You Were Told Tommy John Surgery Means 12 to 18 Months Before Returning to the Mound?
That Is Not the Whole Story.
Ulnar collateral ligament reconstruction — Tommy John surgery — is one of the most common procedures performed on baseball pitchers. It is also one of the most misunderstood. Many pitchers, parents, and coaches assume that a UCL injury automatically means a year or more away from the mound, a single standard operation, and a long road back. None of those assumptions are necessarily true.
The reality is more nuanced — and more hopeful. There are two fundamentally different types of UCL injury, and they require completely different treatments. There is a surgical technique that Dr. Mirzayan invented specifically to address the limitations of traditional Tommy John surgery — with published outcomes showing an average return to play of 9 months, compared to 12 months with the docking technique. And for the right patient with the right injury, surgery may not even be the first option — or the only option.
Getting to the right answer starts with one thing: a detailed, experienced conversation about your history. Not an MRI. Not an X-ray. A conversation.
Call (310) 746-5918 to schedule a consultation. Virtual consultations are available for players and families traveling from out of state.
The Most Important Part of the Evaluation Happens Before Any Imaging Is Ordered
Dr. Mirzayan has spent 25 years caring for baseball players and has performed hundreds of Tommy John surgeries. One of the most important lessons from that experience is this: the history is more valuable than the MRI.
When a pitcher comes in with medial elbow pain, Dr. Mirzayan spends significant time asking detailed questions before ordering a single image. Did the pain happen from one specific pitch, or has it been building over time? Was there pain in the elbow before the major episode — or did it come out of nowhere? How long has this been going on? How much rest has the player had, and for how long? Has there been a change in velo or ball placement? Has the pitcher been shut down, and if so, for how long?
These questions are not formalities. The answers determine everything — the diagnosis, the treatment, and the realistic path back to the mound.
Two Types of UCL Injury. Two Completely Different Treatment Paths.
This distinction is at the heart of every UCL evaluation Dr. Mirzayan performs — and it is the distinction that most evaluations miss.
Type 1 — Chronic wear and tear (approximately 80% of cases)
The vast majority of UCL injuries in pitchers are not the result of a single catastrophic event. They are the result of years of cumulative stress — thousands of pitches, season after season, gradually attenuating and ultimately tearing the ligament. These pitchers often describe a long history of medial (inner) elbow discomfort, changes in velocity or command, and a gradual decline in performance before things became bad enough to seek care. By the time they reach Dr. Mirzayan, most have already tried rest, physical therapy, and other conservative measures without lasting relief. These are also patients who often times improve significantly with Platelet Rich Plasma (PRP) injections.
For these patients — chronic wear-and-tear tears in a ligament that has been degenerating for years — repair is not an option. The tissue is simply not healthy enough to reattach and heal. These patients need reconstruction: a complete rebuild of the ligament using a tendon graft.
Type 2 — Acute traumatic tear (approximately 20% of cases)
A smaller but critically important group of pitchers tears their UCL acutely — from a single pitch, with no meaningful history of prior elbow pain. These athletes describe a sudden pop, immediate pain, and a clear before-and-after. Before that pitch, the elbow was fine. After it, it was not.
For these patients — a healthy ligament that has been acutely avulsed (torn) from the bone — reconstruction is not necessarily required. The ligament can potentially be repaired: reattached back to the bone and backed up with an internal brace. This is a fundamentally different procedure with a fundamentally faster recovery.
The decision between repair and reconstruction cannot be made from an MRI alone, because most MRI reports state "partial tear of the ligament". It requires an experienced surgeon who knows what questions to ask, what the answers mean, and how to translate that history into the right surgical plan.
For Patients Who Need Reconstruction: The Double Button™ Tommy John — Invented by Dr. Mirzayan
For pitchers who need full UCL reconstruction, Dr. Mirzayan performs his own technique: Double Button™ Tommy John surgery, which he first described in the peer-reviewed literature in 2012 — making him one of the earliest adopters and innovators in this space.
Why traditional techniques have limitations
The most commonly performed UCL reconstruction today is the docking technique. Like most traditional approaches, it requires drilling two tunnels in the ulna and two tunnels in the medial epicondyle of the humerus. Creating four tunnels in close proximity carries a real risk: the drill can converge on an adjacent tunnel, causing the tunnels to collapse into one another and creating a single large, compromised tunnel rather than two discrete fixation points. When that happens, the fixation is weakened and the reconstruction is at risk.
The other limitation of traditional techniques is fixation strength. In the docking technique, the graft is secured by suturing it back to itself or tying the tails of the graft over a bony bridge — techniques that are effective but biomechanically inferior to button fixation. The graft is essentially held by suture tied around bone, which can loosen, cut through, or fail under the cyclic loading of a pitcher's elbow.
What makes the Double Button technique different
Dr. Mirzayan's Double Button™ technique requires only one tunnel in the ulna and one tunnel in the humerus — eliminating the tunnel convergence problem entirely. The graft is secured at each end using a cortical button — a small, flat implant that sits flush against the bone surface and distributes load across the cortex rather than concentrating it at a suture knot. Biomechanical studies have shown button fixation to be stronger than traditional docking fixation, more resistant to cyclic loading, and less prone to the failure modes that lead to reconstruction breakdown.
Fewer tunnels. Stronger fixation. A more reliable construct.
The hybrid reconstruction: Double Button plus internal brace
Dr. Mirzayan takes his reconstruction one step further. In addition to the Double Button™ graft reconstruction, he augments every case with an internal brace — a strong synthetic tape that acts as a protective scaffold alongside the graft during the early healing phase. This combination — graft reconstruction backed up by internal brace — is what the baseball and sports medicine world is now calling a hybrid reconstruction, and it represents the current leading edge of UCL surgery.
The internal brace protects the graft while it heals, reduces stress on the reconstruction during rehabilitation, and allows for a more aggressive and accelerated recovery protocol. It is one of the most discussed concepts in Tommy John surgery today — and Dr. Mirzayan has been incorporating it into his technique as a natural extension of the Double Button approach.
The published evidence
Dr. Mirzayan's first publication describing the Double Button™ technique appeared in 2012: Double Button™ UCL Reconstruction — Original Technique Description (2012)
A more recent publication describes the technique in its current modern form: Double Button™ Tommy John — Updated Technique (2021)
The outcomes study — with functional results and proof of the technique — reported an average return to play of 9 months in patients treated with the Double Button reconstruction, compared to 12 months with the traditional docking technique: Double Button™ Tommy John — Functional Outcomes and Return to Play
For Patients Who Qualify for Repair: UCL Repair with Internal Brace
For pitchers with an acute UCL tear — no prior elbow pain, healthy tissue, a clear single-event injury — Dr. Mirzayan performs UCL repair with internal brace augmentation rather than reconstruction. The ligament is reattached to the bone and the repair is protected with an internal brace that immediately restores stability and allows rehabilitation to begin earlier than reconstruction permits.
The recovery from repair is faster than reconstruction. For a pitcher trying to protect a recruitment season, a college career, or a professional contract, the difference matters.
The internal brace concept for UCL repair is demonstrated in this Arthrex animation: MUCL Repair with the InternalBrace System
Not every pitcher with a UCL tear is a candidate for repair. The decision requires careful evaluation of the injury pattern, tissue quality, and the pitcher's history. Dr. Mirzayan will give you an honest assessment of whether repair or reconstruction is the right choice for your specific situation.
What to Expect: Surgery and Recovery
Both UCL reconstruction and UCL repair are performed as outpatient procedures under general anesthesia with a nerve block for postoperative pain control. Patients go home the same day.
After reconstruction, the arm is protected in a brace and range of motion is restored progressively over the first several weeks. Strengthening begins as healing allows, and a structured interval throwing program typically begins around 4 to 5 months. The average return to competitive pitching with Dr. Mirzayan's Double Button™ technique is 9 months.
After repair with internal brace, the recovery timeline is accelerated relative to reconstruction. Dr. Mirzayan will give you a personalized return-to-throwing timeline based on your specific injury, your procedure, and your rehabilitation progress.
Coming from Las Vegas, Phoenix, Texas, Florida, or Out of State?
Tommy John surgery is performed at high volumes across the country — but not all Tommy John surgeries are the same, and not all surgeons have the same depth of experience with the throwing athlete's elbow. Dr. Mirzayan invented his own reconstruction technique, published it in the peer-reviewed literature, and has the outcomes data to back it up. For a pitcher whose career depends on getting this right, that distinction matters.
Dr. Mirzayan regularly treats players and families from Las Vegas, Henderson, Phoenix, Scottsdale, Texas, Florida, and across the country. Baseball is played year-round in many of these states, and the travel ball and showcase circuit already has families accustomed to traveling for the sport. Traveling for the right surgeon is no different.
If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. Dr. Mirzayan's office will verify your coverage before you commit to anything.
Virtual consultations are available. You can submit your imaging in advance, meet Dr. Mirzayan on video, and get a clear assessment of your injury and your options before committing to travel or time away from the game.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is Tommy John surgery?
Tommy John surgery is the common name for ulnar collateral ligament reconstruction of the elbow — a procedure that rebuilds the ligament on the inside of the elbow that stabilizes the joint against the valgus forces generated during overhead throwing. It is named after the Los Angeles Dodgers pitcher who underwent the original procedure in 1974. It is one of the most commonly performed procedures in baseball players at every level of competition.
How do I know if I need repair or reconstruction?
The answer depends almost entirely on your history — not your MRI. Pitchers with a chronic wear-and-tear pattern, a history of gradual elbow pain, and prior conservative treatment need reconstruction. Pitchers with a truly acute tear — sudden onset, no prior elbow symptoms, healthy tissue — may be candidates for repair with internal brace augmentation. Dr. Mirzayan spends significant time taking a detailed history at every UCL evaluation because this distinction determines the entire treatment plan.
What is the Double Button technique and how is it different from docking?
The Double Button™ technique requires only one tunnel in the ulna and one tunnel in the humerus, compared to two tunnels in each bone with traditional techniques. This eliminates the risk of tunnel convergence — a complication where adjacent drill holes collapse into one another and compromise fixation. The graft is secured with cortical buttons rather than suture tied over bone, providing biomechanically superior fixation that has been shown in published studies to outperform traditional docking constructs under cyclic loading.
What is a hybrid reconstruction?
A hybrid reconstruction combines a tendon graft reconstruction — the traditional Tommy John rebuild — with an internal brace that acts as a synthetic scaffold alongside the graft during healing. Dr. Mirzayan incorporates an internal brace into every Double Button™ reconstruction. The internal brace protects the graft, reduces stress on the repair during rehabilitation, and supports a faster, more aggressive recovery protocol.
How long does recovery take after Tommy John surgery?
With Dr. Mirzayan's Double Button™ technique, the published average return to competitive pitching is 9 months — compared to 12 months with the traditional docking technique. Individual timelines vary based on the extent of injury, the procedure performed, and rehabilitation progress. Pitchers who undergo repair rather than reconstruction typically return faster than those who require a full reconstruction.
My son had a UCL injury and was told he needs Tommy John surgery. Should I get a second opinion?
Yes — particularly if the recommendation was made primarily on the basis of an MRI without a detailed discussion of the history of pain. The distinction between a chronic wear-and-tear tear and an acute traumatic tear is critical and changes the treatment entirely. A pitcher who actually has an acute tear may be a candidate for repair rather than reconstruction — a faster procedure with a faster recovery. Dr. Mirzayan offers virtual consultations and is happy to review imaging and history for second-opinion evaluations.
Do you see players from outside Los Angeles?
Yes. Dr. Mirzayan regularly treats pitchers and overhead athletes from Las Vegas, Phoenix, Texas, Florida, Georgia, and across the country. Virtual consultations are available. For a pitcher whose career is on the line, a consultation with Dr. Mirzayan — in person or by video — is often the most important first step. Call (310) 746-5918.
Does being out-of-network mean I will pay full price out of pocket?
Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect before making any decisions.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon, the inventor of Double Button™ Tommy John surgery, and one of the most experienced UCL surgeons in the United States. He first published his Double Button technique in 2012 and has since published updated technique descriptions and a functional outcomes study demonstrating an average return to play of 9 months — three months faster than the traditional docking technique. With 25 years of experience caring for baseball players at every level of competition, hundreds of Tommy John surgeries performed, and a hybrid reconstruction approach that combines Double Button fixation with internal brace augmentation, Dr. Mirzayan brings a depth of expertise and a published track record that is unmatched for this procedure. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, Texas, and Florida, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
