A grade 1 sprain is when the ligament is stretched, but not torn. A grade 2 sprain is a partial tear of the ligament and there are varying degrees of grade 2 sprains. In general, grade 1 and 2 sprains are treated with a period of no throwing followed by a rehabilitation program. This may take 8- 12 weeks or more. Grade 3 sprains are complete or full thickness tears. These are best treated with reconstruction in baseball players and javelin throwers. There may be a role for repair of the ligament in some younger pitchers (early teens) or female athletes if the ligament tears off the bone. There are studies that have shown good results with direct repair of acute tears in these patients.
UCL Reconstruction or Tommy John Surgery is performed by using a tendon graft to replace the UCL (see pictures of procedure below). The graft is placed through tunnels drilled the Ulna (bottom bone) and in the Humerus (top bone) of the elbow. A graft is a tendon used to replace the torn ligament. The most common graft is the Palmaris tendon, which is obtained from the forearm through a small incision in the wrist. The use of this tendon does not lead to any problems with the arm. Not everyone has a Palmaris tendon. Other graft options include use of a hamstring, toe extensor, or donor tendon (allograft). After the graft is passed into the tunnels and fixed, it is repaired directly to the old UCL to strengthen it. The surgery is done through a 3-4 inch incision on the inner part of the elbow.
The surgery is an outpatient procedure allowing patients to go home the same day and a long arm splint is used to protect the repair for the first week. A brace is applied after the first week and worn until 6 weeks after surgery to protect the reconstruction.
Rehabilitation is started 1 week after surgery and continues until the player is able to pitch approximately 10-12 months after surgery (see UCL reconstruction rehabilitation protocol). The initial phase is aimed at decreasing swelling and restoring range of motion. A throwing program is started at 4 months after surgery if rehabilitation goals are met. Flat ground bullpens are started at 8-9 months and mound pitching is allowed at 9-10 months after surgery.
Dr. Khalfayan’s Tip: It is not uncommon to have ups and downs during the throwing program. It is important to treat pain or soreness when it develops and adjust the throwing program as needed when this occurs. If it does not improve, you should inform your physician.
Incision for UCL Reconstruction
Forceps at the humeral attachment
of the torn UCL (white tissue)
UCL is spread open allowing
view of the joint (black arrow at joint)
With gentle stress, the joint opens up due to the UCL tear
Tunnels drilled in Ulna
Close up of completed tunnels in Ulna
Tunnel drilled in the medial epicondyle of the humerus