Tommy John Surgery in Wrestlers, MMA Fighters, Javelin Throwers and Softball Players

Tommy John surgery is described almost entirely in terms of baseball, but the ulnar collateral ligament does not know what sport it is in. Any activity that forces the elbow into valgus — the forearm pushed away from the body while the elbow is bent — can tear it. In practice that means three groups outside baseball show up in my office: wrestlers and MMA fighters, javelin throwers, and softball players. Each is a genuinely different problem, and treating them all like baseball pitchers is a mistake.

The most important difference is this: baseball players almost always tear the ligament gradually, over years of repetitive throwing. Wrestlers and fighters almost always tear it in a single moment. That one distinction changes the diagnosis, the operation and the timeline.

Wrestlers and MMA fighters

How the injury happens

In combat sports the UCL is usually torn acutely, by a specific event the athlete can describe — an arm bar, a scramble where the arm is trapped and levered, a takedown landed on an outstretched arm, or a post that collapsed under body weight. Grapplers spend a great deal of time on the mat bearing weight through a bent, loaded arm, which stresses the ligament in a way that throwing does not.

Unlike a pitcher, who typically reports a season of creeping medial elbow soreness and declining velocity, a wrestler can usually tell me the exact match and the exact position. That history is diagnostic, and it matters more than the MRI.

Why I repair these rather than reconstruct them

In wrestlers and MMA fighters I repair the ligament — reattach the athlete's own torn ligament to bone with suture anchors and suture tape internal brace augmentation — rather than replacing it with a tendon graft. I do this regardless of whether the tear is proximal, off the humerus, or distal, off the ulna.

The reasoning is that the tissue is usually good. A repair depends entirely on the quality of what is left behind, which is why repair fails in the typical baseball player: years of repetitive microtrauma have left a degenerated, attenuated ligament that will not hold sutures. A wrestler who tore a healthy ligament in a single event three weeks ago has normal tissue that simply came off the bone. That is exactly the situation repair was designed for.

I still confirm this at the time of surgery rather than assuming it. I place sutures through the ligament and pull on them — the SPOT test, for suture pull-out test. If the sutures rip through, the tissue is not repairable and I proceed with a full reconstruction. That decision is made in the operating room, with the ligament in view, not from an MRI.

The advantage of repair when it is appropriate is time. There is no graft that has to biologically remodel into a ligament, which is the process that governs the twelve-month timeline in a baseball player. Recovery after repair in this population runs closer to five to six months.

What the literature shows

The published data on non-throwing athletes is limited but consistent with this approach. In a 2025 series of 19 non-throwing athletes — including wrestlers, gymnasts, cheerleaders, an MMA fighter and a boxer — 72.2 percent of tears were proximal, none were mid-substance, and return to play was 85.7 percent after repair compared with 58.3 percent after reconstruction. The authors concluded that the combination of an acute injury mechanism, favorable proximal blood supply, and the absence of chronic degenerative change "could make these injuries more amenable to treatment with repair rather than reconstruction."

A 2026 review of 46 wrestlers found a similar tear distribution — 22 proximal, 10 distal, 5 combined and only 2 mid-substance — and reported that most were managed without surgery initially, though 44 percent of those ultimately required an operation. Wrestlers who had surgery as the primary treatment all returned to sport, at an average of 154 days.

Note that the data support repair as an option in this population but do not settle the question of tear location, since most reported tears were proximal. My practice of repairing distal tears in this group as well rests on the same principle — acute injury in healthy tissue — confirmed intraoperatively by the SPOT test.

When I operate

Quickly. An acute UCL tear in a wrestler or fighter is one of the few situations in UCL surgery where I do not spend months on nonoperative treatment first. A ligament that has retracted and scarred for six months is harder to repair than one addressed in the first weeks, and the window in which repair is technically possible can close. This is the opposite of my approach in a young baseball player with a partial tear, where nonoperative treatment is usually the right first step.

Javelin throwers

The UCL injury was described in javelin before it was described in baseball

The first account of ulnar collateral ligament injury in athletes was Waris's 1946 report on elbow injuries in javelin throwers, published nearly three decades before Frank Jobe performed the first reconstruction on Tommy John in 1974. Javelin generates the highest medial elbow valgus loads in sport. Medial-sided elbow injury is the characteristic javelin injury.

The reason javelin is not thought of as a UCL sport is simply numbers. There are vastly more baseball pitchers than javelin throwers, so the baseball literature dominates even though the per-athlete demand on the ligament is higher in javelin.

How I treat them

Surgically, like a baseball player. The mechanism is the same — repetitive valgus overload in an overhead throwing motion — and the tissue is usually degenerative rather than acutely avulsed, so these are reconstructions rather than repairs. I recently performed a reconstruction on a heptathlete who injured her ligament throwing javelin.

The difference is rehabilitation. An interval throwing program written for baseball does not transfer to javelin, because the implement, the approach and the release are different. I use a javelin-specific interval throwing program that progresses three variables independently and never simultaneously: implement weight, approach length, and effort. A full-approach throw at 75 percent effort loads the elbow more than a standing throw at 100 percent, because the crossover steps and the block generate the whip that the arm has to absorb.

The program also enforces a six-month floor on picking up any javelin, including the lightest safety implement, regardless of how well the athlete feels or how quickly the earlier phases go. That floor exists because the graft is remodeling — ligamentization — and that is a biological timeline, not a fitness one. Competition weight comes at roughly nine months, first full-effort throw at eleven, competition at about twelve.

Technique is treated as a safety parameter rather than a performance one. A dropped elbow or a round-arm delivery sharply increases valgus stress and is the classic mechanical cause of javelin elbow. A thrower who cannot maintain a high elbow through release is not ready to advance, whatever their symptoms.

What to expect

A 2025 systematic review of 34 javelin athletes found 82 percent returned to competition at an average of 11.2 months, with 70.1 percent returning to their pre-injury level. Those numbers are somewhat lower than the roughly 90 percent return and 79 percent return-to-prior-level reported in baseball pitchers, which is worth knowing in advance. The most likely explanation is the extraordinary valgus load the sport places on a reconstructed ligament at return.

Softball players

Softball players do tear the UCL, and I have reconstructed several over the years. But they are almost always position players rather than pitchers, and the reason is mechanical.

The windmill pitching motion is underhand. It is not a low-stress motion — biomechanical analysis found elbow compressive forces of 70 to 98 percent of body weight and shoulder forces reaching 80 to 95 percent of the values calculated for overhand baseball pitching. The windmill delivery is demanding. What it does not produce is valgus load. Peak elbow valgus torque in windmill pitching measured only 4 percent of body weight times height, a fraction of what overhand throwing generates, because the forearm is not being levered away from a flexed, externally rotated arm.

The consequence is that windmill pitchers get a different injury. The same study identified the biceps-labrum complex as the structure at risk, because it has to resist shoulder distraction and flex the elbow at the same time. Shoulder problems, biceps problems and ulnar neuritis are what I see in windmill pitchers. UCL tears are not.

Softball position players, on the other hand, throw overhand exactly as baseball players do. A catcher throwing to second base or an outfielder making a long throw loads the ligament the same way a pitcher does. Those are the softball athletes who tear the UCL, and I treat them the same way I treat a baseball position player.

Gymnasts

Gymnasts are frequently listed among the non-throwing athletes who tear the UCL, and they do appear in the published series. In my own practice I see them rarely. The gymnast's elbow is loaded in axial compression and extension rather than valgus, so the more common elbow problems in that sport are osteochondritis dissecans of the capitellum, olecranon stress injury, and distal radius physeal injury from weight-bearing. A gymnast with medial elbow pain deserves a careful workup, but the UCL is not the most likely answer.

How the treatment differs across these groups

Summarized simply:

• Wrestlers and MMA fighters — acute tear, healthy tissue, repair with internal brace augmentation, operate early, return around five to six months.
• Javelin throwers — chronic overload, degenerative tissue, reconstruction with a tendon graft, javelin-specific interval throwing program, return at about twelve months.
• Softball players — position players who throw overhand, not windmill pitchers; treated the same as baseball position players.
• Baseball players — chronic overload, reconstruction in most cases, standard interval throwing program, return at nine to twelve months.
• Gymnasts — uncommon; medial elbow pain usually has another cause.

What does not change across any of these groups is the surgical principle. The operation has to be done correctly, the graft or repair has to be protected while it heals, and the athlete has to be returned on biological criteria rather than on a date in a season.

The bottom line

You do not have to be a baseball player to tear the ulnar collateral ligament or to need it fixed. Wrestlers and MMA fighters tear it acutely, usually have good tissue, and in my hands are repaired promptly with internal brace augmentation rather than reconstructed — which shortens recovery considerably. Javelin throwers tear it the way pitchers do and are reconstructed the way pitchers are, but rehabilitated on a javelin-specific program with a hard six-month floor before the implement is picked up. In softball it is the position players who throw overhand, not the windmill pitchers. If you have a medial elbow injury in a non-baseball sport, the sport matters, because it changes which operation is right and how long it takes to come back.

References 

1. Johns WL, Patel NK, Miltenberg B, et al. Outcomes after ulnar collateral ligament reconstruction and repair in nonthrowing athletes. Orthop J Sports Med. 2025;13(12):23259671251393527.
2. VanTienderen R, Gregory E, Marshall B, Ortiz SF, Wolf BR, Westermann RW. Evaluating outcomes and return to sport of ulnar collateral ligament injuries in wrestlers. Orthop J Sports Med. 2026;14(Suppl 1):2325967126S00505.
3. Waris W. Elbow injuries of javelin-throwers. Acta Chir Scand. 1946;93(6):563-575.
4. Wallace S, Ober J, Devaney L. Return to sport criteria and outcomes in javelin athletes following ulnar collateral ligament reconstruction: a systematic review. Int J Sports Phys Ther. 2025;20(7):931-942.
5. Dines JS, Jones KJ, Kahlenberg C, Rosenbaum A, Osbahr DC, Altchek DW. Elbow ulnar collateral ligament reconstruction in javelin throwers at a minimum 2-year follow-up. Am J Sports Med. 2012;40(1):148-151.
6. Barrentine SW, Fleisig GS, Whiteside JA, Escamilla RF, Andrews JR. Biomechanics of windmill softball pitching with implications about injury mechanisms at the shoulder and elbow. J Orthop Sports Phys Ther. 1998;28(6):405-414.