Tommy John surgery, formally known as Ulnar Collateral Ligament (UCL) reconstruction, is a procedure frequently undergone by overhead athletes to repair a torn ligament in the elbow. The question of pain is a natural and valid concern for anyone facing this type of major reconstructive surgery. While the procedure itself is not painful, the entire process—from the immediate aftermath to the long months of physical rehabilitation—involves distinct phases of discomfort that must be understood and managed.
Understanding the UCL and the Surgical Procedure
The Ulnar Collateral Ligament (UCL) is a band of tissue on the inner side of the elbow that stabilizes the joint during high-velocity movements like throwing. Repetitive, intense stress can cause the UCL to tear, leading to elbow instability and pain during activity. The Tommy John procedure replaces the damaged ligament with a tendon graft, often harvested from the patient’s own forearm, hamstring, or foot.
The surgery itself is painless due to the use of anesthesia. Surgeons typically administer general anesthesia or a combination of sedation and regional anesthesia. A regional nerve block, such as a brachial plexus block, is often administered before the operation to numb the entire arm. This ensures the patient feels no sensation during the one to two-hour procedure where the graft is placed through tunnels drilled into the elbow bones.
Managing Acute Post-Operative Pain
The period immediately following surgery is when the most intense pain occurs, usually peaking within the first 24 to 48 hours. This acute pain begins once the effects of the pre-operative nerve block wear off, typically 12 to 24 hours after the procedure. The pain is significant because the body is reacting to major surgical trauma involving incisions, tissue manipulation, and bone drilling.
Pain management during this phase is aggressive and typically involves a multimodal approach. This strategy starts with prescription opioid pain relievers for the most severe initial discomfort. These are quickly tapered down to nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as the pain level decreases over the first week. The goal is to keep the patient comfortable enough to begin gentle movements, which are sometimes started within the first week after the splint is removed.
The Distinct Discomfort of Rehabilitation
Rehabilitation, which spans 12 to 18 months for a full return to sport, involves a different kind of discomfort. This phase focuses on regaining range of motion and strength. Physical therapists purposefully push the elbow past its comfort zone to break up scar tissue and restore full extension and flexion.
This stretching and mobilization can be intensely uncomfortable, often described as a deep ache or a burning sensation, especially in the first six to eight weeks. Once range of motion is restored, the focus shifts to strengthening, which brings muscle soreness and stiffness. This discomfort is managed primarily with ice, heat, and over-the-counter medication, and is viewed as necessary for a successful outcome, often referred to as “good pain.”
Long-Term Outcomes and Residual Sensation
Most patients experience a highly successful outcome with minimal long-term pain, though some residual sensations can persist for years. Occasional mild stiffness or aching, particularly in response to changes in weather, is a a common complaint. Studies report that only a small percentage of patients, around three percent, continue to have persistent elbow pain.
A more specific residual issue is the possibility of ulnar nerve irritation, as the nerve may be moved during the procedure. Post-operative swelling or scar tissue can cause compression, manifesting as numbness, tingling, or a burning sensation running down the forearm into the ring and little fingers. While this symptom often resolves on its own, it may require further medical attention if it persists three to six months after the operation.