In my practice, usually not. I leave the ulnar nerve where it is unless you already had nerve symptoms — numbness or tingling in your ring and small fingers — before surgery. That decision matters more than most patients realize. Ulnar nerve trouble is the most common complication of this operation, and two surgical choices drive how often it happens: how the elbow is approached, and whether the nerve is moved. The published data on both is clear, and it is the reason I do it the way I do.
Why the ulnar nerve is part of this conversation at all
The ulnar nerve runs behind the medial epicondyle — the bump on the inside of your elbow — in a groove directly behind the ligament being reconstructed. It is the nerve you hit when you strike your funny bone. It supplies sensation to your ring and small fingers and powers most of the small muscles of the hand.
Any operation on the inside of the elbow happens within a centimeter or two of that nerve. It can be irritated by retraction, by swelling, by scar tissue, or by being moved. So the question is not whether the nerve is near the surgery. It is what the surgeon chooses to do about it.
How often do nerve problems happen?
More often than most patients are told. A systematic review pooled 17 studies covering 1,518 patients who had UCL reconstruction, with an average of 3.3 years of follow-up. Overall, 12 percent developed ulnar neuropathy after surgery — 182 of the 1,518. Slightly under 1 percent required a second operation for it.
But the overall number conceals the thing that actually matters, which is how much the rate varies by technique:
| Surgical variable | Nerve problems | Reoperation |
|---|---|---|
| Muscle-splitting approach | 3.9% | — |
| Muscle retraction approach | 15.9% | — |
| Flexor-pronator detachment approach | 21.9% | 10.9% |
| Nerve left alone | 3.9% | — |
| Nerve transposed (any method) | 16.1% | — |
| Subcutaneous transposition | 15.7% | 0% |
| Submuscular transposition | 23.6% | 12.7% |
Read those two groupings together. An operation performed through a muscle-splitting approach with the nerve left alone carries a reported neuropathy rate of about 4 percent. An operation performed by detaching the flexor-pronator mass with a submuscular transposition carries rates in the low-to-mid twenties. Same surgery, same ligament, a five-fold difference in the most common complication.
Why some surgeons move the nerve routinely
Routine transposition is usually not a judgment call made patient by patient. In several established techniques it is simply part of the operation, built in when the technique was developed.
The original Jobe technique, described in 1986, transposed the ulnar nerve in every case. The technique taught at the American Sports Medicine Institute likewise includes transposition as a standard step rather than an optional one. Surgeons trained in those traditions transpose because that is how the operation is taught, and they get good results doing it.
What changed over time was the approach to the muscle. When the modified Jobe technique introduced a flexor-pronator muscle-splitting approach, it removed much of the reason to move the nerve, and transposition became selective rather than automatic. Docking-style techniques followed the same path, reserving transposition for patients who have symptoms before surgery.
My technique sits in that second group. I use a muscle-splitting approach, a single bone tunnel on each side rather than two, and a button that seats on the front surface of the medial epicondyle. Less dissection, fewer tunnels, and an anterior fixation point together mean there is less reason to disturb a nerve that is working normally.
I want to be careful not to overstate this. Surgeons who transpose routinely are following well-established techniques with long track records, and the choice usually reflects how they were trained rather than a belief that every nerve must be moved. What the pooled data shows is that the transposition itself carries a cost — and when a technique does not require it, that cost can be avoided.
What I do
Two choices, and they are the two associated with the lowest rates in that review.
- I use a muscle-splitting approach. The flexor-pronator muscles that originate on the medial epicondyle are separated along their fibers rather than detached from the bone. The muscle origin stays intact. This gives access to the ligament without the dissection and retraction that put the nerve at risk, and without a muscle repair that has to heal afterward.
- I do not routinely move the ulnar nerve. If you have no nerve symptoms going into surgery, I leave the nerve in its groove. Moving a nerve that is working normally means dissecting it free along its length, relocating it, and holding it in a new position — and every one of those steps is an opportunity to irritate something that was not bothering you.
The logic is simple enough to state in a sentence: a nerve that is not causing a problem does not need to be moved, and moving it triples the reported complication rate.
When I do move it
There is a clear exception, and it is the reason I ask carefully about numbness before surgery.
If you already have ulnar nerve symptoms — numbness, tingling, or a shock-like sensation into the ring and small fingers — then the nerve is already irritated, and reconstruction alone will not address that. In those patients I transpose the nerve, moving it to the front of the elbow where it is no longer stretched over the medial epicondyle with flexion.
This is a decision made from your history and examination before the day of surgery, which is why I take reported numbness seriously even when an athlete mentions it in passing as something they have gotten used to.
The uncomfortable part of the data
Look again at that 3.9 percent figure for patients whose nerve was left alone. Those are people who went into surgery with a completely normal nerve and came out with numbness.
Leaving the nerve undisturbed lowers the risk substantially. It does not eliminate it. Swelling, retraction during the operation, and scar tissue forming afterward can all irritate a nerve that was never directly handled. I would rather tell you that plainly than let a technique discussion imply the complication is impossible.
What technique buys you here is a materially lower chance of a problem, not a guarantee against one.
My published results
In my published series of 36 baseball players who underwent Double Button™ reconstruction, with a minimum of two years of follow-up and an average of more than four and a half years, no patient developed new ulnar nerve symptoms after surgery.
I want to be straightforward about what that does and does not prove. Thirty-six patients is a modest series, and a finding of zero in a group that size is statistically consistent with a true rate somewhat above zero. It is not a claim that the complication is impossible in my hands. What it does show is that a technique built around a muscle-splitting approach and leaving the nerve alone performs the way the pooled literature predicts it should.
What if I have numbness after surgery?
Some transient sensitivity around the incision is normal and comes from small skin nerves that are unavoidably crossed. That is different from ulnar nerve symptoms.
What I want to hear about immediately is numbness or tingling in the ring and small fingers, weakness gripping or spreading the fingers, or any symptom that is new, progressive, or getting worse rather than better. Ulnar nerve surveillance is the priority of the first two weeks after surgery, and it is screened at every visit during that period.
Most post-operative ulnar nerve symptoms are transient and settle as swelling resolves. Fewer than one percent of patients in the pooled review required a second operation for the nerve. But the ones that matter are the ones that progress, and those are far easier to address early.
Questions worth asking any surgeon
If you are choosing a surgeon for this operation, these are fair and specific questions, and the answers tell you a great deal:
- Do you use a muscle-splitting approach, or do you detach the flexor-pronator mass?
- Do you routinely transpose the ulnar nerve, or only when there are pre-operative symptoms?
- What is your own rate of new ulnar nerve symptoms after this operation?
A surgeon who does this operation frequently will have an immediate answer to all three.
The bottom line
The ulnar nerve does not have to be moved during Tommy John surgery, and in most of my patients it is not. Ulnar neuropathy is the most common complication of this operation, reported at about 12 percent overall, but the rate depends heavily on technique — roughly 4 percent with a muscle-splitting approach and the nerve left alone, versus the high teens to low twenties with flexor-pronator detachment or transposition. Some established techniques include transposition as a built-in step, which is why surgeons trained in those traditions move the nerve in every case. I use a muscle-splitting approach with a single bone tunnel on each side, and I transpose only in patients who already have nerve symptoms before surgery. In my published series, no patient developed new ulnar nerve symptoms.
References
- Clain JB, Vitale MA, Ahmad CS, Ruchelsman DE. Ulnar nerve complications after ulnar collateral ligament reconstruction of the elbow: a systematic review. Am J Sports Med. 2018;46(5):1263-1269.
- 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.
- Cain EL, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter JC, Riley RS, Arthur ST. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426-2434.
