How Is Tommy John Surgery Performed?

Tommy John surgery is performed by replacing a torn ulnar collateral ligament in the elbow with a tendon graft taken from the patient’s body or a donor. During the procedure, the surgeon drills small holes into the elbow joint and threads the tendon through them to restore stability. This procedure helps athletes return to throwing activities and recover from UCL injuries that do not respond to nonsurgical care.

At Total Orthopedics & Sports Medicine, Dr. Charles Ruotolo has helped thousands of athletes get back to the sport they love after UCL reconstruction surgery. Instead of following a one-size-fits-all plan, he evaluates your condition and builds a recovery strategy tailored to your activity goals. Call 855-321-6784 to book your appointment today.

How Is the Elbow Repaired With Tommy John Surgery?

During UCL reconstruction, the surgeon removes the damaged ligament and replaces it with a harvested tendon, which is threaded through tunnels drilled into the bones. They begin with a surgical incision along the inner elbow and carefully move the ulnar nerve aside for protection. Then the surgeon drills two or three holes into the surrounding bones to anchor the graft securely. This precise process restores the natural structure of the UCL, also known as the medial collateral ligament.

In fact, according to the American Medical Association, more than 1,000 professional baseball pitchers have undergone Tommy John surgery since 1974. However, the high success rates depend on how accurately the surgeon positions and threads the tendon graft through each bone tunnel in the elbow joint.

Additionally, the success of the surgery depends on the tendon graft chosen for the repair. Usually, the graft is taken from the palmaris longus tendon in your forearm (a tendon your body does not need to function normally). If that tendon is unavailable, surgeons may use a hamstring tendon or a donor tendon from a tissue bank.

When Does a UCL Tear Require Surgery?

You may need UCL surgery if your torn UCL is completely ruptured and no longer responds to rest, bracing, or rehabilitation in 6-12 months. At that point, the damaged tissue simply cannot heal on its own, particularly for baseball pitchers who place intense repetitive strain on their elbow. Because the ligament can no longer hold the elbow joint together, your healthcare provider will recommend surgery to rebuild the stability your elbow has lost.

You may also need Tommy John Surgery in the following situations:

• Your elbow feels unstable during everyday activities, not just during athletic performance.
• You have experienced multiple partial tears over time that have progressively worsened.
• Acute traumatic injuries can result in UCL damage severe enough to require surgical reconstruction.
• You are a young athlete with long-term competitive goals who cannot afford limited elbow function.
• Imaging tests, such as an MRI, confirm a complete rupture with little to no healthy tissue remaining.
• You are experiencing nerve-related symptoms, such as numbness or tingling, alongside joint instability.

At our clinic, we commonly see athletes and active individuals who have been managing elbow pain for months before seeking a surgical evaluation. In these cases, our surgeon, Dr. Charles Ruotolo, carefully reviews each patient’s imaging results, symptom history, and activity level to determine whether surgery is necessary. If you are unsure whether your UCL tear requires surgery, schedule a consultation with Dr. Charles Ruotolo and get a personalized treatment plan.

Dr. Charles Ruotolo’s Personalized Consultation Approach

At many orthopedic practices, your first consultation typically includes a brief physical exam, a printed handout on your diagnosis, and a follow-up appointment scheduled weeks later. At Total Orthopedics & Sports Medicine, we take a direct approach because we know that when your elbow is limiting your game, you cannot afford to wait weeks for a clear answer.

When you call us, our team typically schedules your appointment within the same week. Dr. Charles Ruotolo personally reviews your imaging in detail before you arrive. Moreover, during your appointment, he discusses every finding with you directly. Before you leave, you have a clear diagnosis, a personalized treatment plan, and the clarity that most patients spend months trying to find.

What Tests Help Doctors Plan Tommy John Surgery?

To plan Tommy John Surgery, Dr. Charles Ruotolo orders an MRI scan alongside a thorough physical evaluation of the elbow. The MRI shows the precise extent of the ligament tear and any associated soft tissue damage. On the other hand, the physical examination helps confirm the degree of joint instability. In addition, our surgeon may use the following diagnostic tools to evaluate the full extent of the injury:

• X-rays to detect bone spurs, calcification in the ligament, loose bodies, or stress fractures
• Stress ultrasound to assess how the UCL responds under pressure and detect any abnormal joint opening
• CT scan to evaluate bone structure in more detail when standard imaging is inconclusive
• Valgus stress test to physically assess the integrity and stability of the ligament during movement
• MR Arthrogram in cases when a standard MRI does not provide enough detail about smaller or partial tears

However, not all of these tests are required in every case. Dr. Charles Ruotolo carefully evaluates each patient’s symptoms and activity demands to determine which diagnostic tools are necessary. Together, these findings help him develop a surgical plan that is precise and specific to each individual injury.

What Kind of Anesthesia Is Used During Surgery?

Tommy John Surgery is performed under general anesthesia, which keeps the patient fully unconscious throughout the procedure. In some cases, surgeons may also use a regional nerve block to reduce pain in the elbow and forearm immediately after surgery. This combination helps minimize pain and swelling during the first hours of recovery.

According to a study published in Orthopedic Reviews, regional anesthesia offers precise pain control and reduces opioid consumption. It also enhances postoperative recovery for patients undergoing elbow surgery. Moreover, the nerve block administered during Tommy John Surgery typically remains effective for 12 to 18 hours after the procedure. This provides a smooth, more comfortable transition into early recovery.

Despite these benefits, anesthesia carries some risk. The most commonly reported side effects include nausea, dizziness, and temporary confusion as the patient wakes up from general anesthesia. Because of this, our team monitors each patient closely throughout the procedure and into the early recovery period to ensure these effects are managed safely and promptly.

How Is the Damaged UCL Cleaned Out?

Surgeons remove the damaged UCL by cutting away the torn ligament tissue from its attachment points on the inner elbow bones using specialized tools. During this process, any frayed or degenerated fibers are debrided to create a precise surgical foundation at the medial epicondyle and ulna. This clearing process is essential before bone tunnels can be drilled for the replacement tendon graft in Tommy John surgery (UCL reconstruction).

The extent of this debridement depends on the severity of the ulnar collateral ligament injuries. For example, partial tears may require less tissue removal, as some healthy ligament fibers can be preserved. In contrast, complete ruptures caused by throwing injuries require removing the entire UCL ligament (thick band of ligamentous tissue) from both attachment points on the upper arm bone and the ulna.

Here are the specialized tools surgeons use during ulnar collateral ligament reconstruction:

• Scalpel: Used to make the initial incision and cut away the bulk of the torn ligament tissue from its attachment points at the medial epicondyle
• Rongeurs: Bone-biting instruments to remove small fragments of damaged tissue or bone during elbow surgery
• Curettes: Spoon-shaped tools to scrape away any remaining degenerated fibers and clean the bone surface, reducing the risk of long-term complications
• Periosteal Elevator: Used to carefully lift and separate soft tissue from the bone without causing unnecessary damage to surrounding structures

What Techniques Are Used to Secure the Graft?

Surgeons secure the tendon graft using two primary techniques, the docking technique and the figure-eight technique. In both methods, the graft is threaded through two holes drilled into the upper arm bone and the ulna to hold it firmly in place. However, the choice of technique depends on your specific elbow anatomy and the extent of the ligament damage. Here is how surgeons use each method to secure the graft:

The Docking Technique

In the docking technique, your surgeon loops the tendon graft through converging tunnels drilled into the ulna. Then, they dock the two free ends of the graft into a Y-shaped tunnel in the upper arm bone and tie them securely over a bone bridge using non-absorbable sutures. This method is most widely used in UCL reconstruction because it minimizes disruption to the flexor-pronator mass. Moreover, it reduces the risk of long-term complications.

In fact, according to a 2025 ScienceDirect study, the docking technique now stands as the gold standard in medial ulnar collateral ligament reconstruction. This is due to its reliable results, particularly for professional athletes returning to major league baseball and high-level throwing sports.

The Figure-Eight Technique

In the figure-eight technique, your surgeon threads the tendon graft through tunnels in the ulna and humerus, then loops it back in a continuous figure-eight pattern. This creates a strong, stable structure that recreates the natural path of the ulnar collateral ligament. Surgeons often choose this method based on your elbow anatomy and the specific location of your UCL tear.

How Long Does Tommy John Surgery Usually Take?

Tommy John surgery typically takes 60 to 90 minutes. However, your procedure may take longer if the surgeon identifies and repairs additional elbow injuries during the same session. Once your surgery ends, the medical staff moves you to a recovery room where they monitor you for one to two hours.

During this time, they check your vitals and manage any immediate discomfort before allowing you to go home. Since it is an outpatient procedure, you can return home the same day once the anesthesia wears off. But you will need a trusted person to drive you, as the effects of general anesthesia take time to wear off fully.

How Many Months Does It Take to Heal After Surgery?

Based on our experience, healing after Tommy John surgery typically takes about 12 months for most pitchers. However, your recovery timeline may vary depending on your position and the severity of your injury. The surgeon will keep your arm immobilized for the first 10 days after elbow surgery to protect the new graft. After that, you gradually work toward restoring a full range of motion, within six to eight weeks as rehabilitation progresses.

Here is how our medical team guides your complete recovery after surgery:

• The first week after surgery is all about protection. During this time, your elbow stays secured in a hard splint so your graft can begin healing without disruption.
• As your healing progresses, your arm transitions into a hinged brace for controlled movement.
• By four months, we introduce strengthening exercises to rebuild the power and stability your elbow needs.
• A structured throwing program is introduced gradually when your elbow builds enough strength to handle the repetitive stress of the throwing motion.
• At every stage of recovery, our team monitors your progress to ensure you return to your previous level of play.

What Is the Success Rate of Tommy John Surgery?

In our 30 years of experience, 85-90% of athletes fully recover after Tommy John surgery. In fact, a study published in the American Journal of Sports Medicine found that 83% of MLB pitchers successfully returned to play after this surgery. Besides that, these pitchers performed at a higher level post-surgery than before.

In addition, according to a study published in PubMed Central, 96% of MLB pitchers returned to play after Tommy John surgery, with 82% specifically returning to the major leagues. Another study in ScienceDirect reports that up to 25% of MLB pitchers have undergone ulnar collateral ligament reconstruction, with 89% returning to play and 78% achieving the same level of performance as before their UCL tear.

Can Elbow Surgery Improve Your Throwing Performance?

Yes, elbow surgery can improve your throwing performance. The tendon graft used in ulnar collateral ligament reconstruction is stronger than the original injured ligament. This gives your elbow a more stable foundation. Most baseball players who follow a structured throwing program successfully return to the same level of play.

What Are the Common Risks of Tommy John Surgery?

Ulnar nerve damage is one of the most common risks associated with Tommy John surgery. Additionally, general anesthesia can temporarily impair lung function during the operation. As with all surgical procedures, infection at the surgical site is also a common risk that can develop during the early stages of recovery.

Here are some other risks associated with Tommy John surgery:

• Stiffness and loss of range of motion: Some patients experience lasting tightness in the elbow joint that limits full extension or flexion.
• Graft failure: The tendon graft can stretch, loosen, or tear under excessive stress before it fully integrates with the bone.
• Blood vessel injury: Surrounding blood vessels can be damaged during the drilling of bone tunnels.
• Scar tissue formation: Excessive scar tissue can develop around the surgical site and restrict elbow movement during recovery.
• Re-injury: Returning to throwing activity too soon significantly increases the risk of re-tearing the reconstructed ligament.
• Chronic pain: Some patients experience persistent elbow discomfort that continues well beyond the expected recovery period.

Every surgical procedure carries risk, but experience, precision, and personalized care significantly reduce the risk of complications. With over 30 years of experience in UCL reconstruction, Dr. Charles Ruotolo has helped thousands of patients undergo Tommy John surgery safely and successfully. He evaluates every patient individually and builds a surgical plan tailored to your specific anatomy, health, and recovery goals.

How Much Does Tommy John Surgery Cost?

Tommy John surgery costs between $10,000 and $25,000 in the US without insurance coverage. However, the total cost can be higher depending on the surgeon’s experience, the facility, and whether additional elbow repairs are performed during the same procedure. Most major insurance plans cover UCL reconstruction when it is medically necessary, though your out-of-pocket expenses will vary based on your deductible and coverage plan.

Beyond the surgical fee, your total cost also includes anesthesia, post-operative imaging, and rehabilitation. At Total Orthopedics & Sports Medicine, we coordinate with patients to manage their insurance coverage and identify the most cost-effective treatment path. If you have questions about what your insurance plan covers, call us at 855-321-6784. Our team will help you get the clarity you need before moving forward.

What Non-Surgical Options Do You Have for a UCL Tear?

Our orthopedic specialist may recommend rest and platelet-rich plasma (PRP) injections for a UCL tear before proceeding with surgery. Similarly, an internal brace technique offers a less invasive alternative that supports the ligament without full reconstruction. Depending on your condition, our specialist may also recommend the following non-surgical options:

• Activity modification limits movements that aggravate the injury and allows natural healing.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce pain and swelling during the early recovery phase.
• Corticosteroid injections manage severe inflammation when other conservative treatments fall short.
• Ultrasound therapy uses sound waves to promote tissue healing and reduce elbow pain.
• Ice and heat therapy control swelling and improve blood flow to the injured ligament.

How Does Tommy John Surgery Compare to Non-Surgical Care?

Tommy John surgery is the preferred treatment for complete UCL tears, while non-surgical care is highly effective for patients who seek timely evaluation. Usually, patients who visit us at the first sign of elbow pain respond well to non-surgical treatment and heal through PRP injections, rest, and structured rehab.

On the other hand, patients who delay seeking treatment have advanced ligament damage that cannot heal with non-surgical care. In fact, up to 50% of patients may lose full elbow motion. In such cases, UCL reconstruction is the most effective approach to regain elbow function.

Additionally, the treatment also depends on your activity level. For example, pitchers and overhead-throwing athletes often require surgery for complete tears because their elbows absorb more repetitive stress than position players. However, if you are a non-throwing athlete or an active individual suffering from tennis elbow, you can recover fully through non-surgical care, without spending 12 months in rehabilitation.

Visit Dr. Charles Ruotolo in Syosset for a Second Opinion Before Tommy John Surgery!

You’ve just been told you need Tommy John surgery, and that diagnosis can leave you unsure about your next step. That uncertainty is completely valid because not every UCL injury requires surgery. In this situation, rushing into a major procedure without a second opinion could mean committing to months of unnecessary recovery.

At Total Orthopedics & Sports Medicine, our elbow specialist, Dr. Charles Ruotolo, provides specialized second-opinion evaluations for athletes managing UCL injuries and other elbow conditions. He reviews your imaging, assesses your injury, and provides a treatment recommendation based on your specific condition, not a generalized protocol. Call 855-321-6784 or visit our clinic to schedule your consultation with Dr. Charles Ruotolo.

FAQs