Tommy John surgical reconstruction for ulnar collateral ligament injuries was first described by Frank Jobe in 1974. Although he estimated the chance for successful return very low, John, famous baseball pitcher, was able to return to play for another 14 years. Modern techniques and better understanding of anatomy and biomechanics have now resulted in a return-to-play rate of more than 80%. Ulnar collateral ligament injuries occur mainly in overhead athletes. Generally, partial tears can be treated nonoperatively, but in baseball pitchers, success rates are less than 50%. Complete tears often require surgery. Primary repair or reconstruction are feasible options, and the choice will depend not only on the clinical scenario, but also the surgeon. Unfortunately, the current evidence is not convincing, and a recent expert consensus study exploring diagnosis, treatment options, rehabilitation, and return to sports showed agreement among the experts, but not necessarily a consensus.

To establish consensus statements on the treatment of ulnar collateral ligament (UCL) injuries and to investigate whether consensus on these distinct topics could be reached.
A modified consensus technique was conducted among 26 elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90% to 99% agreement.
Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus.
There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and previous injury. There was unanimous agreement that advanced imaging in the form of either magnetic resonance imaging or magnetic resonance arthroscopy should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of nonoperative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery, and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for return to sport (RTS) were regarding portions of the physical examination should be considered when determining whether to allow a player to RTS; unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS.
V, expert opinion.