Surgical Versus Conservative Management of Ulnar Collateral Ligament Injuries in the Overhead Athlete: A Narrative Review.

Abstract

Ulnar collateral ligament (UCL) injuries are common in overhead athletes, and optimal selection of nonoperative versus operative treatment remains variable. This narrative review summarizes contemporary evaluation and management of UCL injuries in overhead athletes, emphasizing how symptoms, athlete goals, chronicity, and tear morphology guide decision-making. Nonoperative care is generally initially utilized for low-grade, proximal partial-thickness tears, and centers on kinetic-chain-based rehabilitation with staged return-to-throwing, with reported return-to-play (RTP) rates near 80%. Adjunctive platelet-rich plasma has gained interest, but available evidence reflects heterogeneous protocols and mixed clinical benefit. Surgery is typically indicated for high-grade, distal, or chronic pathology in high-demand athletes. UCL reconstruction provides reliable RTP rates often exceeding 90% but requires a longer rehabilitation timeline (approximately 12-18 months). Contemporary UCL repair with internal brace augmentation can achieve comparable outcomes with accelerated RTP (approximately 4-7 months) in appropriately selected acute proximal or distal tears with adequate tissue quality. Key gaps include predicting nonoperative failure, standardizing biologic and rehabilitation protocols, defining objective RTP criteria, and strengthening evidence in nonthrowing overhead athletes.