E. Lyle Cain

The ulnar collateral ligament (UCL) is the primary static restraint to valgus stress at the elbow. Since Jobe pioneered reconstruction in 1974, thousands of throwers have undergone UCL reconstruction, and good results have been achieved. The high-profile nature of the elite pitcher has brought this technique into the spotlight, and extensive research has been performed with new techniques emerging. The standard reconstruction, modified only slightly since Jobe's original description, remains the gold standard for treatment of UCL insufficiency. Throwers are able to return to the same or even higher levels of competition in the majority of cases. In this article, we present our standard technique and results and discuss emerging techniques for treatment of UCL injuries.

Background: The anterior bundle of the ulnar collateral ligament (UCL) is the primary anatomical structure providing elbow stability in overhead sports, particularly baseball. Injury to the UCL in overhead athletes often leads to symptomatic valgus instability that requires surgical treatment. Hypothesis: Ulnar collateral ligament reconstruction with a free tendon graft, known as Tommy John surgery, will allow return to the same competitive level of sports participation in the majority of athletes. Study Design: Case series; Level of evidence, 4. Methods: Ulnar collateral reconstruction (1266) or repair (15) was performed in 1281 patients over a 19-year period (1988—2006) using a modification of the Jobe technique. Data were collected prospectively and patients were surveyed retrospectively with a telephone questionnaire to determine outcomes and return to performance at a minimum of 2 years after surgery. Results: Nine hundred forty-two patients were available for a minimum 2-year follow-up (average, 38.4 months; range, 24-130 months). Seven hundred forty-three patients (79%) were contacted for follow-up evaluation and/or completed a questionnaire at an average of 37 months postoperatively. Six hundred seventeen patients (83%) returned to the previous level of competition or higher, including 610 (83%) after reconstruction. The average time from surgery to the initiation of throwing was 4.4 months (range, 2.8-12 months) and the average time to full competition was 11.6 months (range, 3-72 months) after reconstruction. Complications occurred in 148 patients (20%), including 16% considered minor and 4% considered major. Conclusion: 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 previous or higher level of competition in less than 1 year.

The overhead throwing motion generates enormous force in the elbow. Repetitive near failure loads lead to chronic adaptive changes and occasionally acute injury. The physician caring for the thrower must understand the complex anatomy and function of the elbow joint, along with the biomechanics of throwing, to accurately diagnose and treat elbow pathology. Evaluation of elbow pain in the throwing athlete must begin with a thorough and detailed throwing history including duration of symptoms, location of pain, timing during the phases of throwing motion, and associated symptoms. Physical examination should include inspection, range of motion, palpation, and specific tests to better define the pathology. A detailed history and physical examination will allow the astute clinician to obtain the proper diagnosis and start the appropriate operative or nonoperative treatment often without reliance on ancillary testing. Treatment and rehabilitation of these injuries must be tailored to the pathology present and focused towards a return to the athlete's activity.