I inject bone marrow aspirate concentrate or platelet-rich plasma directly into the graft during surgery, with the goal of helping it mature into a ligament faster. I believe it helps, based on what I have seen in my own patients. I also want to be straightforward with you about three things before you read any further: there is no published evidence specific to the elbow, the evidence from knee ligament surgery is genuinely mixed, and neither treatment is covered by insurance. Here is what I use, how it works, and what is and is not known about it.
What problem this is trying to solve
When your ulnar collateral ligament is reconstructed, the graft that replaces it is a tendon, not a ligament. Over the following months the body remodels that tendon into something that behaves like a ligament — a process called ligamentization. Much of the original graft tissue dies first, new blood vessels grow in, cells repopulate it, and the collagen slowly reorganizes.
That process is the reason recovery takes about a year. Strength training does not speed it up. The graft is at its mechanically weakest around six months, which is exactly when athletes feel ready to push.
Biologics are an attempt to influence that biology rather than wait it out passively — to give the graft a better cellular and vascular environment to remodel in during the window when it is most vulnerable.
What I use, and why I prefer bone marrow concentrate
I use bone marrow aspirate concentrate when I can, and platelet-rich plasma when I cannot.
The difference is what is in each one. platelet-rich plasma is a concentrate of your own platelets and the growth factors they release — PDGF, TGF-beta, VEGF and IGF-1 among them — which drive cell recruitment and matrix production. Bone marrow concentrate contains those signaling molecules as well, but it also contains progenitor cells: the mesenchymal cells capable of becoming the tissue you are trying to build. That is a meaningful difference. PRP largely sends signals. Marrow concentrate sends signals and cells.
For that reason bone marrow concentrate is my preference and my recommendation. It is also the more expensive of the two, and neither is paid for by insurance — which is why the choice in practice often comes down to what a patient and family can afford.
Where the marrow comes from
I harvest the marrow from the iliac crest, the rim of the pelvis you can feel at your beltline. It is done under the same anesthetic as your reconstruction, so there is no separate procedure and nothing additional to recover from beyond some soreness at the aspiration site.
The iliac crest is used because it reliably yields the highest concentration of progenitor cells. The aspirate is then processed in the operating room to concentrate those cells before it is used.
How it is delivered
The concentrate is injected directly into the graft with a fine needle, and around the graft as well. It is placed into the tissue that has to remodel, rather than simply poured into the joint or the wound.
In my Double Button™ reconstruction this happens after the graft is prepared and positioned, so the biologic is delivered into the construct that will become your new ligament.
What the evidence actually shows
This is the section most practice websites leave out, and I would rather you had it.
The biological rationale is sound and well described. Both PRP and marrow concentrate deliver factors known to be involved in tendon and ligament healing, and that is not in dispute.
The clinical evidence is a different matter. Almost all of it comes from anterior cruciate ligament reconstruction in the knee, not from the elbow. In that literature, both treatments have shown improvements on imaging — marrow concentrate has been associated with better MRI graft signal characteristics and less widening of the bone tunnels, and PRP with reduced early post-operative pain and better short-term function. But a 2025 review of this field concluded that evidence of long-term functional or biomechanical superiority remains inconclusive, and a randomized controlled trial of 175 patients followed for two years found that neither PRP nor marrow concentrate produced better clinical or radiological outcomes than reconstruction alone.
To my knowledge there is no published study of biologic augmentation in ulnar collateral ligament reconstruction specifically. The elbow is not the knee, and I am not going to pretend that knee data settles the question for a throwing athlete.
So here is my honest position. I use it because the mechanism is plausible, because the risk is essentially limited to some soreness where the marrow was taken, because it uses your own tissue, and because what I have observed in my own patients has been favorable. That is clinical judgment, not proof. Anyone who tells you biologics are proven to speed up return from Tommy John surgery is telling you something the literature does not currently support.
What it will not do
It will not eliminate the wait. Ligamentization takes the time it takes, and no injection converts a tendon into a ligament on a schedule of your choosing. If biologics help, they help at the margins — a better environment for a process that still has to run its course.
It will not change the rehabilitation program, and it will not let you throw sooner than the criteria allow. I do not accelerate anyone's protocol because they had marrow concentrate.
And it is not a substitute for the operation being done well. Fixation, tunnel placement, graft tensioning and technique determine the outcome. Biology is an adjunct to good surgery, never a rescue for poor surgery.
The cost conversation
Neither bone marrow concentrate nor PRP is covered by insurance for this indication. Both are out-of-pocket, and marrow concentrate costs more than PRP.
I raise this before surgery rather than after, because it is a real decision for most families and it deserves to be made with the numbers in front of you. If the budget allows, I recommend marrow concentrate. If it does not, PRP is a reasonable alternative. And if neither is affordable, your reconstruction is still a good operation with a good expected outcome — the published return-to-play results for this surgery come from patients who did not receive biologics at all.
Nobody should feel that they are compromising their child's recovery by declining an unproven add-on. That is the honest framing, and it is the one I use in clinic.
Disclosure
I am a paid consultant and educator for Arthrex, which manufactures systems used to prepare platelet-rich plasma and bone marrow concentrate. I disclose this on every page where biologics are discussed. It does not change my clinical recommendations, and I have set out above exactly where the evidence for these treatments is strong and where it is not.
The bottom line
Biologics are an attempt to improve the environment in which your graft becomes a ligament. I inject bone marrow concentrate, harvested from the iliac crest, directly into and around the graft during surgery — or platelet-rich plasma when cost is a barrier, since neither is covered by insurance. The rationale is sound and the risk is low, but the clinical evidence comes from knee surgery rather than elbow surgery and is mixed even there. I use it because I think it helps and because it costs you very little in risk to try. I will not tell you it is proven, and I will not tell you it shortens your year.
References — publish at the bottom of the page, smaller type
- Pham GM. Biologic augmentation in anterior cruciate ligament reconstruction and beyond: a review of PRP and BMAC. J Clin Med. 2025;14(19):6959.
- Biologically enhanced anterior cruciate ligament reconstruction: platelet-rich plasma or bone marrow aspirate concentrate does not lead to better clinical or radiological outcomes — a randomized controlled trial of 175 cases with 2 years of follow-up. PMID 42319381. [JOURNAL, YEAR, VOLUME AND PAGES TO BE COMPLETED]
- Yao S, Fu BC, Yung PS. Graft healing after anterior cruciate ligament reconstruction (ACLR). Asia Pac J Sports Med Arthrosc Rehabil Technol. 2021;25:8-15.
- Mirzayan R, Benvegnu N, Sidell M, Acevedo DC, DeWitt DO, Lowe N, Singh A. Functional outcomes of ulnar collateral ligament reconstruction with a novel double suspensory fixation. J Shoulder Elbow Surg. 2020;29(8):1530-1537.
