Tommy John Surgery: What Is It?

Medically Reviewed by Zilpah Sheikh, MD on December 09, 2023
7 min read

Tommy John surgery repairs a torn ulnar collateral ligament (UCL), which is located inside your inner elbow. This ligament connects the bone of your upper arm (humerus) to a bone in the forearm (ulna) and helps keep your elbow stable.

When your UCL is torn, you may feel pain, have less motion in your elbow, or can't throw a ball as hard and fast as you normally can—or at all.

College and pro athletes who play sports that involve overhead throwing are more likely to have a Tommy John injury. Baseball pitchers, who must repeat this motion many times each game, are the athletes who most often need this surgery.

During Tommy John surgery, an orthopedic or a sports medicine surgeon replaces your torn UCL with a tendon taken from somewhere else in your body, usually your forearm or hamstrings. The goal is to stabilize your elbow so you have little to no pain and can move your elbow through a normal range of motion. Athletes often have this surgery so they can return to playing their sport.

Why is it called Tommy John surgery?

UCL tears used to end the careers of professional athletes. In 1974, Frank Jobe, MD, did the first surgery of this type on a well-known Major League Baseball pitcher, Thomas ("Tommy") Edward John Jr. After sitting out for a season, John became the first professional baseball pitcher with a UCL tear to return to the game.

Overuse injuries, which develop gradually, are the most common type of injuries that require Tommy John surgery. These injuries happen when you do the same motions over and over, such as throwing a ball. The stress caused by the repeated motion can eventually cause your UCL to stretch or tear partly or completely.

Traumatic injuries, such as falling onto your outstretched arm when you're playing a contact sport, can tear your UCL or cause it to break away from your humerus. This can chip off a small piece of bone, which is called an avulsion fracture. Traumatic UCL injuries are rare, but when they happen, they can also dislocate or fracture your elbow.

Anyone can get a Tommy John injury, but most of the time, they happen to people who play sports that involve overhead throwing.

If you play one of these sports for fun, you can likely recover from a UCL injury with rest and other nonsurgical treatments such as physical therapy. But pro or college athletes, who regularly stress their UCLs over long periods, often need Tommy John surgery to continue playing their sport.

Besides baseball, sports that can cause Tommy John injuries include:

  • Javelin throw
  • Racquet sports like tennis
  • Softball
  • Football
  • Wrestling
  • Cheerleading

Symptoms associated with a Tommy John injury include:

  • Feeling one sudden pop inside your elbow during a pitch and losing your ability to throw right afterward
  • Pain on the inside of the elbow that gets worse over time
  • A sense of looseness or instability in the elbow
  • Irritation of the funny bone (ulnar nerve)—you will probably feel this as tingling or numbness in your small finger and ring finger.
  • Loss of pitching strength and speed in athletes

Only rarely do UCL injuries interfere with activities that don't involve a throwing motion, such as:

  • Everyday tasks
  • Exercising
  • Lifting weights
  • Batting in baseball
  • Running

A doctor specializing in orthopedics or sports medicine can often diagnose a UCL injury by reviewing your medical history and doing a physical examination.

During the physical exam, your doctor will probably:

  • Measure range of motion in your shoulder, cervical spine (neck area), and elbow
  • Do a valgus stress test, where they test joint stability by pressing on your elbow to see if this causes pain
  • Tap the skin over your ulnar nerve, or funny bone, to see if you feel tingling or numbness, which is called a Tinel sign

They may do other tests, including:

  • X-rays of both elbows, to compare the injured and uninjured sides
  • Ultrasound of your elbow
  • MRI, which can help them learn whether your UCL is partly or fully torn
  • MRI with contrast, which involves injecting gadolinium dye into your elbow to help the radiologist see your elbow structures more clearly

Tommy John surgery is most often recommended for athletes who:

  • Have a complete UCL tear caused by overuse
  • Aren't helped by nonsurgical treatments
  • Want to resume competitive sports involving strenuous overhead or throwing activities

Your doctor will first do a physical exam and diagnostic tests to learn whether your UCL is stretched or partly or completely torn.

If your UCL is stretched or partly torn, you may start with nonsurgical therapies like:

  • Rest
  • Ice
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen
  • Physical therapy that doesn't involve throwing to strengthen muscles around your injured UCL

Your doctor will probably ask you whether you play sports competitively, whether you wish to continue, and how fast you want to return to play.

Your answers will help them decide whether to recommend surgical or nonsurgical treatment. It can take up to a year to recover from Tommy John surgery. About 85% of pitchers with partial tears can return to the game after nonsurgical treatment.

As your Tommy John surgery begins, your anesthesiologist will give you general anesthesia, which will make you sleep and keep you from feeling pain. Then, your surgeon may use a technique called elbow arthroscopy to see if you have injuries elsewhere in your elbow joint. If so, they may decide to repair those during the same procedure.

Your surgeon will then remove a tendon from somewhere in your body, most often your forearm, hamstrings (located at the back of your knee), or big toe. These harvested tendons are called “grafts.” Sometimes, surgeons use a tendon from the body of someone who has died.

Next, your surgeon will:

  • Make a cut on the inside of your elbow, split open the surrounding muscle, and remove any damaged tissue.
  • Drill small holes in your forearm bone (ulna) and upper arm bone (humerus).
  • Fix the graft inside your elbow by threading the donor tendon through the holes.
  • Suture, or stitch, the graft in the right position.
  • Test the strength of your graft.
  • Use stitches to close your muscle and skin.
  • Apply a clean surgical dressing.
  • Put your elbow into a hard splint that covers your arm from above your elbow to your palm underneath your fingertips. This limits your movement and supports your elbow.

It usually takes surgeons about 60-90 minutes to reconstruct a UCL tear. Your surgery may last longer if you need other repairs.

UCL reconstruction surgical techniques

Your surgeon can use several different techniques to secure the graft when repairing your UCL. The most common ones are:

  • Jobe technique (Figure of 8 graft): The donor tendon is inserted in a figure-8 pattern and then stitched to the bones.
  • Docking technique (triangular graft): In this case, fewer holes need to be drilled in the bone, and the graft is shaped more like a triangle. This technique is commonly used for pro baseball players.

Tommy John surgery success rate

Surgeons usually judge the success of Tommy John surgery based on your ability to return to playing your sport. Between 80% and 95% of professional baseball players can return to play after this procedure.

A recent study found that the success rates of the figure-8 and docking techniques are about the same. But your age, what kind of rehabilitation you do, and the kind of throwing your sport involves can affect the success of your surgery.

Your surgeon will keep your arm in the long-arm hard splint for 1-2 weeks. At the first visit after your surgery, they'll replace it with a brace that allows you to do gentle range-of-motion exercises. You'll work with a physical therapist to do these exercises using your wrist, hand, and shoulder.

A month to 6 weeks after surgery, your physical therapist will help you start doing exercises to strengthen your arm and shoulder. About 4 months after the surgery, baseball players usually begin a supervised throwing program.

The most common complication of this surgery is damage to the ulnar nerve, which affects about 12% of people. Other complications can include infection of the operated area and numbness around the incision.

Recovering from Tommy John surgery usually takes between 12 and 18 months. How fast you can return to play depends on your circumstances, including your sport and position. For example, baseball pitchers often take longer to return to play than those with field positions.