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Ulnar Collateral Ligament Injury (Tommy John Injury)

Medial UCL valgus instability in overhead athletes: moving valgus/milking exam, stress US/MRI, non-operative rehab, UCL reconstruction (docking/modified-Jobe) and repair with internal brace.

Overview

Ulnar collateral ligament (UCL) injury, once considered a career-ending event for overhead athletes, now allows a highly likely return to previous or higher levels of participation following reconstruction [5]. For athletes failing nonsurgical management, UCL reconstruction is a viable option to return to competition [1]. While primary reconstruction remains the standard, MUCL repair has emerged as a viable alternative to reconstruction in select indications [30].

Primary Reconstruction: Hybrid fixation techniques result in low complication rates and allow full recovery to preinjury performance levels in the majority (85%) of patients [3]. Outcomes in javelin throwers are good with a low rate of reinjury or reoperation [15]. Augmented Repair: UCL repair with suture augmentation may be superior to reconstruction for patients with proximal or distal tears and good quality tissue, offering biomechanical advantages and excellent return to sport rates [14]. This approach is also a potentially viable option for younger patients with acute proximal or distal UCL insertion injuries [7]. Augmented repair offers a quicker return to sport at 6 months on average and high rates of return to play (0.90) for appropriate candidates [8]. Internal Bracing: Full activity is allowed at 6 months and participation in contact sports at 1 year following UCL repair with an internal brace [2]. The shoelace repair with internal bracing technique may be useful for UCL instability along with Little League elbow [6].

Revision UCL reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction [4]. Despite this, UCL repair is safe and effective, characterized by low complication rates and high rates of return to sport [9].

Anatomy & Pathophysiology

Ligamentous Stability and Biomechanics

Isolated transection of the anterior bundle of the ulnar collateral ligament (UCL) demonstrates a significant contribution to medial elbow stability [16]. UCL dysfunction increases equivalent stress on the humeral capitellum under elbow valgus stress with the elbow flexed at 90 degrees and the forearm in a neutral position [22]. The moving valgus stress test produces more UCL change in length during extension than during flexion, whereas neither static testing nor flexion movement creates the same biomechanical environment as extension for the ligament [20]. In professional baseball players, the dominant arm UCL demonstrates increased thickness, a larger joint space gap on gravity stress, and lower elasticity on shear wave elastography compared to the nondominant arm [27].

Reconstruction Biomechanics

Regarding surgical technique, there is no significant biomechanical advantage of one UCL reconstruction method over another regarding contact forces and valgus stability in the posteromedial compartment [17]. Utilization of an anatomic tunnel location in UCL reconstruction has similar biomechanical properties compared to the traditional method at the time of initial fixation [12], with ulnohumeral joint gapping and resistance to valgus stress being similar between anatomic and docking techniques [28]. Bisuspensory fixation restores valgus laxity to the native state with load-to-failure biomechanical properties comparable to the docking technique [29]. Both UCL repair with internal brace augmentation and traditional reconstruction restore elbow joint torque and stiffness to levels not statistically different from the intact state [11]. Biomechanical comparison of docking UCL reconstruction with and without an internal brace evaluated time-zero performance compared to native UCL properties [21]. Repair with internal bracing and reconstruction with a posterolateral band of the lateral ulnar collateral ligament (LUCL) showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability [23]. A percutaneous lateral UCL reconstruction procedure provides isometry over the range of motion and sufficiently restores posterolateral rotatory stability comparable to the intact situation and open reconstruction [25].

Post-Operative Kinematics and Rehabilitation

Elbow extension, elbow velocity, and shoulder velocity differed between pitchers with a recent history of UCL repair and a matched control group, though there were no differences in ball velocity or passive range of motion between these groups [26]. Use of a radar gun to guide partial-effort throwing during rehabilitation may protect the reconstructed elbow from excess medial torque [24].

Classification

Surgical Modality Selection: Nonoperative management is indicated for low-grade partial tears of the UCL [10]. UCL reconstruction is the gold standard for complete tears of the UCL [10]. Ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition when nonsurgical management fails [1].

Repair Techniques: Full activity is allowed at 6 months following ulnar collateral ligament repair with an internal brace, with participation in contact sports permitted at 1 year [2]. The shoelace repair with internal bracing technique may be useful in the treatment of UCL instability along with a Little League elbow in throwing athletes [6]. Suture tape augmentation is proposed as a potentially viable option for younger patients with acute proximal or distal UCL insertion injuries [7]. Both UCL repair with internal brace augmentation and traditional reconstruction restored elbow joint torque and stiffness to levels not statistically different from the intact state [11]. Utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties compared to the traditional method at the time of initial fixation [12]. UCL repair with internal brace provided consistent results among several surgeons when compared with a single surgeon [31].

Reconstruction Outcomes: Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate [3]. Ulnar collateral ligament reconstruction based on a hybrid fixation technique allows full recovery to preinjury level of performance in the majority (85%) of patients [3]. Development and continued evolution of UCL reconstruction have made return to previous or higher level of athletic participation in sports highly likely for overhead athletes [5].

Revision Considerations: Revision ulnar collateral ligament reconstruction is a rare procedure [4]. Outcomes of revision ulnar collateral ligament reconstruction are not as promising as primary reconstruction [4]. Revision UCL reconstruction showed relatively high return to play rates (77%) in professional baseball [13]. Only 55% of professional baseball players returned to their same level of play following revision UCL reconstruction [13].

Other Considerations: Isolated transection of the anterior bundle of the UCL demonstrates its significant contribution to medial elbow stability [16].

Clinical Presentation

The clinical presentation of ulnar collateral ligament (UCL) injury in overhead athletes has evolved from a career-ending diagnosis to a condition where return to previous or higher levels of participation is highly likely [5]. While injury to the UCL was once considered definitive for career termination, the continued evolution of UCL reconstruction has significantly altered outcomes [5]. Treatment strategies depend strictly on the type of tear, with nonoperative management indicated for low-grade partial tears [10]. Conversely, UCL reconstruction remains the gold standard for complete tears of the UCL [10].

Diagnosis and Stability: The anterior bundle of the UCL contributes significantly to medial elbow stability, as evidenced by increased ulnohumeral gapping following its isolated transection [16]. Proper diagnosis is paramount, particularly for revision cases where outcomes are less promising than primary reconstruction [4]. Revision UCL reconstruction is a rare procedure with return to play rates of 77%, though only 55% of players return to their same level of play [13]. Success in revision cases relies on proper diagnosis, surgical technique, and rehabilitation [4].

Surgical Options and Outcomes: For appropriate candidates, UCL repair with suture augmentation offers biomechanical advantages and excellent return to sport rates [14]. This technique may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue [14]. Augmented UCL repair provides a quicker return to sport at 6 months on average and high rates of return to play (0.90) [8]. UCL repair is safe and effective with low complication rates and high return to sport rates [9]. For younger patients with acute proximal or distal UCL insertion injuries, elbow UCL reconstruction using suture tape augmentation is a potentially viable option [7]. The Shoelace repair with internal bracing technique may be useful for UCL instability in throwing athletes, including those with Little League elbow [6].

Rehabilitation and Return to Activity: Failing nonsurgical management, UCL reconstruction is a viable option to return the throwing athlete to competition [1]. Full activity is permitted at 6 months following UCL repair with an internal brace, with participation in contact sports allowed at 1 year [2]. Hybrid fixation techniques result in low complication rates and allow full recovery to preinjury performance levels in the majority (85%) of patients [3]. UCLR in javelin throwers results in good outcomes and a low rate of reinjury or reoperation [15]. Anatomic tunnel locations in UCL reconstruction demonstrate biomechanical properties similar to traditional methods at initial fixation [12], with both anatomic and traditional tunnel methods restoring elbow joint torque and stiffness to levels not statistically different from the intact state [11]. UCLR provides excellent patient-reported and clinical outcomes with low complication and revision rates at medium-term follow-up [19].

Investigations

Plain radiography: While specific radiographic signs are not detailed in the provided evidence base, imaging is utilized to assess elbow stability and bony anatomy. The development and continued evolution of UCL reconstruction have made return to previous or higher level of athletic participation in sports highly likely for overhead athletes [5].

MRI: The MRI grading system for UCL injury demonstrated a significant correlation with valgus stability evaluated with stress US [33]. Better correlation between the MRI grading system and valgus stability was observed using microscopic MRI [33].

Other Considerations: Treatment of UCL injuries depends on the type of tear [10]. Nonoperative management is indicated for low-grade partial tears of the UCL [10], whereas UCL reconstruction is the gold standard for complete tears of the UCL [10]. The increase in ulnohumeral gapping with isolated transection of the anterior bundle of the UCL demonstrates its significant contribution to medial elbow stability [16].

Surgical Management and Outcomes: Ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition when nonsurgical management fails [1]. Full activity is allowed at 6 months following ulnar collateral ligament repair with an internal brace, with participation in contact sports permitted at 1 year [2]. Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate and allows full recovery to preinjury level of performance in the majority (85%) of patients [3]. Revision ulnar collateral ligament reconstruction is a rare procedure, yet outcomes are not as promising as primary reconstruction [4]. Revision UCL reconstruction showed relatively high return to play rates (77%), but only 55% of players returned to their same level of play following revision UCL reconstruction [13].

Repair Techniques: The shoelace repair with internal bracing technique may be useful in the treatment of UCL instability along with a Little League elbow in throwing athletes [6]. Elbow ulnar collateral ligament reconstruction using suture tape augmentation is a potentially viable option for younger patients with acute proximal or distal UCL insertion injuries [7]. Augmented UCL repair offers a quicker return to sport at 6 months on average and has high rates of return to play (.90%) for appropriate candidates [8]. UCL repair is safe and effective, with patients having low complication rates and high rates of return to sport [9]. UCL repair with suture augmentation may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue, demonstrating excellent return to sport rates and biomechanical advantages [14].

Biomechanics: Both traditional Jobe bone tunnel and ISR procedures restored elbow joint torque and stiffness to levels not statistically different from the intact state [11]. Utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties compared to the traditional method at the time of initial fixation [12]. There is no significant biomechanical advantage of one UCL reconstruction technique over another [17]. However, the failure strength and initial and overall stiffness of a traditional Jobe bone tunnel UCL reconstruction are superior to those of an ISR, with only traditional Jobe bone tunnel reconstruction reproducing the initial and overall stiffness of an intact UCL [34].

Treatment

Non-Operative

Nonoperative management is indicated for low-grade partial tears of the UCL [10]. Surgical intervention is considered a viable option to return the throwing athlete to competition when nonsurgical management fails [1].

Operative

Indications: Treatment of UCL injuries depends on the type of tear [10]. UCL reconstruction is the gold standard for complete tears of the UCL [10]. Elbow ulnar collateral ligament reconstruction using suture tape augmentation is a potentially viable option for younger patients with acute proximal or distal UCL insertion injuries [7]. UCL repair with suture augmentation may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue [14].

Surgical Approach / Technique: The shoelace repair with internal bracing technique may be useful in the treatment of UCL instability along with a Little League elbow in throwing athletes [6]. Both UCL repair with internal brace augmentation and traditional reconstruction restored elbow joint torque and stiffness to levels not statistically different from the intact state [11]. Utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties compared to the traditional method at the time of initial fixation [12]. There is no significant biomechanical advantage of one UCL reconstruction technique over another regarding contact forces and valgus stability in the posteromedial compartment of the elbow [17].

Implant Selection: Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate [3]. Augmented UCL repair offers a quicker return to sport at 6 months on average [8].

Pain Management: No specific evidence regarding analgesia regimens is provided in the source bullets.

Adjuncts: No specific evidence regarding tourniquet, tranexamic acid, drains, navigation, or robotics is provided in the source bullets.

Setting of Care: No specific evidence regarding outpatient versus inpatient settings is provided in the source bullets.

Revision: Revision ulnar collateral ligament reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction [4]. Proper diagnosis, surgical technique, and rehabilitation are paramount for revision ulnar collateral ligament reconstruction [4].

Other Considerations: Full activity is allowed at 6 months following ulnar collateral ligament repair with an internal brace, with participation in contact sports permitted at 1 year [2]. Ulnar collateral ligament reconstruction based on a hybrid fixation technique allows full recovery to preinjury level of performance in the majority (85%) of patients [3]. Augmented UCL repair has high rates of return to play (.90%) for appropriate candidates [8]. UCL repair is safe and effective, with patients having low complication rates and high rates of return to sport [9]. Development and continued evolution of UCL reconstruction have made return to previous or higher level of athletic participation in sports highly likely for overhead athletes [5].

Complications

Return to Sport and Functional Outcomes: While UCL injury was historically considered career-ending, reconstruction has made return to previous or higher levels of athletic participation highly likely [5]. Failing nonsurgical management, UCL reconstruction remains a viable option for returning throwing athletes to competition [1]. UCL repair is safe and effective, characterized by low complication rates and high return-to-sport rates [9]. Augmented UCL repair offers a quicker return to sport at 6 months on average with high rates of return to play (0.90) for appropriate candidates [8]. UCLR in javelin throwers results in good outcomes with a low rate of reinjury or reoperation [15]. At medium-term follow-up, UCLR provides excellent patient-reported and clinical outcomes with low complication and revision rates [19].

Revision and Reoperation: Revision UCL reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction [4]. Revision UCL reconstruction showed relatively high return to play rates (77%), but only 55% of players returned to their same level of play [13]. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft [32].

Technique-Specific Considerations: UCL reconstruction based on a hybrid fixation technique results in a low complication rate [3]. Treatment of UCL injuries depends on the type of tear, with nonoperative management for low-grade partial tears and UCL reconstruction as the gold standard for complete tears [10]. UCL repair with suture augmentation may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue, demonstrating excellent return to sport rates and biomechanical advantages [14]. The authors propose suture tape augmentation as a potentially viable option for younger patients with acute proximal or distal UCL insertion injuries [7]. UCL repairs have increased over the study period, while rates of UCL reconstruction as compared to rates of UCL repair did not increase significantly [35].

Other Considerations: No specific data regarding infection, aseptic loosening, instability, periprosthetic fracture, thromboembolism, patellar/extensor-mechanism issues, stiffness/arthrofibrosis, nerve palsy, wound complications, or polyethylene wear is provided in the source evidence for this section.

Recovery

Light activity (weeks): Nonoperative management is indicated for low-grade partial tears of the UCL [10], whereas surgical intervention typically follows failed nonsurgical management [1]. Following ulnar collateral ligament repair with an internal brace, full activity is permitted at 6 months [2]. Augmented UCL repair offers a quicker return to sport with an average of 6 months [8].

Full activity (months): Participation in contact sports is allowed at 1 year following ulnar collateral ligament repair with an internal brace [2]. The shoelace repair with internal bracing technique may be useful in the treatment of UCL instability along with a Little League elbow in throwing athletes [6]. UCL repair is safe and effective with low complication rates [9] and demonstrates high rates of return to sport [9]. Augmented UCL repair has high rates of return to play (0.90) for appropriate candidates [8].

Complete recovery / outcome plateau (months): Ulnar collateral ligament reconstruction based on a hybrid fixation technique allows full recovery to preinjury level of performance in 85% of patients [3]. Development and continued evolution of UCL reconstruction have made return to previous or higher level of athletic participation in sports highly likely for overhead athletes [5]. UCL reconstruction in javelin throwers results in good outcomes with a low rate of reinjury or reoperation [15]. Revision UCL reconstruction showed relatively high return to play rates of 77% in professional baseball players, though only 55% returned to their same level of play [13].

Rehabilitation protocol: Proper diagnosis, surgical technique, and rehabilitation are paramount for revision ulnar collateral ligament reconstruction [4]. Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate [3].

Functional milestones: Revision ulnar collateral ligament reconstruction is a rare procedure [4], and outcomes are not as promising as primary reconstruction [4]. Media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have influenced the game of baseball and players' decisions to return to sport [18].

Other Considerations: UCL reconstruction is the gold standard for complete tears of the UCL [10].

Key Evidence

  • [L5] Failing nonsurgical management, ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition. (10.5435/jaaos-22-05-315)
  • [L4] Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate and allows full recovery to preinjury level of performance in the majority (85%) of patients. (10.1177/0363546510385401)
  • [L5] Revision ulnar collateral ligament reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction; proper diagnosis, surgical technique, and rehabilitation are paramount. (10.5435/jaaos-d-16-00341)
  • [L4] Although injury to the UCL was once a career-ending injury in overhead athletes, development and continued evolution of UCL reconstruction have made return to previous or higher level of athletic participation in sports highly likely. (10.1177/0363546508319053)
  • [Paper] This technique may be useful in the treatment of UCL instability along with a Little League elbow in throwing athletes. (10.1016/j.eats.2021.04.008)
  • [L5] The authors propose this method as a potentially viable option for younger patients with acute proximal or distal UCL insertion injuries. (10.1016/j.xrrt.2020.12.005)
  • [L5] Augmented UCL repair offers a quicker return to sport at 6 months on average with high rates of return to play (.90%) for appropriate candidates. (10.5435/jaaos-d-24-00839)
  • [L4] It also found that UCL repair is safe and effective, with patients having low complication rates and high rates of return to sport. (10.1016/j.xrrt.2025.05.020)
  • [L5] Treatment of UCL injuries depends on the type of tear, with nonoperative management for low-grade partial tears and UCL reconstruction as the gold standard for complete tears. (10.1016/j.arthro.2020.02.022)
  • [L5] Both procedures also restored elbow joint torque and stiffness to levels not statistically different from the intact state. (10.1177/23259671211001069)
  • [L5] These results suggest that utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties compared to the traditional method at the time of initial fixation. (10.1177/2325967121s00550)
  • [L4] Revision UCL reconstruction showed relatively high RTP rates (77%), but only 55% of players returned to their same level of play. (10.1177/2325967119864104)
  • [L5] UCL repair with suture augmentation may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue, demonstrating excellent return to sport rates and biomechanical advantages. (10.1016/j.arthro.2023.10.041)
  • [L4] UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. (10.1016/j.jse.2021.10.003)
  • [L5] The increase in ulnohumeral gapping with isolated transection of the anterior bundle of the UCL demonstrates its significant contribution to medial elbow stability. (10.1016/j.jse.2018.11.060)
  • [L2] There is no significant biomechanical advantage of one UCL reconstruction technique over another. (10.1016/j.arthro.2014.04.057)
  • [L4] On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport. (10.1016/j.jor.2020.03.049)
  • [L4] UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. (10.1136/jisakos-2021-000614)
  • [L5] Neither static testing nor flexion movement creates the same biomechanical environment as extension. (10.1016/j.jse.2019.12.025)
  • [L5] The study evaluated the time-zero biomechanical performance of UCL docking reconstruction with and without an internal brace compared to native UCL properties. (10.1016/j.jse.2019.04.061)
  • [L5] Under elbow valgus stress with elbow flexion of 90 degrees and the forearm in the neutral position, ulnar collateral ligament dysfunction increased equivalent stress on the humeral capitellum during the finite element analysis. (10.1016/j.jseint.2020.10.022)
  • [L5] Repair-IB and Recon-PL of the LUCL showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability to the native state in a cadaveric model. (10.1177/03635465231157735)
  • [L5] Use of a radar gun to guide partial-effort throwing during throwing rehabilitation programs may protect the reconstructed elbow from excess medial torque. (10.1016/j.jse.2019.08.014)
  • [L5] In an in vitro setup, the new percutaneous procedure provides isometry over the range of motion and sufficiently restores posterolateral rotatory stability comparable to the intact situation and open reconstruction. (10.1007/s00167-012-2019-1)
  • [L3] Elbow extension, elbow velocity, and shoulder velocity differed between pitchers with a recent history of UCL repair and a matched control group, but it is unclear whether this has clinical significance, as there were no differences in ball velocity and passive range of motion. (10.1177/2325967119866199)
  • [L3] In professional baseball players, the elbow UCL of the dominant arm demonstrated increased thickness, with a larger joint space gap on gravity stress and lower elasticity in SWE as compared with the nondominant arm. (10.1177/23259671221138134)
  • [L5] Ulnohumeral joint gapping and resistance to valgus stress were similar between the anatomic technique and the docking technique for UCLR. (10.1177/03635465221076149)
  • [L5] The bisuspensory fixation technique is an easily reproducible reconstruction that restores valgus laxity to the native state with comparable load-to-failure biomechanical properties as the docking technique. (10.1177/0363546513481957)
  • [L4] MUCL repair has emerged as a viable alternative to reconstruction in select indications, potentially offering quicker return to sport and fewer complications. (10.1016/j.asmr.2020.12.004)
  • [L5] UCL repair with internal brace provided consistent results among several surgeons when compared with a single surgeon. (10.1177/23259671221134829)
  • [L4] The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature. (10.1016/j.jse.2023.10.023)
  • [L4] The MRI grading system for UCL injury demonstrated a significant correlation with valgus stability evaluated with stress US, with better correlation observed using microscopic MRI. (10.1016/j.jseint.2021.05.011)
  • [L5] The failure strength and initial and overall stiffness of a traditional Jobe bone tunnel UCL reconstruction are superior to those of an ISR, and only traditional Jobe bone tunnel reconstruction reproduces the initial and overall stiffness of an intact UCL. (10.1016/j.arthro.2006.09.004)
  • [L3] UCL repairs have increased over the study period, while rates of UCL reconstruction as compared to rates of UCL repair did not increase significantly. (10.1016/j.arthro.2019.11.083)

References

[1] Ulnar Collateral Ligament Injuries in the Throwing Athlete. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-05-315

[2] Ulnar Collateral Ligament Repair with an Internal Brace. 2020.

[3] Long-Term Results of Ulnar Collateral Ligament Reconstruction in Throwing Athletes Based on a Hybrid Technique. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510385401

[4] Revision Ulnar Collateral Ligament Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00341

[5] The Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508319053

[6] Elbow Ulnar Collateral Ligament Shoelace Repair with Internal Bracing for Treating Throwing Athletes Who Have Ulnar Collateral Ligament Instability. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.04.008

[7] Elbow ulnar collateral ligament reconstruction using suture tape augmentation. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2020.12.005

[8] Current Concepts in the Surgical Management of Elbow Medial Ulnar Collateral Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00839

[9] Elbow ulnar collateral ligament repair: a systematic review of trends and outcomes. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.05.020

[10] Elbow Ulnar Collateral Ligament Injuries: Indications, Management, and Outcomes. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.02.022

[11] The Effect of Ulnar Collateral Ligament Repair With Internal Brace Augmentation on Articular Contact Mechanics: A Cadaveric Study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211001069

[12] Paper 12: Biomechanical Comparison of Anatomic Restoration of the Ulnar Footprint Versus Traditional Ulnar Tunnels in Ulnar Collateral Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00550

[13] Revision Ulnar Collateral Ligament Reconstruction in Professional Baseball: Current Trends, Surgical Techniques, and Outcomes. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119864104

[14] Editorial Commentary : Ulnar Collateral Ligament Repair With Suture Augmentation May Be Superior to Reconstruction for Proximal or Distal Tears With Good‐ Quality Tissue. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.10.041

[15] Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.10.003

[16] Medial elbow stability assessment after ultrasound-guided ulnar collateral ligament transection in a cadaveric model: ultrasound versus stress radiography. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.060

[17] Impact of Distal Ulnar Collateral Ligament Tear Pattern on Contact Forces and Valgus Stability in the Posteromedial Compartment of the Elbow. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.04.057

[18] A qualitative assessment of return to sport following ulnar collateral ligament reconstruction in baseball players. Journal of Orthopaedics. 2020. DOI: 10.1016/j.jor.2020.03.049

[19] Ulnar collateral ligament reconstruction of the elbow at minimum 48-month mean follow-up demonstrates excellent clinical outcomes with low complication and revision rates: systematic review. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2021-000614

[20] The moving valgus stress test produces more ulnar collateral ligament change in length during extension than during flexion: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.025

[21] Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.061

[22] Ulnar collateral ligament dysfunction increases stress on the humeral capitellum: a finite element analysis. JSES International. 2021. DOI: 10.1016/j.jseint.2020.10.022

[23] Biomechanical Stability of Lateral Ulnar Collateral Ligament Reconstruction and Repair of the Elbow: The Role of Ligament Bracing on Gap Formation and Stabilization. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231157735

[24] Importance of radar gun inclusion during return-to-throwing rehabilitation following ulnar collateral ligament reconstruction in baseball pitchers: a simulation study. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.08.014

[25] Percutaneous lateral ulnar collateral ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2019-1

[26] Baseball Pitching Biomechanics Shortly After Ulnar Collateral Ligament Repair. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119866199

[27] Assessment of the Ulnar Collateral Ligament of the Elbow Using Ultrasonic Shear Wave Elastography in Professional Baseball Players. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221138134

[28] Comparison of a Novel Anatomic Technique and the Docking Technique for Medial Ulnar Collateral Ligament Reconstruction. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221076149

[29] Ulnar Collateral Ligament Reconstruction Using Bisuspensory Fixation. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513481957

[30] Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2020.12.004

[31] Intersurgeon Consistency of Ulnar Collateral Ligament Repair With Internal Brace: A Biomechanical Analysis. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221134829

[32] Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.10.023

[33] Validation study of novel grading system for ulnar collateral ligament injury of the elbow with high-resolution magnetic resonance imaging. JSES International. 2021. DOI: 10.1016/j.jseint.2021.05.011

[34] A Biomechanical Comparison of 2 Ulnar Collateral Ligament Reconstruction Techniques. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.09.004

[35] Trends in Medial Ulnar Collateral Ligament Repair and Reconstruction in the United States. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.11.083

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.