Overview
Valgus instability from attritional failure of the anterior bundle of the medial ulnar collateral ligament (UCL) is by far the most common form of recurrent elbow instability (Campbell). The anterior bundle has an anterior band (taut at 0-60 degrees) and a posterior band (taut at 60-120 degrees); during the acceleration phase of throwing up to 60 N is applied, near its failure point. Fatigue, poor mechanics and overuse lead to partial and then complete failure, with secondary radiocapitellar chondromalacia, posteromedial olecranon osteophytes, loose bodies and ulnar nerve symptoms (Campbell).
Since Jobe's first reconstruction in 1974, about 25% of Major League and 15% of minor league pitchers have had UCL reconstruction (Campbell).
Risk factors: higher pitch velocity, innings and pitch counts, few pitch types, small stature, inadequate rest, poor mechanics and glenohumeral internal rotation deficit (GIRD) (Campbell).
Evaluation (Campbell)
Inspect for atrophy and swelling; palpate the flexor-pronator mass, UCL and posteromedial olecranon. Tenderness 2-3 cm distal to the olecranon tip may indicate an olecranon stress fracture.
Valgus stress at about 30 degrees of flexion with the forearm pronated: note medial opening, end point and pain.
Valgus extension overload test: valgus stress while extending from 30 degrees; posteromedial pain suggests posteromedial impingement.
Moving valgus stress test (thought to be the most accurate): shoulder abducted and externally rotated, valgus applied while the elbow is moved rapidly between 120 and 30 degrees; medial pain indicates incompetence. Milking maneuver: valgus via the thumb while ranging 30-120 degrees.
Evaluate the ulnar nerve (Tinel sign, subluxation with flexion) and test for posterolateral rotatory instability.
Imaging: AP, lateral and two 45-degree oblique views; Jones view for posteromedial osteophytes; gravity stress radiograph (not very sensitive). Gadolinium-enhanced MR arthrography is currently the best test: the T sign (contrast leaking around the ulnar or humeral attachment without extracapsular leakage) indicates an undersurface tear.
Arthroscopic valgus stress test: viewing from the anterolateral portal with the elbow at 70-90 degrees, ulnotrochlear opening of more than 1-2 mm indicates medial instability.
Indications (Campbell)
Acute complete or high-grade partial rupture in a competitive throwing athlete who wants to continue.
Partial tear with chronic pain or instability not improved after at least 4-6 weeks of supervised nonoperative care (relative rest, forearm and shoulder strengthening, core and conditioning, anti-inflammatories, then a short-toss program from 4-6 weeks). Recurrent medial pain that prevents progression of a monitored throwing program indicates ligament incompetence.
Options (Campbell)
Modified Jobe: muscle split, figure-eight graft through ulnar and divergent humeral tunnels; ulnar nerve not routinely transferred.
Andrews et al.: flexor carpi ulnaris retracted, open tunnels, routine anterior ulnar nerve transposition.
Docking (Altchek et al.): muscle-splitting approach in a safe zone, no obligatory nerve transfer, grafts in bone tunnels, a single humeral tunnel and simplified tensioning; 39 of 40 athletes returned to their previous level in one report. Pull-out studies favor docking over interference screws; the authors do not use absorbable interference screws because of bone resorption.
Repair with internal brace (Dugas): for avulsions in otherwise healthy ligaments (often high school and college athletes); 93% good-to-excellent results with return to play around 6 months; augmented repair is as strong as reconstruction at time zero with more resistance to gapping.
Graft: ipsilateral palmaris longus (absent in 15-20%; a unilateral palmaris often has a short tendon), contralateral palmaris, gracilis or hamstring (consider for attritional tears with an ossicle). Symptomatic graft heterotopic ossification occurs in about 0.6% overall and 10% with gracilis.
Technique 52.15: Docking Reconstruction (Altchek et al.) (Campbell)
Harvest the ipsilateral palmaris longus through a 5-mm to 1-cm incision at the distal wrist crease with a tendon stripper; place a No. 1 braided nonabsorbable Krackow suture in one end and keep it moist.
Exsanguinate and inflate the tourniquet.
Incise from the distal third of the intermuscular septum across the medial epicondyle to 2 cm beyond the sublime tubercle, preserving the cutaneous nerve branch that crosses the field.
Incise the flexor carpi ulnaris fascia longitudinally and split the underlying muscle; maintain exposure with a deep self-retaining retractor.
Incise the anterior bundle longitudinally; 2 mm or more of joint opening with valgus stress confirms laxity.
Expose the ulnar tunnel sites; for the posterior tunnel stay subperiosteal and protect the ulnar nerve (transpose it if it subluxes and cannot be protected).
With a No. 3 burr (or guide), create tunnels anterior and posterior to the sublime tubercle with a 2-cm bridge; connect them with a small curved curette without breaching the bridge and pass a looped 2-0 suture.
Humeral tunnel: in the anterior half of the medial epicondyle at the anterior origin of the native ligament, create a longitudinal tunnel up the epicondylar axis to a depth of 15 mm with a No. 4 burr. Make two small exit tunnels on the upper epicondyle, just anterior to the intermuscular septum, 5 mm to 1 cm apart, and pass looped sutures.
With the elbow reduced, repair the longitudinal ligament incision with 2-0 absorbable suture.
Pass the graft through the ulnar tunnel from anterior to posterior; dock the sutured limb in the humeral tunnel with its sutures exiting one small tunnel.
Reduce the elbow with forearm supination and gentle varus; keep tension while flexing and extending to remove creep.
Estimate the final graft length against the humeral tunnel, mark it, place a Krackow suture and dock the second limb with its sutures exiting the other small tunnel (alternatively, quadruple the graft as described by Paletta).
Perform final tensioning through a full range of motion with varus stress; tie the two suture sets over the humeral bone bridge.
Deflate the tourniquet, irrigate, close the FCU fascia, subcutaneous tissue and skin; splint at 60 degrees of flexion.
Technique 52.13: Modified Jobe Reconstruction (key points) (Campbell)
Remove calcification from the ligament; drill holes at the anatomic attachments; the graft must not rub on the epicondyle or ulna, its ends buried in tunnels, in a figure-eight configuration; handle the medial antebrachial cutaneous and ulnar nerves meticulously.
Split the flexor-pronator mass at its posterior third without detaching it; lightly retract the ulnar nerve without transfer.
Ulna: anterior and posterior 3.2-mm holes at the level of the coronoid tubercle with a 1-cm bridge. Humerus: a 4-mm common anterior hole (1 cm deep) at the UCL origin with divergent 3.2-mm tunnels ("lazy Y") exiting anterior to the septum 0.5 cm apart.
Graft about 15 cm (palmaris, plantaris or Achilles), passed in a figure-eight and tensioned at 45 degrees of flexion in neutral varus-valgus, then sutured to the native remnant.
Transpose the ulnar nerve only with symptoms and heavy scarring.
Postoperative: posterior splint 7-10 days; active elbow motion from 10 days; wrist and forearm strengthening at 4-6 weeks; elbow strengthening after 6 weeks; no valgus stress until 4 months; competitive pitching at about 1 year.
Postoperative Care after Docking (Campbell)
Sutures out at 1 week; hinged brace allowing 45-90 degrees, advanced to full over 3 weeks.
Formal therapy and gradual forearm and shoulder strengthening from 6 weeks, avoiding valgus loading.
More vigorous strengthening at 12 weeks (light-to-moderate bench press).
Throwing program from 4 months.
Revision or tunnel blow-out: a single ulnar tunnel with button fixation is a salvage option.
Outcomes and Complications (Campbell)
Primary reconstruction: return to the same level in about 83% (Cain et al., 743 athletes); 67% of 147 MLB pitchers returned to the same level. Return to play typically around 13 months, with improvement for another year. Revisions return 42-63% of the time.
Results of the modified Jobe and docking techniques are similar.
Ulnar nerve transfer causes neurapraxia in 12% and slightly lower return-to-play scores.
References
Lamplot JD, Brolin TJ. Recurrent dislocations. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 52, Techniques 52.13-52.16.