Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

If you are a baseball pitcher, another overhead athlete, or the parent of a young player with inner elbow pain, the difficult question may be whether a damaged ulnar collateral ligament needs surgery. You may have been told to rest, try rehabilitation, consider an injection, or prepare for Tommy John surgery. Those recommendations can sound contradictory when you are trying to protect an athletic career.

At Caring Medical, we hear from athletes who want to avoid surgery but also worry about losing time on a treatment that will not work. Some have rested for months and felt better in ordinary activities, only for the pain to return during harder throwing. Others have already received an injection and want to understand why their elbow still hurts.

There is no single answer for every UCL injury. A partial tear, an acute tear pulled away from its attachment, and a chronically deteriorated ligament are different problems. The choice also depends on tissue quality, elbow stability, associated injuries, and the demands of the athlete’s sport.

What the UCL does, and how it can become injured

The medial ulnar collateral ligament connects the upper-arm bone to the ulna on the inside of the elbow. It helps resist valgus force—the force tending to open the inner side of the joint during throwing. Injury can occur suddenly or through accumulated stress. Pain, reduced throwing control, and reduced velocity may accompany injury, but those symptoms are not specific enough to establish the diagnosis alone. (1)

The forearm muscles and the rest of the throwing chain also contribute to function. Shoulder strength, trunk movement, mechanics, and workload matter alongside the ligament. The UCL should not be described as a simple rubber band whose tension alone determines fastball velocity.

“I rested, but the pain came back when I started throwing”

This is a common concern among throwing athletes. An athlete may tolerate daily activities and easy throws, then develop pain as distance, effort, or pitch volume increases. That does not automatically mean rest was wasted or surgery is inevitable. It means the elbow has not demonstrated tolerance for the required load.

Nonoperative care is more than waiting for the calendar to advance. A 2025 rehabilitation publication describes protection of the injured ligament followed by progressive strengthening and a monitored return to throwing. It is a proposed rehabilitation framework, not a randomized trial proving that every tear can heal without surgery. (2)

Trying to push through recurrent throwing pain to finish a season can obscure whether the elbow is tolerating the load. Neither the desire to avoid surgery nor pressure to return quickly should substitute for understanding the injury.

Partial tear or complete tear: why the details matter

The words “partial” and “complete” describe the extent of injury, but they do not tell the entire story. The location of the tear, condition of the remaining tissue, chronicity, and functional instability also matter. A review of UCL evaluation distinguishes proximal, midsubstance, and distal tears and emphasizes associated pathology, including ulnar nerve symptoms. (1)

Finding	Why it matters
Lower-grade partial tear	A nonsurgical approach may be reasonable in selected athletes; the label alone does not predict success.
Proximal tear, near the upper-arm attachment	Some nonoperative studies report better outcomes than for distal tears, but their populations are selected.
Acute avulsion with usable ligament tissue	Direct repair, sometimes with suture-tape augmentation, may be considered in selected cases.
Chronic attritional damage or poor tissue quality	Reconstruction may be more suitable than trying to repair inadequate native tissue.
Complete tear with high-demand throwing goals	Surgical assessment is often important. Some acute attachment tears may be repairable; not every complete tear requires the same operation.
Numbness, hand weakness, tendon pain, or mechanical locking	Additional nerve, tendon, or joint problems may affect symptoms and treatment decisions.

Rare anecdotes about exceptional athletes functioning with unusual ligament anatomy should not be treated as evidence that another pitcher can safely throw without a functioning UCL. The relevant question is whether that athlete’s elbow can meet that athlete’s demands.

Examination, MRI, and ultrasound

A suspected UCL tear requires a focused history and examination, including assessment of stability and nearby structures. A 2023 expert consensus supported advanced imaging when an athlete with a suspected or known tear plans to continue overhead sport, or when imaging could change management. That recommendation differs from routine imaging for uncomplicated tendon pain. (3)

MRI, sometimes with an arthrogram, can help define the tear and associated pathology. Ultrasound can provide additional information, including assessment under stress when appropriately performed. Imaging does not replace the examination, and a single measurement should not be interpreted without the symptom pattern and sporting demands.

For pain centered at the medial tendon attachment, see our golfer’s-elbow article. Progressive stiffness or locking may require consideration of arthritis, old trauma, or other joint problems.

What are the realistic nonsurgical options?

Rest from provocative throwing, progressive rehabilitation, and attention to associated deficits are central parts of published nonsurgical approaches. PRP is sometimes added. The important research question is whether an injection improves the outcome beyond what rehabilitation and time would achieve.

A systematic review of 15 studies involving 365 patients reported an overall nonoperative return-to-sport rate of 79.7%. Return was more frequent for proximal tears than distal tears: 89.7% versus 41.2% in the relevant subgroups. Lower-grade injuries generally did better, and the review found no statistically significant return-to-sport difference between patients who received PRP and those who did not. (4)

Those percentages are pooled observations, not an individual prognosis. They should not be applied to an athlete without accounting for tear characteristics, level of play, treatment selection, and how each study defined a successful return.

PRP for UCL tears: promising reports, uncertain added benefit

Platelet-rich plasma is prepared from the patient’s blood to concentrate platelets and associated signaling proteins. That provides a biological rationale for research, but it does not establish that the injection restores a torn UCL or prevents surgery.

The professional-baseball comparison remains important

A 2019 study identified 544 professional baseball players treated nonoperatively for UCL injury: 133 received PRP and 411 did not. Its comparative and matched-cohort analyses did not establish improved return-to-play outcomes or ligament survivorship with PRP. Preparation, timing, rehabilitation, and injury characteristics varied. (5)

This finding directly addresses the assumption that adding PRP must improve the result. It does not prove that PRP cannot help anyone. It also does not establish that a poor outcome was caused by failure to inject every surrounding ligament or joint structure.

What the newer review adds

A systematic review published online in 2024 and in a 2025 issue included eight studies with 278 partial-thickness and 44 full-thickness tears. Return-to-sport rates ranged from 46% to 100%, with substantial variation between studies. Reports with longer rehabilitation and leukocyte-poor PRP had more favorable patterns, but the underlying evidence consisted of lower-level studies. These comparisons cannot isolate the effect of PRP formulation from patient selection and rehabilitation. (6)

A 2025 report in five collegiate pitchers

Five collegiate pitchers with low- to intermediate-grade partial UCL injuries returned to their prior competitive level after PRP, physical therapy, and a structured return-to-play program. Mean clearance occurred 174 days after injury. This small retrospective series illustrates a possible successful course, but without a control group it cannot determine how much PRP contributed or establish a timetable for other athletes. (7)

The evidence supports discussing uncertainty. Successful return after a combination of treatments does not prove which component produced the result. The 2023 expert consensus specifically identified insufficient evidence supporting orthobiologics for UCL tears; subsequent small reports have not resolved that question. (3)

What about Prolotherapy and other regenerative injections?

Dextrose Prolotherapy is an injection approach intended to stimulate a repair response in painful supporting tissues. At Caring Medical, our clinical perspective includes considering ligament injury and surrounding structures when the symptoms suggest more than an isolated tendon problem.

Our published 2016 review examined dextrose Prolotherapy for several chronic musculoskeletal conditions. It provides background on the rationale and broader evidence, including lateral elbow tendinopathy. It does not establish efficacy for healing a throwing-related medial UCL tear or returning a pitcher to competition. (8)

A proposed repair mechanism should therefore remain separate from a demonstrated clinical result. It is too strong to state that an injection reliably tightens the UCL, restores its original tensile strength, or returns fastball velocity. Evidence for tennis elbow, golfer’s elbow, or another ligament cannot automatically answer those questions.

Does combining PRP and Prolotherapy improve the result?

These treatments have different preparations and are sometimes discussed together. The rationale for combining them is not proof that the combination is superior. The UCL studies reviewed here do not establish that adding dextrose Prolotherapy to PRP produces a better return-to-sport result than either treatment alone or rehabilitation without injections.

The football-player case report: useful, but not a pitching protocol

A December 2025 report described a professional football running back with a grade 2 partial UCL tear who had received PRP and injections described as stem-cell therapy, followed by multimodal rehabilitation. He returned to performance-based training over a six-week period. This was one patient receiving several interventions, and football loading differs from repeated high-velocity pitching. The report cannot establish the contribution of either injection or justify a six-week return-to-pitching expectation. (9)

Public stories about professional athletes receiving “stem cells” also cannot establish which preparation was used, why treatment succeeded or failed, or whether another athlete would have the same result. These products should not be treated as interchangeable or as a proven substitute for surgery in a structurally deficient elbow.

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

What Tommy John surgery actually does

Tommy John surgery is UCL reconstruction: a tendon graft is used to reconstruct the damaged ligament. It is different from directly repairing the athlete’s existing UCL. Reconstruction is often considered when native tissue is too damaged for repair or when instability and sporting demands make nonsurgical recovery unlikely.

The original 1986 report described 16 throwing athletes treated with reconstruction. Ten returned to their previous level, one to a lower level, and five retired from professional athletics. Ulnar nerve complications were also reported. Techniques, patient selection, and rehabilitation have evolved substantially since this historical report. (10)

Return to play is not the same as return to performance

“Back on the field” may mean playing one game, returning at a lower level, resuming the same position, or sustaining the previous workload and performance. These are different outcomes. When a family hears a success percentage, the definition matters as much as the number.

A foundational review of 22 retrospective studies involving 2,289 athletes found overall return to sport of 90%, compared with 79% returning at the previous level. It also identified low-level, high-bias evidence and considerable variation between studies. This helps explain why an apparently high success rate may coexist with reduced workload or performance. (11)

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. 

Position players have different demands from pitchers

An earlier study of 35 Major League Baseball position players reported 80% returning to their prior level of competition. Some offensive and workload measures declined, and catchers had particularly challenging results. Those findings are relevant to the player’s role, but they do not show that every postoperative decline results from another untreated tissue injury. (12)

Professional-baseball results should also not be presented as a direct forecast for a school athlete, recreational player, gymnast, or contact-sport athlete. Competitive selection, career opportunity, and sport-specific load influence what “return” means.

Internal-brace repair: an alternative for selected tears

Repair attempts to preserve and reattach usable native ligament tissue. Internal-brace augmentation adds a supporting suture-tape construct during healing. The tape is not a replacement ligament made of collagen and is not the same intervention as an injection intended to stimulate collagen production.

Repair may be suitable for selected attachment tears with adequate tissue quality. It is not automatically appropriate for every partial tear, and some acute complete avulsion tears may be repairable. Widespread chronic degeneration may instead favor reconstruction. A 2025 systematic review emphasizes that repair is feasible only in an appropriate subset of injuries. (13)

What the 2025 pooled outcomes show

That review included 31 studies, with 496 repair patients and 2,277 reconstruction patients. Pooled return-to-sport rates were 91.1% after repair and 88.7% after reconstruction. However, the included studies were noncomparative: the groups did not represent patients randomly assigned to competing procedures. The percentages support favorable outcomes in selected populations; they do not prove repair is better or suitable for everyone. (13)

A 2026 comparison: earlier return, with selection caveats

A retrospective, single-surgeon study of 73 patients reported 97% return to play in both groups. Average return to full play was 8.3 months after repair and 10.0 months after reconstruction. Reported complications were 10% and 3%, respectively, despite less postoperative ulnar neuritis after repair. Different indications influenced the choice of operation, so these are associations rather than evidence that one procedure is universally faster or safer. (14)

A larger database study of 1,820 patients also found generally favorable outcomes but a higher revision risk after repair. Estimated two-year revision-free survival was 97.9% after repair and 99.5% after reconstruction. Absolute revision rates were low, and the retrospective design limits causal conclusions. Faster recovery in some repair studies should be considered alongside durability and injury selection. (15)

Does reconstruction create a stronger-than-normal elbow?

No study should be used to promise a “better-than-new” ligament. A 2026 biomechanical systematic review included 24 eligible laboratory studies, with 19 in quantitative analysis. At time zero—before biological healing—reconstruction showed lower strength or stiffness than intact native ligament in some measurements, while other measurements did not differ significantly. (16)

These laboratory findings do not show that a healed reconstruction can never function well. They challenge the idea that surgery instantly creates a superior ligament. Likewise, an athlete who throws harder after recovery may have benefited from restored function, training, conditioning, and rehabilitation; an individual improvement does not establish surgery as performance enhancement.

Young pitchers: protect the career, not just the next season

Young athletes and parents face difficult tradeoffs involving development, team opportunities, and the time required for recovery. Neither “you are young, so you will recover faster” nor “early surgery ruins a career” is justified as a blanket rule.

A study published online in October 2025 examined 851 pitchers drafted in the first five MLB rounds between 2011 and 2020. Earlier-career reconstruction, defined as surgery at age 19.49 or younger, was associated with longer recovery than late-career reconstruction at age 25.67 or older: approximately 19.8 versus 15.4 months. Earlier surgery was also associated with lower career earnings. These observational findings do not prove that surgery caused the differences or predict the future of an individual teenager. (17)

The developmental context matters, but age alone does not determine outcome. The severity of injury, opportunity to rehabilitate, and competitive demands also need consideration.

Why misconceptions about surgery still matter

In a survey of 189 players, 15 coaches, and 31 parents, 51% of high-school athletes and 37% of parents believed Tommy John surgery could be performed on an uninjured player to enhance performance. Many underestimated recovery time. These were findings from one historical survey, not current population-wide prevalence estimates. (18)

A separate survey of 516 media members found misconceptions about indications, performance gains, and return to competition. These studies explain why success stories need context. They do not establish that media coverage or parental beliefs caused the rise in surgeries. (19)

Tommy John surgery is treatment for an injury, not a preventive upgrade to a healthy elbow. The 2023 consensus identified overuse, high velocity, poor mechanics, and prior injury as relevant risk factors. Workload and preparation deserve attention, but risk factors are not a guarantee that an injury can be prevented. (3)

Repeat Tommy John surgery: a different prognosis

Revision reconstruction is surgery after an earlier reconstruction has failed or become inadequate. It should not be discussed using the same expectations as a first operation.

In a 2016 study, 17 of 26 MLB pitchers with sufficient follow-up returned for at least one major-league game after revision, while 11 returned for at least 10 games. Mean recovery among those who returned was approximately 20.8 months. The contrast between one game and sustained participation remains an important learning point. (20)

A 2026 study of 61 MLB pitchers after revision reported return-to-play estimates of 44.1% at two years and 63.2% at three years, lower than the primary-surgery comparison. Detailed performance analysis was limited to a smaller eligible subgroup and showed that many did not regain their earlier performance. The findings reinforce the distinction between returning and performing, without providing an individualized forecast for every athlete. (21)

Questions that help make treatment comparisons meaningful

• Is the diagnosis a UCL tear, a flexor-pronator tendon problem, ulnar nerve irritation, or a combination?
• Where is the tear, how extensive is it, and is the remaining tissue suitable for repair?
• Does the evidence concern athletes with the same injury and sporting demands?
• Does “success” mean less pain, return to any play, or sustained performance at the previous level?
• If an injection is proposed, what supports its added benefit over rehabilitation?
• If surgery is proposed, why does repair or reconstruction fit the injury?

At Caring Medical, our interest in nonsurgical options should be read alongside these evidence limits. Some athletes may recover without surgery; others need surgical treatment to meet their goals. The decision requires matching the treatment to the injury rather than assuming that surgery always succeeds or injections reliably rebuild every ligament.

When symptoms need prompt assessment

A sudden pop with substantial loss of throwing function, progressive hand weakness or numbness, or significant injury-related swelling warrants timely medical assessment. A visibly deformed elbow, a cold or pale hand, or a hot swollen joint with fever requires urgent care.

This article is for education and does not replace an individual medical evaluation, diagnosis, or treatment recommendation. Study averages are not personal recovery schedules or clearance to return to sport.

References

1 Bowman EN, Smith MV, Freehill MT, Chalmers PN. Ulnar Collateral Ligament Tears: Evaluation and Nonsurgical Management. Instructional Course Lectures. 2025;74:43–50. [Google Scholar]

2 Wyatt PB, Vanderkwaak B, Brown R, Goodloe JB. Nonoperative Management of Ulnar Collateral Ligament Injuries in the Throwing Athlete: A Framework for Return to Throwing. Video Journal of Sports Medicine. 2025;5(2):26350254251326953. [Google Scholar]

3 Erickson BJ, Hurley ET, Mojica ES, Jazrawi LM; Ulnar Collateral Ligament–Delphi Consensus Group. Elbow ulnar collateral ligament tears: a modified consensus statement. Arthroscopy. 2023;39(5):1161–1171. [Google Scholar]

4 Gopinatth V, Batra AK, Khan ZA, Jackson GR, Jawanda HS, Mameri ES, McCormick JR, Knapik DM, Chahla J, Verma NN. Return to sport after nonoperative management of elbow ulnar collateral ligament injuries: a systematic review and meta-analysis. The American Journal of Sports Medicine. 2023;51(14):3858–3869. [Google Scholar]

5 Chauhan A, McQueen P, Chalmers PN, Ciccotti MG, Camp CL, D’Angelo J, Potter HG, Fealy SA, Erickson BJ, Hoenecke HR, Keefe D, McCauley J, Fronek J. 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;47(13):3107–3119. [Google Scholar]

6 Fucaloro SP, Kang AS, Bragg JT, Krivicich L, Salzler MJ. Return to sport after ulnar collateral ligament tears treated with platelet-rich plasma injections is influenced by length of rehabilitation and leukocyte content of injections: a systematic review. Arthroscopy. 2025;41(2):343–356. Published online March 18, 2024. [Google Scholar]

7 Shukla A, Kilgore JE III, Frey C, Locascio LM, Hymel A, Matarazzo CP, Porras L. Platelet Rich Plasma Treatment in Collegiate Baseball Players Who Suffered Partial Ulnar Collateral Ligament Tears: A Case Series from a Single Center’s Experience in Return to Play and Performance. Orthopedic Research and Reviews. 2025;17:489–495. [Google Scholar]

8 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;9:139–159. [Google Scholar]

9 Lane N, Rees GA, D’Angelo K. Platelet-rich plasma (PRP)/stem-cell therapy for a partial torn ulnar collateral ligament in a professional football player: case report. Journal of the Canadian Chiropractic Association. 2025;69(4):414–424. [Google Scholar]

10 Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. The Journal of Bone and Joint Surgery. American Volume. 1986;68(8):1158–1163. [Google Scholar]

11 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;27(3):561–571. [Google Scholar]

12 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;27(2):282–290. [Google Scholar]

13 Dave U, Rubin J, Chang N, Kumar N, Madden D, Mamonov A, Atkins M, Harkin W, Bi AS, Verma NN. Ulnar collateral ligament repair and reconstruction have similar return to sport rates with low complication rates: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2025;5(4):948–959. [Google Scholar]

14 Kirkham MS, Alvandi BA, Christy KB, Staten TM, Guy CR, Tashjian RZ, Joyce CD, Chalmers PN. Return to sport after ulnar collateral ligament repair and reconstruction. Journal of Shoulder and Elbow Surgery. 2026;35(11):2778–2785. [Google Scholar]

15 Varady NH, Parise S, Kunze KN, Brusalis CM, Williams RJ III, Altchek DW, Dines JS. Favorable Outcomes Following Elbow Ulnar Collateral Ligament Reconstruction and Repair, Though Repair Associated with Increased Risk of Revision Surgery. Arthroscopy. 2025;41(7):2297–2304.e1. [Google Scholar]

16 Looney AM, Hanna AJ, Coladonato C, Sonnier JH, Bodendorfer BM, Anderson CG, Sarna N, Freedman KB, Ciccotti MG, Ciccotti MC, Erickson BJ, Cohen SB. Elbow Ulnar Collateral Ligament Reconstruction and Repair: A Systematic Review and Meta-analysis of Biomechanical Studies. Orthopaedic Journal of Sports Medicine. 2026;14(1):23259671251407657. [Google Scholar]

17 Kriz PK, Staffa SJ, Kriz JP, Kocher MS. Early-career ulnar collateral ligament reconstruction in elite baseball pitchers: impact on professional career performance, longevity, and earning potential. JSES International. 2026;10(1):101391. Published online October 15, 2025. [Google Scholar]

18 Ahmad CS, Grantham WJ, Greiwe RM. Public perceptions of Tommy John surgery. The Physician and Sportsmedicine. 2012;40(2):64–72. [Google Scholar]

19 Conte SA, Hodgins JL, ElAttrache NS, Patterson-Flynn N, Ahmad CS. Media perceptions of Tommy John surgery. The Physician and Sportsmedicine. 2015;43(4):375–380. [Google Scholar]

20 Liu JN, Garcia GH, Conte S, ElAttrache N, Altchek DW, Dines JS. Outcomes in revision Tommy John surgery in Major League Baseball pitchers. Journal of Shoulder and Elbow Surgery. 2016;25(1):90–97. [Google Scholar]

21 Mastroianni MA, Timoney BF, Dillon MR, Obana KK, Chen AZ, Gonzalez M, Luzzi AJ, Alexander FJ, Ahmad CS. Return to Play and Performance After Revision Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers. Orthopaedic Journal of Sports Medicine. 2026;14(6):23259671261449637. [Google Scholar]

• her than the Return-To-Sports at a pre-injury level. In other words, you can get back, but not as good.
• Return-To-Sports at pre-injury level outcomes were lower in professional players, particularly Minor League Baseball compared with collegiate and high school players.
• Pitching performance significantly decreased postoperatively in most studies.

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.

A January 2026 study in the Orthopaedic journal of sports medicine (19) is notable for refuting the misconception that UCLR (Tommy John) surgery produces a new ligament that is biomechanically superior to the original anatomy. The study analysis of findings from 153 specimens across 10 biomechanical studies indicated that the reconstruction was not as robust as the native intact ligament.

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:

• There have been 215 ulnar collateral reconstructions performed on Major League Baseball pitchers.
• There is a significant proportion of players (18%) who do not resume major league careers.
• For those that return, a high proportion return to the disabled list, both for arm conditions (in general) and specifically for elbow pain (47% and 23%, respectively).
• Moreover, many performance statistics showed a decline following surgery, most notably in ERA, WHIP, opposing batting average, innings pitched, percentage of fastballs thrown and fastball velocity.”

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:

• Since 1999, 235 MLB pitchers have undergone Tommy John surgeries;
  • 31 pitchers (13.2%) underwent revision surgery, and
  • 37% underwent revision within 3 years of the index procedure.
  • Twenty-six revisions had more than 2 years of follow-up;
  • 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games.
  • Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, pitched fewer innings, and had fewer total pitches per season. (6)

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:

• Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP). Platelet-rich Plasma is injections of your own blood platelets as a healing solution.
• In some patients, repair of the UCL has shown a promising return to sport rates by using modern suture and suture anchor techniques. (There are companies who produce “surgical kits,” which help standardize the surgery and the outcomes. The modern techniques of surgery attempt to improve on the tunnels in the bone that are drilled and the screw fixation of the transplanted tendon.)
• Proximal avulsion injuries (where the ligament has pulled a chip of bone off) have shown the best results after repair.

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

• Currently, there is a growing interest in the augmentation of UCL repair with an internal brace.
  • (Note the internal brace method is intriguing in its concept especially for a Prolotherapy doctor. Here there is no reconstruction surgery but rather, the damaged ligament is repaired with suturing techniques and wrapped in a collagen-based fiber tape as the internal brace. This sounds like the Prolotherapy concept. In Prolotherapy, injections of a simple dextrose liquid instead of suture repair the ligament. The Prolotherapy injections bring reparative collagen to the area and patch, rebuild, and strengthen the ligament. Contact me via email using the form at the bottom of the page to discuss this further).

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

• The treatment of UCL injuries involves complex decision-making.
• UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes.
• However, non-reconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries.

The younger the pitcher the less hopeful the long-term outcome

An October 2025 study in the Journal of shoulder and elbow surgery (20) found baseball pitchers between 15 and 19 years old experiences a higher incidence of ulnar collateral ligament reconstruction (Tommy John) surgeries than any other demographic. Recent trends among elite pitchers indicate a consistent decrease in the average age at which they undergo their first ulnar collateral ligament reconstruction. However, there is a lack of literature assessing the effects of early-career UCL-R on an elite pitcher’s professional trajectory, including aspects such as performance, career longevity, and earnings. What the researchers of this study sought to understand was how these younger age – early-career ulnar collateral ligament reconstruction impacted these pitcher’s professional trajectory, including aspects such as performance, career longevity, and earnings.

What they found was pitchers who had younger age surgery had recovery time to return to sport (at any level) following primary reconstruction was significantly longer for early-career ulnar collateral ligament reconstruction pitchers compared to their late-career counterparts (15 year olds compared to 20 year olds).

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.

• “Medial ulnar collateral ligament injuries of the elbow that require surgical management are uncommon. There is growing evidence, however, suggesting that the incidence of UCL reconstruction  procedures is rapidly increasing.”
  • In other words, elbow injuries are common and usually do not require surgery. Then, the researchers ask, Why are so many (a disproportionate number) of people getting surgery? – i.e., Tommy John Surgery.

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. . .

• The public’s perception of Tommy John surgery may be incorrect with regard to the indications, operative technique, risks, recovery time, and benefits obtained from the procedure.”(9)

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:

• An incredible 30% of coaches, 37% of parents, 51% of high school athletes, and 26% of collegiate athletes believed that Tommy John surgery should be performed on players without elbow injury to enhance performance.
• Thirty-one percent of coaches, 28% of players, and 25% of parents did not believe the number of pitches thrown to be a risk factor, and 38% of coaches, 29% of players, and 25% of parents did not relate pitch type (eg, curveballs) with risk of injury.
• Many players (28%) and coaches (20%) believed that performance would be enhanced beyond the pre-injury level.
• Individuals underestimated the time required to return to competition. Twenty-four percent of players, 20% of coaches, and 44% of parents believed that return would occur in less than nine months.

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.

• 45% did not know if an athlete needed an elbow injury as a prerequisite for UCL reconstruction and 25% believed the primary indication was performance enhancement.
• eighty percent recognized that pitching speed is typically reduced following surgery, but the remaining 20% felt that velocities actually increased compared with pre-injury velocities.
• Return to play: fifty-two percent overestimated the ability of pitchers to return back to professional baseball and 51.2% believed return would occur in 12 or fewer months.
• Overuse injuries: less than half (48.4%) believed the use of pitch counts to be important in the prevention of UCL injury and 33.2% felt that throwing injuries were not preventable in adolescent baseball. (10)

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.

• Historically, ulnar collateral ligament injuries have been treated with surgical reconstruction techniques, using a tendon autograft. A recently developed UCL repair procedure with an internal brace, utilizing collagen tape, is gaining popularity. The primary goal of this surgery is to enhance elbow joint stability while the ligament is healing and to allow earlier return to sport after UCL reconstruction.

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.

• “Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing.
• Conventional treatment is a reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation.
• Modern surgical techniques have led to renewed interest in the repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. “

Prolotherapy

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.

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.

• The UCL is like a strong, thick rubber band. If you can imagine a bow and arrow. If the bow has a lot of tension, the arrow flies long and strong. If the bow loses its tension, the arrow loses speed, it flies off wobbly. To get the arrow to fly right you need to put tension in the bow. To regain velocity you need to put tension back in the UCL with the repair.

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)

• “A major goal of prolotherapy in chronic musculoskeletal conditions is the stimulation of regenerative processes in the joint that will facilitate the restoration of joint stability by augmenting the tensile strength of joint stabilizing structures, such as ligaments“

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

• PRP treatment re-introduces your own concentrated blood platelets into your elbow.
• Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.

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

•  In basic terms, PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor, and others, which exert their effects on fibroblasts causing proliferation and thereby accelerating the regeneration of injured tissues.
• Specifically, PRP enhances the fibroblastic events involved in tissue healing including chemotaxis, the proliferation of cells, proteosynthesis, reparation, extra-cellular matrix deposition, and the remodeling of tissues. The bottom line here is that PRP helps the healing process.

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.

• The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who have treated nonoperatively for elbow UCL injuries between 2011 and 2015.
• Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group).
• Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]).

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.

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

A December 2025 paper in The Journal of the Canadian Chiropractic Association, (18) presented a unique case of non-operative management of a partial ulnar collateral ligament (UCL) tear where the athlete was able to return to performance-based training in a brief six-week period.

A 29-year-old male running back consulted a sports specialist chiropractor for post-injection management following a grade 2 partial tear of the right UCL, which was treated with ultrasound-guided platelet-rich plasma (PRP) and stem cell injections. The physical examination revealed limitations in elbow range of motion (ROM) and positive orthopedic tests that confirmed a UCL injury. The patient reported that they had tried some light isometric exercises but had not been back to strength training since the injection. Additionally, he reported that his elbow was consistently sore when sleeping at night.

The management approach included multimodal chiropractic care, incorporating active release therapy (ART), electroacupuncture, and rehabilitation exercises. The patient’s enhancement in strength and function without the need for surgical intervention underscores the potential role of biologic injections as a non-operative management strategy when integrated with multimodal care to expedite recovery from UCL injuries in elite athletes.

Further research is needed to determine the benefits of combination therapy using traditional rehabilitation, PRP, and MSC on ligament healing time, return to performance, and to help inform sports clinicians on optimal rehabilitation strategies to help athletes return to play efficiently.

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.
[Google Scholar]
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]
7  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]
9. Ahmad CS, Grantham WJ, Greiwe RM. Public perceptions of Tommy John surgery. Phys Sportsmed. 2012 May;40(2):64-72. [Google Scholar]
10. Conte SA, Hodgins JL, ElAttrache NS, Patterson-Flynn N, Ahmad CS. Media perceptions of Tommy John surgery. Phys Sportsmed. 2015 Nov;43(4):375-80. [Google Scholar]
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“. ESPN.com.
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.
18 Lane N, Rees GA, D’Angelo K. Platelet-Rich Plasma (PRP)/stem-cell therapy for a partial torn ulnar collateral ligament in a professional football player: case report. J Can Chiropr Assoc. 2025 Dec;69(4):414-424. Epub 2025 Dec 30.
19 Looney AM, Hanna AJ, Coladonato C, Sonnier JH, Bodendorfer BM, Anderson CG, Sarna N, Freedman KB, Ciccotti MG, Ciccotti MC, Erickson BJ. Elbow Ulnar Collateral Ligament Reconstruction and Repair: A Systematic Review and Meta-analysis of Biomechanical Studies. Orthopaedic Journal of Sports Medicine. 2026 Jan;14(1):23259671251407657. [Google Scholar]
20 Kriz PK, Staffa SJ, Kriz JP, Kocher MS. Early-career ulnar collateral ligament reconstruction in elite baseball pitchers: impact on professional career performance, longevity, and earning potential. JSES international. 2025 Oct 15. [Google Scholar]