Sometimes — and the operation works well in young athletes when it is genuinely needed. Roughly 84 percent of adolescents return to the same level of competition or higher, with a low complication rate. But reconstruction is being performed on teenagers far more often than it used to be, and not all of that increase is driven by elbows that required surgery. Before anyone operates on your son or daughter, three questions deserve honest answers: is the ligament actually the problem, has proper nonoperative treatment been tried, and is anyone addressing the thing that caused this in the first place?
The results in adolescents are genuinely good
Let me start with the encouraging part, because it is true.
A systematic review of nine studies covering 414 adolescent athletes — 404 baseball players and 10 javelin throwers — found that 84.3 percent returned to the same level of competition or higher. Complications were reported in 3.9 percent and reoperation in 1.8 percent. A separate review of 2,019 patients across all levels put the return-to-sport rate for high school athletes at 89.4 percent.
So this is not an operation that fails young people. When the diagnosis is right and the rehabilitation is done properly, most adolescents get back to where they were.
But surgery is rising faster than injury
Reconstruction rates have risen sharply, and the steepest rise is in exactly this age group. Published figures describe a 193 percent increase in reconstruction rates between 2002 and 2011, with an annual increase of roughly 9 percent among adolescents specifically.
Some of that is real — more year-round throwing, higher velocity at younger ages, more competitive innings. But some of it is diagnostic and cultural, and that portion is worth examining before your child becomes part of the statistic.
A partial tear on an MRI is not by itself a reason to operate
This is the single most important thing on this page.
If your child has been throwing competitively since Little League, their ulnar collateral ligament has changed. Elbow abnormalities on MRI have been documented in 53 percent of asymptomatic baseball players aged nine to thirteen and 65 percent of asymptomatic high school players. Those are athletes with no pain and no complaints, imaged for research purposes.
A radiology report that says "partial tear of the ulnar collateral ligament" in a teenage pitcher is, very often, an accurate description of a throwing elbow rather than a diagnosis of an injury. What makes that finding meaningful is symptoms that match it — medial elbow pain in the cocked position, unexplained loss of velocity or command, or inability to throw at full effort.
I do not operate on imaging. I operate on a symptomatic athlete whose examination and history support the finding.
Nobody should be having this surgery to throw harder
It is worth stating plainly, because the belief is widespread and it is measurably affecting decisions.
In survey research, 51 percent of high school athletes and 37 percent of parents said they would support ulnar collateral ligament reconstruction in a player with no injury at all, as a way to improve performance. The American Sports Medicine Institute has stated that 25 to 50 percent of amateur players, parents and coaches believe the surgery increases velocity, and that this is not true.
Tommy John surgery does not add velocity. The largest study of pitch speed before and after reconstruction found fastball velocity slightly lower afterward. I will not perform this operation on a healthy elbow, and no responsible surgeon will.
What actually causes these injuries
The risk factors in adolescent pitchers have been studied directly. In a case-control study comparing 95 adolescent pitchers who required shoulder or elbow surgery against 45 uninjured pitchers, the injured group differed on a consistent set of variables: more months pitched per year, more games and innings per season, more pitches per game and per year, more warm-up pitches, more frequent starting roles, participation in more showcases, higher throwing velocity, and pitching despite arm pain and fatigue.
The authors' conclusion was direct: the factors with the strongest associations with injury were overuse and fatigue.
Read that list again, because almost every item on it is a decision an adult made. Pitch counts, rest days, how many months a year a child throws, whether he plays on three teams at once, whether he pitches at a showcase two days after a start, and whether anyone listens when he says his elbow hurts — those are coaching and parenting decisions, not bad luck.
Warning signs that should stop the season, not start it
- Medial elbow pain during throwing, particularly with the arm cocked back
- Velocity or command declining without an obvious explanation
- Inability to throw at full effort, or fading noticeably by the middle of an outing
- Numbness or tingling in the ring and small fingers
- Pain that returns every time throwing resumes after a break
- An athlete who has started hiding symptoms to stay in the rotation
Caught early and shut down, most of these elbows are manageable without surgery. The same elbow after another six months of competitive throwing is a much harder problem — and often a surgical one. In my experience the athletes who do poorly are overwhelmingly the ones who pitched through it.
What I do differently in a skeletally immature athlete
If a young athlete does need reconstruction, the operation is the same but the surrounding decisions are not.
- Every rehabilitation phase is extended. I do not compress the throwing progression in a growing athlete to meet a season.
- Age-appropriate throwing programs. I use youth interval throwing programs rather than the adult ladder, which was written for a college or professional arm.
- Pitch count and rest day guidelines are enforced on return. This is not optional. If the overuse that caused the injury is not addressed, the reconstruction is treating a symptom.
- Growth plates are considered. In a skeletally immature elbow, the medial epicondyle growth plate can be the structure that fails rather than the ligament itself — which is a different injury with a different treatment.
The conversation I have with parents
Most families arrive worried that saying no to surgery means falling behind. I want to reframe that.
The question is not whether your child can have this operation. It is whether they need it, and what the year costs them. A reconstruction takes roughly a year out of a young athlete's career — a season and much of another, at an age when development matters and recruiting timelines are short.
If the ligament genuinely requires reconstruction, that year is worth spending and the outcomes are good. If it does not, that year is gone for nothing, and your child has a graft in their elbow instead of their own ligament, plus a revision conversation in their future if it ever fails.
I would rather send a family home with a shutdown plan, a therapy program and a workload conversation than schedule an operation that a well-managed three months would have prevented.
The bottom line
Tommy John surgery works well in adolescents, with about 84 percent returning to the same level or higher and a low complication rate. But surgery in this age group has risen faster than injury has, a partial tear on MRI is extremely common in young throwers who feel fine, and the operation does not increase velocity. Surgery is appropriate for a young athlete with a symptomatic, functionally significant ligament injury who has failed properly supervised nonoperative treatment — not for an imaging finding, and never for performance. The most valuable thing most families can do is address workload, rest and mechanics early, because the elbow that gets shut down in April is far easier to treat than the same elbow in October.
References
- Hadley CJ, Edelman D, Arevalo A, Patel N, Ciccotti MG, Dodson CC. Ulnar collateral ligament reconstruction in adolescents: a systematic review. Am J Sports Med. 2021;49(6):1636-1643.
- Olsen SJ, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34(6):905-912.
- Erickson BJ, Chalmers PN, Bush-Joseph CA, Verma NN, Romeo AA. Ulnar collateral ligament reconstruction of the elbow: a systematic review of the literature. Orthop J Sports Med. 2015;3(12):2325967115618914.
- Ahmad CS, Grantham WJ, Greiwe RM. Public perceptions of Tommy John surgery. Phys Sportsmed. 2012;40(2):64-72.
- Tanaka K, Okamoto Y, Makihara T, et al. Clinical interpretation of asymptomatic medial collateral ligament injury observed on magnetic resonance imaging in adolescent baseball players. Jpn J Radiol. 2017;35(6):319-326.
- Hurd WJ, Eby S, Kaufman KR, Murthy NS. Magnetic resonance imaging of the throwing elbow in the uninjured, high school-aged baseball pitcher. Am J Sports Med. 2011;39(4):722-728.
- American Sports Medicine Institute. Position statement for Tommy John injuries in baseball pitchers. asmi.org.
