Pro Pitchers: Under the Knife for Medial UCL Injuries?

Tear location matters for medial UCL injury

By Salvatore J. Frangiamore, MD, Michael D. Vaughn, MD, and Mark Schickendantz, MD

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Medial ulnar collateral ligament (UCL) injury of the elbow is increasingly common in professional baseball pitchers. The number of “Tommy John” surgeries in Major League Baseball (MLB) pitchers nearly tripled from 2011 to 2013. The Tommy John procedure, named after the MLB pitcher on whom the surgery was first performed in 1974, involves reconstruction of the medial UCL of the elbow.


Figure 2: T2-weighted coronal fat-suppressed MRI image of the elbow shows disruption of the distal attachment of the anterior bundle of the UCL. Notice the high signal intensity surrounding the torn ligament and within the bone marrow of the ulnar insertion.

Despite the increase in Tommy John surgeries, no clear algorithm has been established for operative versus nonoperative management of these injuries, and predictors of success and failure are not well defined. We decided to approach this question through a retrospective analysis of 32 pitchers from one professional baseball organization who underwent an initial trial of nonoperative treatment for UCL tears.

Predictive model tested

Our study examined how objective measures, including physical exam, MRI characteristics and performance data can predict success or failure of nonoperative management of UCL injuries.

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We analyzed age, preseason physical exam, MRI characteristics and performance metrics in these pitchers. Successful nonoperative management was defined as return to same level of play (RTSP) or higher for greater than one year. Failure was defined as recurrent pain or weakness requiring surgical intervention after a minimum of three months’ rest when attempting a return-to-throw rehabilitation program.

Thirty-four percent of the pitchers failed and required subsequent ligament reconstruction. Sixty-six percent successfully returned to the same level of play for one year without surgical intervention. We saw no significant difference in physical exam findings or performance metrics between these patients.


Figure 1: Likelihood of failing nonoperative management (odds ratio) adjusted for tear location, grade and presence of chronic changes on MRI.

MRI scans reveal that distal tears fare worse

When comparing MRI findings between groups, 82 percent (9 of 11) (P < 0.001) who failed nonoperative management had distal tears and 81 percent (17 of 21) who did not fail had proximal tears (P < 0.001). When adjusting for age, location and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.4 times greater (P = 0.02) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88 percent (7 of 8) failed nonoperative management.

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When to consider nonoperative therapy

We concluded that in professional pitchers, distal UCL tears show significantly higher rates of failure with nonoperative management compared to proximal UCL tears. Thus, tear location should be considered when deciding between operative and nonoperative management of this injury.

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Dr. Frangiamore ( and Dr. Vaughn ( are residents in the Department of Orthopaedic Surgery. Dr. Schickendantz is the Director of Cleveland Clinic Center for Sports Health. He also serves as head team physician for the Cleveland Indians MLB team.