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Tommy John Surgery - Overview of Injury to Recovery

Updated: May 10, 2023

Tommy John surgery is a common surgical procedure used to repair the ulnar collateral ligament (UCL) in the elbow joint. The UCL connects the humerus bone in the upper arm to the ulna bone in the forearm and helps to stabilize the elbow during throwing and other overhead activities.

The surgery is named after former Major League Baseball pitcher Tommy John, who underwent the procedure in 1974 and was able to return to the sport after a lengthy recovery period. Since then, the surgery has become increasingly popular among athletes in a variety of sports, including baseball, gymnastics, weight lifting, and tennis. In this article, we will discuss the structures involved, common ways it is injured and go over surgical techniques used to help repair this important ligament.


The elbow joint is a complex joint that connects the upper arm bone (humerus) to the two bones in the forearm (radius and ulna). The joint is made up of three main bones and several important structures, including muscles, tendons, ligaments, and nerves.

The elbow joint is surrounded by a capsule, which is a tough membrane that helps hold the bones together. Inside the joint, there are several important structures that contribute to the joint's stability and movement. These include the articular cartilage, which is a smooth, shiny material that covers the ends of the bones and helps them move smoothly against each other, and the synovial membrane, which produces synovial fluid to lubricate the joint.

One of the most important structures in the elbow joint for Tommy John surgery is the ulnar collateral ligament (UCL). The UCL is a thick band of tissue that runs from the inner side of the humerus to the inner side of the ulna. It is responsible for providing stability to the elbow joint, particularly during throwing motions.

Other important structures in the elbow joint include the flexor and extensor tendons of the forearm, which are responsible for bending and straightening the elbow, respectively. The radial head, which is the top of the radius bone, also plays an important role in elbow joint stability and movement. The ulnar nerve also runs near this area and can often be stressed with repetitive motions.

Mechanism of Injury

As we stated early, the UCL helps to stabilize the joint during throwing motions. It is commonly injured in overhead athletes, particularly baseball pitchers, due to the high amount of stress placed on the elbow during repetitive throwing motions.

The mechanism of injury for the UCL is often described as a "valgus overload" or "valgus stress" injury. This occurs when the elbow is forcefully bent outwards (away from the body) while simultaneously being rotated, such as during the arm cocking phase of a throwing motion. This causes a significant amount of stress to be placed on the UCL, which can lead to small tears or complete rupture of the ligament.

When the UCL is injured, it can lead to pain, instability, and a decreased ability to throw with speed and accuracy. In some cases, the athlete may be able to manage the symptoms with rest and physical therapy, but in more severe cases, surgery may be necessary.

When we are in pain, we tend to localize our problem to the specific area the pain is coming from. However, much of the abnormal stress happening at the elbow often can be explained by chain reactions starting all the way from your feet to your shoulder. Some of these factors can include lack of thoracic mobility, core weakness, poor scapular rhythm, or bad throwing mechanics. These factors can lead to increased stress on the elbow joint, particularly during the arm cocking and acceleration phases of the throwing motion. Therefore, it's incredibly important to go over all factors when considering why your elbow may be bothering you.

What is Tommy John Surgery

Tommy John surgery is a surgical procedure that is designed to reconstruct the damaged UCL using a graft from another part of the body or a donor. The graft is typically attached to the humerus and ulna bones with screws or other fixation devices and over time, the graft integrates with the existing tissue to form a new UCL.

The rehabilitation process after Tommy John surgery typically involves a gradual progression of exercises designed to restore range of motion, strength, and throwing mechanics. Physical therapy is an important part of the recovery process, and its of vital importance to work closely with a qualified therapist to ensure that they are progressing safely and effectively. It's important you find a therapist that understands the mechanism of injury and the surgical process so you can have a better understanding as what to expect from the procedure and the recovery process.

Do Other Surgical Options Exist?

In recent years, a technique known as "internal brace" has been developed that has shown promising results in improving outcomes after Tommy John surgery.

The internal brace technique involves placing a small, strong suture tape alongside the UCL graft during surgery. This suture tape acts as a reinforcement for the graft, helping to protect it during the early stages of healing and providing additional stability to the elbow joint. The suture tape is anchored to the bones using small metal screws or other fixation devices.

The actual surgical procedure for Tommy John surgery with internal brace is typically performed under general anesthesia and involves several steps:

  1. An incision is made on the inside of the elbow to access the damaged UCL.

  2. The damaged UCL is carefully removed and the bones are prepared to receive the graft.

  3. A graft is harvested from another part of the patient's body (often the forearm or hamstring), or a donor graft may be used.

  4. The graft is carefully threaded through tunnels that have been drilled in the humerus and ulna bones.

  5. The internal brace is attached to the graft using small metal screws or other fixation devices.

  6. The incision is closed with sutures or staples.

After surgery, the patient will typically need to wear a brace for several weeks to allow the graft to heal properly. Physical therapy will look fairly similar to normal UCL surgery and will involve various exercises and modalities to help regain strength, range of motion, and throwing mechanics.

It's important to remember every case is highly unique and should be taken on a case by case basis with your surgeon. This surgery may be a suitable option for athletes who are looking to return to their sport as quickly and safely as possible.

Time To Recovery

The recovery process following Tommy John surgery can be lengthy, and the time frame for returning to throwing can vary depending on a number of factors. In general, over the next several weeks, you can expect to gradually regain mobility in the elbow joint through a series of passive range of motion exercises. These exercises are designed to help prevent the development of scar tissue and to promote healing of the graft. You will also work on building strength in the surrounding muscles, including the shoulder, forearm, and wrist, through a series of resistance exercises. I find this a particular amazing time to work on all of the weaker parts of the athlete that may have existed prior to surgery including core stability, scapular control, and leg strength.

Around the two to three-month mark, you'll typically begin to transition to a more active range of motion and strengthening exercises. This can include the use of bands, cables, or light weights, to improve strength and stability in the elbow joint and surrounding muscles. Throughout this process, you should be working closely with all parties involved (surgeon, therapist, coach, etc) to monitor progress, manage pain and inflammation, and ensure that you are progressing safely and effectively.

Return To Throwing

The amount of time it takes to return to throwing will depend on a number of factors, including swelling, the extent of the UCL injury, and the success of the surgical procedure. The process of returning to throwing after Tommy John surgery is a long and careful one, with the goal of gradually building up the strength and mobility in the elbow joint and surrounding muscles while minimizing the risk of re-injury. Here's a breakdown of the criteria for returning to throwing, as well as some tips for progressing safely and effectively.

Criteria for Returning to Throwing

The criteria typically involve a combination of physical exams, imaging studies, and subjective feedback from the patient, and can vary depending on the patient's individual circumstances.

Basic criteria that must be met before starting a throwing program include:

  • Adequate range of motion in the elbow joint

  • Good shoulder and scapular mobility

  • Adequate strength and stability in the elbow and surrounding muscles

  • No pain or swelling in the elbow joint

  • Full healing of the graft site

Once these criteria have been met, patients can begin a structured throwing program designed to gradually build up their throwing volume and intensity.

Phases and Timelines:

A return to throwing protocol involves several phases, each with its own set of goals and guidelines. The first phase, which lasts for 4-6 weeks, involves gentle range-of-motion exercises and light tossing at a short distance to gradually increase the load on the elbow joint.

The second phase, which lasts for 4-6 weeks, focuses on building strength and endurance in the elbow and surrounding muscles through a combination of throwing exercises and resistance training. During this phase, patients gradually increase their throwing distance and intensity, while also incorporating exercises to improve shoulder and scapular mobility.

The third phase, which lasts for 6-8 weeks, involves more intense throwing exercises designed to mimic game situations, such as long toss and bullpen sessions. Patients continue to work on improving their mechanics and form during this phase and are closely monitored for any signs of pain or discomfort.

Throughout the return to throwing protocol, it cannot be stressed enough the importance of proper mechanics and form to minimize stress on the elbow joint. An underestimated aspect of a good return to throwing protocol is open communication between patients and their medical team. This encourages patients to listen to their bodies and take breaks as needed to avoid overloading the elbow joint. In addition to communication with the patient, the medical providers, strength coaches, and pitching coaches should be on the same page about timelines and setting expectations.

By following a structured return to throwing protocol, patients can gradually build up their strength and endurance, improve their mechanics, and safely return to pitching at 100% capacity.

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