What is an ulnar collateral ligament (UCL) injury?

The ulnar collateral ligament (UCL) is tissue or ligament on the inner side of the elbow that help keep the elbow joint intact. The UCL is one of the main stabilizing ligaments in the elbow and is essential for overhead activities like throwing. 

UCL injuries are more common in athletes who take part in sports that require repetitive throwing motions at high velocity – such as pitchers. When the elbow joint is repeatedly stressed, the UCL can stretch or tear making the joint unstable. UCL injuries can cause pain and affect an athlete’s performance long-term if not treated promptly.

The types of UCL injuries are graded depending on severity:

• Grade I – the ligament is stretched, but not torn
• Grade II – the ligament is stretched and partially torn
• Grade III – the ligament is completely torn

UCL injuries can affect athletes at any age but are most likely to affect athletes with closed medial epicondyle growth plates on the inner elbow. Re-injury of the UCL is possible and typically recovery will take longer with each subsequent injury. Depending on the severity of the UCL injury, treatment may include rest, rehabilitation and/or surgery to repair or reconstruct the damaged ligament.

What are signs and symptoms of ulnar collateral ligament injuries? 

The most common symptom of a UCL injury is pain, which typically occurs along the inside of the elbow. This may be a chronic issue – such as recurrent pain for several weeks or months – or a more acute injury occurring after a specific throw or fall. The pain tends to worsen after certain activities like throwing or impact loading.

Other symptoms of UCL injuries may include:

• A sudden “pop” or clicking sound on the inside of the elbow
• Pain when throwing or accelerating the arm forward to throw a ball
• Pain on the inside of the elbow after repeated overhand throws or overhead activity
• Stiffness or swelling in the elbow joint
• Limited range of movement and/or decrease in strength
• Sudden loss of velocity and accuracy in pitchers or an inability to pitch
• Difficulty straightening the arm at the elbow joint
• Numbness or tingling in the pinky and/or ring fingers may be associated with this injury, as the ulnar nerve runs in close proximity to the UCL on the inside of the elbow

UCL injuries can affect anyone, regardless of age. It’s important for children and teens to be evaluated by specially trained orthopedic physicians who are experienced in supporting the bone and joint needs of children and adolescents who are still growing. While CHOP physicians excel at treating pediatric patients, they are also proficient at treating young adult/collegiate athletes with closed growth plates who need dedicated care and treatment. Our experts can evaluate your child’s injury and plan for any treatment needed.

 If a UCL injury is left untreated, the condition generally worsens. 

Testing and diagnosis of UCL injuries

To diagnose a UCL injury, an orthopedic physician will perform a physical exam on your child to check their range of motion, strength and stability of the elbow joint; and identify any weakness, tenderness or swelling. An elbow valgus stress test is often performed to assess if there is pain or instability in the elbow joint. Imaging tests – such as X-ray and MRI – and often used to identify the extent and location of the tear and to rule out other possible causes of elbow pain. 

How are ulnar collateral ligament injuries treated?

Treatment for UCL injuries depends on the severity of the condition. In mild cases, where the UCL is stretched – but not torn – non-surgical treatment is generally recommended. Conversely, when the UCL is completely torn (Grade III injury), surgery is almost always needed. Treatment for a partly torn UCL (Grade II injury) varies and should be determined by a qualified pediatric sports medicine expert.

Non-surgical treatment options for UCL injuries

Conservative treatment is generally recommended for minor UCL sprains and tears, including all Grade I injuries and some Grade II injuries. Treatment typically includes: 

• Rest from all throwing activities for 6 to 12 weeks depending on the severity of the injury, response to treatment and decrease in pain
• Ice to reduce swelling and discomfort
• Anti-inflammatory medications, as needed

Other non-surgical treatments that may be recommended include:

• Bracing to limit motion and provide support for the joint during healing
• Physical therapy and exercises to improve flexibility and strength

Many young athletes with UCL injuries can benefit from continued physical training activities while resting their elbow. Activities like jogging, using a stationary bike, swimming and core strengthening may continue as long as it does not involve the affected joint. Activities to avoid include competitive sports, handstands, push-ups and upper-body weightlifting.

In most cases, patients who have stretched their UCL (Grade I injuries) should be able to return to full competitive play within 10-12 weeks. This may be sooner depending on the patient’s symptoms and if physical therapy functional goals are met. Patients with partially torn UCLs (Grade II injuries) typically require longer to recover, and some may need surgery. Surgery is typically recommended for patients with complete UCL tears (Grade III injuries) to help them to return to their overhead sport(s).

It’s important for kids, teens and young adult athletes with elbow pain to be seen by pediatric sports medicine physicians who have expertise evaluating and treating individuals with bones that are still growing – and who can offer surgical treatment, as well non-surgical options. At Children’s Hospital of Philadelphia (CHOP), our team has decades of experience treating UCL injuries in both pediatric patients with open growth plates and young adult patients with closed growth plates.

Surgical treatment for UCL injuries (“Tommy John Surgery”)

There are two primary surgical treatment for UCL injuries:

• UCL repair
• UCL reconstruction 

When a Grade I UCL injury happens acutely (or quickly), usually due to a specific incident, it may be able to be repaired by reinforcing the ligament with a special suture to allow it to heal with appropriate tension. Typically, patients can recover and return to their sport about 6 months after UCL repair surgery. In some cases, Grade II UCL injuries may also be amendable to this treatment.

For most Grade II and III UCL injuries, UCL reconstruction – also known as “Tommy John surgery” – is recommended. UCL reconstruction surgery involves replacing the torn ligament with a “graft” tendon or ligament from another part of the patient’s own body (autograft) or from a donor (allograft). 

At CHOP, Tommy John surgery is typically an outpatient procedure. It is performed under general anesthesia, and your child can return home the same day.

What happens during UCL reconstruction/Tommy John surgery?

During UCL reconstruction, your child’s surgical team will:

• Sedate your child
• If autograft is selected preoperatively, the surgeon will harvest a tendon or ligament from your child’s wrist or thigh (the best option for your child’s specific case will be discussed with your family before surgery). If allograft is selected, a donor tendon will be used.
• Make a 3- to 4-inch incision on the inside of the elbow
• Examine the nearby nerve
• Carefully dissect the surrounding soft tissues to visualize the region of the torn ligament
• Attach the new graft inside the elbow by:
  • Drilling holes into the upper arm bone (humerus) and ulna bone on the inside forearm
  • Securing the new UCL tendon graft with sutures, screws or buttons

The goal of Tommy John surgery is to stabilize the elbow, eliminate or reduce pain, and restore range of motion. CHOP’s orthopedic surgeons and sports medicine physicians are experts at treating UCL injuries and can guide your family through what to expect at every stage of treatment and recovery. 

Follow-up care for ulnar collateral ligament injuries 

Our orthopedic experts will work with you to create an individualized postoperative treatment plan. The most important thing to remember is that recovery takes time. For UCL reconstruction surgery, recovery typically takes 9 months to a year to return to peak performance. If the patient is a candidate for UCL repair, recovery may be closer to 6-9 months. Most pitchers do not return to competitive pitching before 1-year post-op.

In most cases, rehabilitation after Tommy John surgery involves phases that vary in timing depending on the patient and their rate of healing.

• Phase I – immediately after surgery. The patient’s elbow is bent at a 60- to 90-degree angle and held with a brace. This protects the tissue as it heals and reduces swelling and inflammation. In most cases, physical therapy can begin but should focus on the shoulder, biceps, wrist and fingers.
• Phase II – 1-2 weeks after surgery. Patients can begin to move their elbow joint but will be given a brace and sling to keep the elbow bent at a certain angle when not exercising. During this phase, physical therapy will focus on increasing range of motion at the elbow.
• Phase III – 4-6 weeks after surgery. Patients should now be able to fully extend and bend their arm and elbow and may stop wearing the brace/sling for normal day-to-day activities, unless needed for comfort. With regular physical therapy, most patients can resume their elbow’s full range of movement in 2-4 months.
• Phase IV – 6-12 weeks after surgery. With full range of motion returned, patients can begin focusing on strengthening under the guidance of the sports physical therapy team.
• Phase V – 3-6 months after surgery. This is the advanced strengthening phase where plyometric activity can be introduced under the strict guidance of physical therapy. 

A return to throwing progression typically takes several months and should begin no sooner than the 6-month, post-operative mark for UCL reconstruction surgery.

Recommendations about when your child/teen can return to exercise, activities and sports are different for every patient. It’s important for patients to follow all postoperative instructions and continue a vigorous strengthening and stretching regimen after returning to play.