD, Chalmers PN et al. Ulnar Collateral Ligament Reconstruction. Sports Health. 2015 Nov; 7(6): 511–517. doi:10.1177/1941738115607208

American Society of Anesthesiologists. Preparing for Surgery: Checklist

American College of Surgeons. Quit Smoking Before Your Operation.

Emory Healthcare. Tommy John Surgery for UCL Tear.

Frank RM, Shinsako K. University of Colorado Sports Medicine. Ulnar Collateral Ligament Reconstruction — Post-Operative Instructions.

Camp CL, Desai V, Conte S et al. Revision Ulnar Collateral Ligament Reconstruction in Professional Baseball: Current Trends, Surgical Techniques, and Outcomes. Orthop J Sports Med. 2019 Aug; 7(8): 2325967119864104. doi:10.1177/2325967119864104

University of Wisconsin Sports Medicine. Rehabilitation guidelines for elbow ulnar collateral ligament (UCL) reconstruction.

By Jennifer Whitlock, RN, MSN, FN
Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.