Michael G. Ciccotti, MD, has watched nearly every part of ulnar collateral ligament care change.
The director of the sports medicine team at Philadelphia-based Rothman Orthopaedics trained under Frank Jobe, MD, who developed the operation that became known as Tommy John surgery. He later spent three decades as the MLB’s Philadelphia Phillies team physician and remains involved in MLB research.
“This is something that I literally have just lived and breathed for almost 40 years,” Dr. Ciccotti told Becker’s.
Yet for all the progress in diagnosing and treating UCL injuries, the field has not solved the problem baseball cares about most: keeping athletes from tearing the ligament in the first place.
A diagnosis shift
The first major shift has been knowing exactly what surgeons are treating. In the early days of UCL reconstruction, Dr. Ciccotti said diagnosis relied heavily on symptoms, relatively imprecise physical examination and plain X-rays that tended to show changes only after an injury had been present for a long time.
MRI transformed that picture, but it still captures the elbow while the athlete is stationary.
At Philadelphia-based Thomas Jefferson University, Dr. Ciccotti and his colleagues have extensively studied stress ultrasound as a way to add motion back into the assessment. A clinician places an ultrasound probe along the medial elbow while manually stressing the joint, allowing physicians to compare ligament stability with the athlete’s opposite arm.
The result is a dynamic view of whether the UCL is functioning. That matters because there is a spectrum from subtle partial damage to high-grade tears, and the degree of instability can help determine whether an athlete should undergo rehabilitation or surgery.
Dr. Ciccotti believes the next step is becoming even more precise with partial injuries. Instead of treating an athlete nonoperatively for several months only to discover that the ligament was unlikely to heal, clinicians may eventually be able to identify poor candidates for conservative care much earlier.
That could change one of the most consequential decisions in UCL care: not simply whether the ligament is torn, but whether waiting is likely to help.
Where the ligament tears now matters
One advance in nonoperative care is the recognition that two partial UCL tears are not necessarily the same injury. Dr. Ciccotti said research has increasingly shown that tear location affects both stability and healing potential.
Partial tears closer to the middle of the ligament or farther down toward the hand tend to be more unstable and have poorer blood supply, making spontaneous healing less likely. More proximal tears, closer to the shoulder, may have better vascularity and can be more appropriate candidates for nonsurgical treatment.
“Where the tear occurs is really important in its ability to heal or not to heal,” he said.
The same level of precision has not yet arrived with biologics. Dr. Ciccotti and his colleagues studied professional baseball players with partial UCL injuries who received traditional nonsurgical treatment, comparing them with athletes who received the same treatment plus platelet-rich plasma.
They did not find a statistically significant improvement in return to play or reduction in subsequent surgery among athletes who received PRP. Although Dr. Ciccotti said biologics could eventually become an important part of UCL treatment, the unresolved questions are more specific: which biologic, for which injury, at what point in treatment and followed by what rehabilitation protocol.
“We just haven’t been able to figure out the precise type, the sequencing of it, the rehab post-PRP or biologic treatment,” he said.
For now, precision diagnosis has moved ahead of precision biologics.
‘The gold standard remains’
Surgical technique has changed considerably since Dr. Jobe performed the original reconstruction. The principle has not.
“There are very rare instances where someone picks up a dart for the first time and throws a bull’s-eye,” Dr. Ciccotti said of Dr. Jobe’s original operation.
Early reconstruction required more disruption of the muscle and tendon overlying the UCL and routinely involved moving the nearby ulnar nerve. Surgeons subsequently developed muscle-splitting approaches, changed tunnel placement and made nerve transposition more selective.
More recently, repair with internal-brace augmentation has created another option for appropriate injuries. Rather than replacing the ligament entirely, surgeons can repair suitable native tissue and reinforce it. Hybrid approaches add similar support to a traditional reconstruction.
The objective is greater initial stability while potentially supporting rehabilitation and return to competition.
But Dr. Ciccotti is cautious about declaring the newer approaches replacements for the operation that preceded them. Intermediate- and long-term evidence is still developing for internal-brace repair and hybrid reconstruction.
“The gold standard still remains,” he said. “The essence of it is the procedure that Frank Jobe created.”
The elbow is no longer treated as an island
Rehabilitation has undergone an equally fundamental change. Early UCL recovery concentrated heavily on the elbow: restoring motion and strengthening the muscles immediately surrounding the joint.
Sports medicine has since come to understand throwing as a whole-body event. That means an elbow rehabilitation program can miss part of the problem if weakness or limited mobility exists elsewhere.
Dr. Ciccotti said modern rehabilitation looks for those deficiencies and uses recovery not simply to restore the repaired ligament, but to optimize the athlete around it.
That becomes especially important as pitchers throw harder. If greater velocity means greater forces moving through the elbow, the rest of the kinetic chain has to transfer those forces as efficiently as possible.
The goal is no longer simply to heal an elbow. It is to return a better-functioning athlete.
2 complications in focus
For all those advances, prevention remains difficult. Dr. Ciccotti sees two forces at the center of the problem: workload and velocity.
Baseball has made major efforts to track pitch counts and establish rest recommendations, particularly for young athletes. But the number recorded next to a pitcher’s name does not necessarily reflect the total stress placed on the arm.
Dr. Ciccotti calls the missing workload “hidden pitches.” A young athlete may pitch twice in one week and appear to remain within recommended limits. But that same athlete may also catch two games, play middle infield, throw during practices and warm up repeatedly. Those throws still count to the ligament, even if the official pitch count does not.
Dr. Ciccotti compared it to a car: No matter how well it is built, constant use eventually wears the tires. “We have these chronologically young athletes who have physiologically older UCLs because of the number of throws,” he said.
Better prevention may therefore require moving beyond pitch counts toward a more complete accounting of throwing workload.
Then comes the second problem.Dr. Ciccotti remembers when only a small number of professional pitchers reached 100 mph. Today, elite pitchers increasingly operate in the high 90s and triple digits.
He calls it the “need for speed.” The problem is mechanical: As throwing velocity rises, so do the forces the UCL has to withstand.
Dr. Ciccotti does not expect competitive baseball to simply abandon velocity. Instead, he believes the sport has to become better at preparing bodies to tolerate it.
That returns prevention to the kinetic chain. If athletes are going to pursue greater velocity, their legs, hips, core and shoulders have to be strong and mobile enough to transfer energy efficiently instead of leaving the elbow to absorb excessive stress.
Returning to the mound is no longer enough
The definition of success has changed, too. Historically, a successful UCL reconstruction could mean an athlete eventually returned to a game.
Dr. Ciccotti believes that bar is no longer sufficient. “There is a difference between return to play and return to prior performance,” he said.
Modern baseball gives clinicians a deeper baseline against which to judge recovery.
At the collegiate and professional levels, physicians and researchers can track velocity, control and other sport-specific performance metrics before injury and compare them with what happens after return. That allows surgeons to ask a more demanding question: The pitcher may be back, but is that person the same pitcher?
The answer can reveal deficits that a simple return-to-play statistic misses, lost velocity, diminished command or subtle performance changes that suggest recovery remains incomplete. It also captures how far UCL care has come since Dr. Jobe first confronted an injury physicians could barely define.
The field can now diagnose instability dynamically, separate tears by healing potential, tailor surgical technique, rehabilitate the entire kinetic chain and measure performance with extraordinary granularity.
What it still cannot reliably do is stop the ligament from failing in the first place. That may be the next great challenge in the legacy Dr. Jobe started: figuring out how fewer pitchers need UCL surgery at all.
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