American Journal of Sports

Medicine
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The Modified Docking Procedure for Elbow Ulnar Collateral Ligament Reconstruction: 2-Year
Follow-up in Elite Throwers
George A. Paletta, Jr and Rick W. Wright
Am. J. Sports Med. 2006; 34; 1594 originally published online Jul 10, 2006;
DOI: 10.1177/0363546506289884

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The Modified Docking Procedure for Elbow
Ulnar Collateral Ligament Reconstruction
2-Year Follow-up in Elite Throwers
George A. Paletta Jr,* MD, and Rick W. Wright,†‡ MD
From the *Center for the Athlete’s Shoulder and Elbow at the Orthopaedic Center of
‡
St Louis, Chesterfield, Missouri, and Department of Orthopaedic Surgery, Washington
University School of Medicine at Barnes-Jewish Hospital, St Louis, Missouri

Background: Ulnar collateral ligament injury is most common in the overhead-throwing athlete. Jobe et al published the first
report of ulnar collateral ligament reconstruction in throwing athletes with a 62.5% success rate. Recently, Altchek developed a
new docking technique for reconstruction of the ulnar collateral ligament. The authors report the first series using a further mod-
ification of the docking technique using a 4-strand palmaris longus graft for reconstruction of the ulnar collateral ligament.
Hypothesis: The modified docking technique yields a high rate of successful return to preinjury level of competition in elite base-
ball players.
Study Design: Case series; Level of evidence, 4.
Methods: The authors retrospectively reviewed 25 elite professional or scholarship collegiate baseball players who underwent
elbow ulnar collateral ligament reconstruction using the modified docking procedure with a minimum 2-year follow-up.
Results: Twenty-three of 25 (92%) were able to return to their preinjury levels of competition. The mean time to return was 11.5
months (range, 10-16 months). Complications included 1 transient postoperative ulnar nerve neurapraxia and 1 stress fracture
of the ulnar bone bridge that occurred at 14 months postoperatively, after a full return to pitching.
Conclusion: The modified docking technique yields highly successful return to preinjury level of competition rates (92%) in a
select group of elite baseball players.
Keywords: ulnar collateral ligament (UCL); elbow; pitchers

The primary restraint to valgus force at the elbow is the
anterior bundle of the anterior band of the ulnar collateral
ligament (UCL).14-17 During throwing, the anterior bundle is
subjected to high tensile loads as a result of the extreme val-
gus stress placed on the elbow during the throwing motion.
The initiation of valgus load on the elbow coincides with the
initiation of the acceleration phase of the throwing motion.
In the 30 to 40 milliseconds from the initiation of the accel-
eration phase to the time of ball release, the elbow rapidly
extends and achieves a mean angular velocity of 2300
deg/s.4,5,7,8,23 The resulting valgus force produces tensile
forces of up to 290 N concentrated on the medial elbow. The
estimated static tensile force placed on the UCL during
† 62.5% success rate as defined by return to preinjury level of
Address correspondence to Rick W. Wright, MD, 1 Barnes Jewish
Plaza, Suite 11300, St Louis, MO 63110 (e-mail: Rwwright1@aol.com).
Presented at the 28th annual meeting of the AOSSM, Orlando, Florida,
June 2002.
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 34, No. 10
DOI: 10.1177/0363546506289884
© 2006 American Orthopaedic Society for Sports Medicine
pitching has been estimated at 35 N, whereas the ultimate
tensile strength has been reported to be only 33 N.8-10,12,18,20
Although a portion of the medial tensile forces is likely resis-
ted by the medial flexor-pronator muscles and the osseous
anatomy of the elbow joint, it is clear that the UCL is sub-
jected to repetitive high tensile loads. With such high repet-
itive tensile loads, it is easy to understand why pitchers
most commonly suffer injury to this ligament.
Jobe et al13 published the first report of UCL reconstruction
in throwing athletes. The “Tommy John procedure” used the
palmaris longus tendon as an autograft for reconstruction of
the UCL. This original technique involved detachment of the
flexor-pronator muscles at their origin with obligatory sub-
muscular transposition of the ulnar nerve. It resulted in a
sports participation but had a 31.25% complication rate
related primarily to the ulnar nerve. Since that report,
Thompson et al22 reported improved success and fewer com-
plications using a modified technique employing a muscle-
splitting approach without obligatory transposition of the
ulnar nerve. Numerous other authors have reported similarly
successful results using various modifications of the initial

1594
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Vol. 34, No. 10, 2006
Jobe technique.1-3 More recently, Rohrbough et al19 reported a
new technique for reconstruction of the UCL. Using this mod-
ified technique, called the docking technique, the authors
reported that 33 of 36 throwing athletes were able to return to
preinjury levels of sports participation by 2 years after surgery.
Since 1998, the authors have been using a further mod-
ification of the docking technique using a 4-strand pal-
maris longus graft for reconstruction of the UCL. The
purpose of this study was to evaluate the results of this
modified docking technique in a group of elite professional
and collegiate baseball players.
MATERIALS AND METHODS
Between January 1998 and January 2000, 25 elite male
baseball players underwent UCL reconstruction performed
by one of the authors (G.A.P.). Twenty were professional
players, of which 19 were pitchers and 1 was a catcher. One
professional played at the major league level and 19 played
at the minor league level. Of those who played at the minor
league level, 3 played at AAA level, 6 played at AA level,
7 played at A level, and 3 played for independent league pro-
fessional teams. The remaining 5 were Division I scholar-
ship collegiate pitchers. High school and amateur throwers
were excluded. The mean age was 24.5 years, with a range
of 19 to 27 years. The dominant extremity was involved in
all cases. There were 20 right-handed pitchers and 5 left-
handed pitchers. Nine (36%) reported a distinct injury with
sudden onset of symptoms after a single pitch or throw. The
remaining 16 (64%) recalled no distinct injury but rather
described gradual onset of progressive medial elbow pain
and associated decreased pitching performance. All players
reported an inability to continue to pitch secondary to pain
or diminished pitching performance, including loss of veloc-
ity and/or control. Three (12%) patients underwent surgery
within 2 weeks of injury or diagnosis. Eight (32%) under-
went surgery within 2 to 6 weeks of injury or diagnosis. The
remaining 14 (56%) underwent surgery more than 6 weeks
after initial injury or diagnosis. The mean time to surgery
in this delayed group was 14 weeks. Only 2 patients had
undergone previous surgery on the affected elbow. One
player with chronic symptoms had undergone previous iso-
lated ulnar nerve transposition 2 years earlier. One player
with acute injury had undergone arthroscopy with postero-
medial osteophyte excision for valgus extension overload 1
year earlier.
All players underwent a thorough history and physi-
cal examination. History included information regarding
duration of symptoms (acute or chronic injury), pitch type
thrown at time of injury, correlation of symptoms with
phase of throwing and pitch type, and the player’s percep-
tion of pitching performance since onset of symptoms.
Physical examination included inspection, palpation, and
determination of elbow range of motion for both extremi-
ties, valgus stress testing at 30° and 90°, flexor-pronator
and extensor-supinator muscle groups examination, com-
plete neurovascular examination with special attention to
ulnar nerve function, and evaluation for the presence of a
palmaris longus tendon.
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Modified Docking Procedure for UCL Reconstruction 1595
Standard radiographs were performed on all patients
and included AP, lateral, oblique, and radiocapitellar views.
Anteroposterior maximum manual valgus stress radio-
graphs were performed on both the involved and uninvolved
elbows by a single examiner (G.A.P.) in all cases. Standard-
ized mechanical valgus stress views were not performed
because of the unavailability of a fixed arm-holder device. All
patients underwent a gadolinium-enhanced MR arthrogram
of the elbow using a 1.5-T scanner and dedicated elbow coil
with 3-mm coronal sections through the UCL.
Indications for early surgery (within 6 weeks of initial
presentation) included a complete tear of the anterior band
of the UCL as demonstrated by leakage of gadolinium on
MRI scan or by more than 2 mm of relative valgus laxity of
the throwing elbow as demonstrated on stress radiographs.
Athletes with partial tears without significant valgus laxity
were initially treated nonoperatively with a minimum of
6 weeks of rest, avoidance of throwing, nonsteroidal anti-
inflammatory drugs, and physical therapy. The indications
for surgical reconstruction in those athletes with partial
tears without significant valgus laxity were persistent pos-
itive laxity or pain with a valgus stress test at 6 weeks after
injury or an inability to return to pain-free throwing after
a minimum of 12 weeks of nonsurgical treatment. The
mean time to surgery for this group was 14 weeks.
The technique used was a modification of the docking
technique described by Rohrbough et al.19 A quadruple-
stranded palmaris longus graft was used instead of a double-
stranded palmaris graft. The contralateral palmaris longus
tendon was the graft of choice when available to avoid addi-
tional surgical risk to the dominant arm and was used in 21
of 25 cases. The ipsilateral palmaris longus was the second
preference and was used in 2 of 25 cases. The gracilis tendon
was used when a palmaris tendon was not available; it was
used in 2 of 25 cases. In those patients in whom a gracilis ten-
don was selected as graft choice, a double-looped gracilis ten-
don graft was used.
Arthroscopy was performed only in cases with clear indi-
cations for the procedure such as intra-articular loose bod-
ies or large posteromedial osteophytes. Arthroscopy was
performed in 6 of 25 cases in standard fashion. An arthro-
scopic valgus stress test, such as that described by Field
and Altchek,6 was performed and had a positive result in
4 of 6 cases. Subcutaneous transposition was required in
2 cases in which the ulnar nerve was hypermobile or sub-
luxating as described by Azar et al.2
The ulnar tunnel was prepared by subperiosteally expos-
ing the posterior ulna with careful protection of the ulnar
nerve. A 3-mm bur on a 90° dental drill was used to create
bone tunnels anterior and posterior to the sublime tubercle.
Care was taken to preserve a 10- to 15-mm bone bridge
between the anterior and posterior holes. A No. 1 Ethibond
Excel OS-2 needle (Ethicon Inc, Johnson & Johnson,
Somerville, NJ) was used to pass a looped 2-0 nonabsorbable
suture with the looped side exiting the anterior tunnel. The
humeral tunnel was positioned in the central 2 quartiles or
50% of the medial epicondyle in the anterior position of the
existing UCL. A 4- or 5-mm bur (selected based on the size
of the palmaris tendon graft) on a straight microdrill was
used to create a tunnel to a depth of 25 mm. Care was taken
1596 Paletta and Wright The American Journal of Sports Medicine

to preserve the anterior and posterior cortices of the medial

epicondyle. The anterior portion of the upper border of the
medial epicondyle was exposed using a muscle split just
anterior to the intermuscular septum. A 2-mm bur on the
90° dental drill was then used to create 2 small tunnels that
connected with the main humeral tunnel in a Y-like shape.
These 2 small tunnels were separated by a 10-mm bone
bridge. The looped end of the doubled palmaris was passed
initially through the ulnar tunnel from anterior to posterior
(Figure 1). In the case of a gracilis graft, 1 free end of the
graft was prepared by placing a No. 1 braided nonab-
sorbable suture in a Krackow fashion. The Krackow suture
was then passed through the ulnar tunnel and used to pull
the free end of the graft through. The elbow was reduced Figure 1. The looped end of the doubled palmaris longus
with varus force, and the underlying native UCL was imbri- tendon has been passed from anterior to posterior through
cated using No. 0 Panacryl suture. The looped end of the pal- the ulnar tunnel and docked in the humeral tunnel with the
maris graft was then prepared by placing a No. 1 braided sutures exiting 1 of the small Y limb tunnels.
nonabsorbable suture in a Krackow fashion. The free ends of
the Krackow suture were then passed through 1 of the small
Y limb drill holes using the previously placed looped suture
(Figure 1). The end of the graft was then pulled into the
humeral tunnel and securely “docked” completely within it.
The graft was tensioned and the elbow put through a full
range of motion to eliminate potential creep in the graft. The
final length of the graft was determined by placing the
undocked free limb of the graft adjacent to the humeral tun-
nel. The length of the graft was trimmed after estimating
adequate length to allow 10 mm of the free end to enter the
mouth of the humeral tunnel. This point was marked, and a
No. 1 braided nonabsorbable suture was placed in the free
end in a Krackow fashion. The remainder of the free end of
the graft distal to the ink mark was amputated. The free end
of the graft was then docked securely in the humeral tunnel
with the Krackow suture exiting the second of the small Y Figure 2. The free limb of the palmaris graft has now been
limb tunnels. Both limbs of the graft were then tensioned docked in the humeral tunnel. The graft is tensioned, and the
so that 15 to 17.5 mm of each limb was docked within the sutures are tied over the proximal bone bridge.
humeral tunnel (Figure 2). Final tensioning was performed
with the elbow reduced with varus, the forearm in neutral
rotation, and the elbow flexed at 45°. The graft was ten-
sioned, and the 2 sets of sutures exiting the proximal
At 16 weeks after surgery, a formal progressive return to
humeral tunnels were tied over the bone bridge.
throwing program was instituted. At 7 months after sur-
The elbow was maintained in the initial postoperative
gery, pitchers began throwing from the mound with an
splint with the elbow at 80° of flexion and the forearm in neu-
anticipated return to competitive throwing at 10 months
tral rotation for 10 to 14 days. After the splint was removed,
after surgery.
the elbow was placed in a hinged brace, which was worn at
all times except during supervised physical therapy. Range of
motion was initiated immediately on removal of the initial RESULTS
postoperative splint. The brace was set to allow 30° to 90°
range of motion for postoperative weeks 2 to 4 and 15° to All 25 players were available for follow-up at a mean of 30
105° for postoperative weeks 4 to 6. months and a minimum of 24 months after surgery. Twenty-
At 6 weeks after surgery, the brace was discontinued. Res- three of 25 (92%) returned to their preinjury levels of com-
toration of full range of motion was emphasized. Gradual petition or to higher levels (defined as still throwing at the
forearm and shoulder strengthening was begun with avoid- same or a higher level at the time of minimum 2-year follow-
ance of valgus stress at the elbow. At 12 weeks after surgery, up). The mean time to return to competitive throwing was
increased strengthening was instituted with gradual pro- 11.5 months (range, 9-16 months). There was no difference
gression of valgus stress on the elbow. The athlete was in time to return to play between the professional and colle-
allowed to begin rehabilitation in the 90° of external rotation/ giate players.
90° of abduction position, including manual isometric and iso- All 20 professional players had a good outcome, but only 19
tonic strengthening exercises and gentle throwbacks in prepa- of 20 returned to preinjury levels of competition or higher.
ration for a return to throwing. One player was released by his team before completing his

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Vol. 34, No. 10, 2006
rehabilitation and decided to retire without returning to play.
At the time of follow-up, he had a stable, pain-free elbow and
was playing recreational baseball without limitation. Four of
5 collegiate players returned to preinjury levels of competi-
tion. One player was unable to return to competitive pitching
because of persistent medial elbow pain with pitching. He
had no evidence of valgus laxity; however, sequential plain
radiographs demonstrated progressive widening of the ulnar
bone tunnel without evidence of fracture.
The mean preoperative range of motion was 8° to 138°.
The range of preoperative loss of flexion was 0° to 40°.
Twenty-three of 25 (92%) had tenderness medially in the
region of the UCL. Only 4 of 25 (16%) had clearly detectable
valgus laxity on preoperative clinical valgus stress testing.
Twenty of 25 (80%) had a positive milking maneuver sign.
Two of 25 (8%) had preoperative sensory changes in the
ulnar nerve distribution, but none had ulnar nerve motor
dysfunction. The Tinel sign was positive at the cubital tun-
nel in 8 (32%) patients. Flexor-pronator provocative tests
had positive results in 7 (28%) patients. A palmaris longus
tendon was present in 22 (88%). The contralateral palmaris
was present in 21 of 22, whereas 1 player had only an ipsi-
lateral palmaris longus tendon present. Of the 9 who
recalled acute onset of symptoms with a single pitch, 4
recalled throwing a curveball, 3 recalled throwing a fastball,
and 2 recalled throwing a slider.
Plain radiographs demonstrated findings common to the
thrower’s elbow, including posteromedial osteophyte forma-
tion. One patient had obvious loose bodies. There were no
avulsion fractures. Maximum manual stress radiographs
were positive with more than 2 mm relative valgus laxity in
9 (36%) patients. The MR arthrogram was positive for either
complete or partial tears in all patients. Five of 25 (20%) had
complete tears with extra-articular leakage of the gadolin-
ium. All others had evidence of a partial tear.
Postoperative range of motion averaged 5° to 132° (range,
–5° to 138°). The range of postoperative flexion contracture
was 0° to 15°. Valgus stress radiographs at 24 months after
surgery demonstrated no player with more than 1 mm of rel-
ative valgus laxity versus the nonthrowing elbow. Complica-
tions included 1 transient postoperative ulnar nerve sensory
neurapraxia, which resolved within 6 weeks, and 1 stress
fracture of the ulnar bone bridge, which occurred at 14
months after surgery after a full return to pitching. No
patients reported complications related to graft harvest
site. No patients required reoperation. The player with the
ulnar bridge stress fracture was a collegiate pitcher who
had returned to pitching 12 months after surgery. He devel-
oped symptoms at 14 months after surgery after having
pitched successfully for 2 months. He was treated with 3
months of rest and use of an ultrasound bone stimulator. The
stress fracture healed, and he has subsequently returned to
pitching without recurrence of the stress fracture.
DISCUSSION
Ulnar collateral ligament injury is most common in the
overhead-throwing athlete. Baseball pitchers experience the
highest incidence of this injury. Although partial injuries
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Modified Docking Procedure for UCL Reconstruction 1597
may be managed nonoperatively, frequently complete tears
with demonstrable valgus laxity require surgical recon-
struction to return to overhead activities. Elbow UCL recon-
struction results in significant interruption of a player’s
career progression with a mean recovery time of 12 to 16
months. In the past 25 years, reconstruction techniques
have made successful return to preinjury levels of compe-
tition more likely, thereby converting this from a career-
ending injury to a career-threatening injury.
Isolated repair of the UCL has yielded poor results, with
previous studies reporting more favorable results with
reconstruction.13 In the original report by Jobe et al,13 62.5%
of throwing athletes were able to return to preinjury levels
of competition. However, the original surgical technique had
an unacceptably high complication rate of 31.25% related
primarily to submuscular transposition of the ulnar nerve.
After modifying their technique, the same group reported
80% good or excellent results with a reduced complication
rate of 20%.22 Subsequently, Andrews and Timmerman1 and
Azar et al2 have reported results of UCL reconstruction
without submuscular ulnar nerve transposition. In these
series, subcutaneous ulnar nerve transposition was per-
formed. The complication rates in these series were less
than 10%; 81% of players were able to return to preinjury
levels of competition in the series reported by Azar et al.
Rohrbough et al have further refined the technique of UCL
reconstruction with the description of the docking tech-
nique.19 The authors reported a 92% success rate in return-
ing 33 of 36 competitive throwing athletes to preinjury
levels of competition.19 The authors performed subcuta-
neous ulnar nerve transposition in 2 patients.
We report a similar success rate in a group of elite profes-
sional and collegiate throwers using a further modification of
the docking technique. This technique offers highly pre-
dictable results, with 92% of players returning to preinjury
levels of competition. Our time from injury to surgery was
shorter than in earlier studies, and we believe this reflects
improved means to diagnose these injuries and a better
understanding of the poor natural history of complete UCL
tears in this population over the decade since the earlier stud-
ies were performed. A minimum of 6 weeks of nonoperative
treatment was recommended for partial tears with less than
2 mm of valgus laxity. Earlier studies have used a minimum
of 12 weeks of nonsurgical treatment, and most of our patients
tried longer periods of nonsurgical management, as evidenced
by the mean time to surgery of 14 weeks in this group.
The technique is performed through a muscle-splitting
approach, thereby preserving the flexor-pronator origin.11,21,22
The technique does not mandate transposition of the ulnar
nerve yet allows reliable protection of the nerve. The tech-
nique minimizes the number and size of the humeral bone
tunnels, thereby decreasing risk of medial epicondyle frac-
ture, yet allows placement of the graft securely within ulnar
and humeral bone tunnels. The technique allows secure fix-
ation and proper tensioning of the graft. The use of 4 strands
of palmaris tendon graft also offers the advantage of incor-
poration of increased collagen tissue into the reconstruction.
Paletta et al have reported that the biomechanical profile of
this modification of the docking technique offers improved
initial strength and strain parameters as compared with the
1598 Paletta and Wright
traditional Jobe technique (see pages 1599-1603).
Limitations of the study include its retrospective nature and
its exclusion of high school and amateur throwers. Although
it may be assumed that the excellent results noted in this
high-demand population are generalizable to other throw-
ers, this is not known and should be addressed in future
studies.
CONCLUSION
The modified docking technique yields highly successful
return to preinjury levels of competition rates in a select
group of elite baseball players. It is a safe and predictable
technique for reconstruction of the UCL. The technique
offers a predictably high rate of success and a low compli-
cation rate. In our series of elite baseball players, 92% were
able to return to preinjury or higher levels of competition.
ACKNOWLEDGMENT
The authors thank Mr Barry Weinberg, ATC; Mr Brad
Henderson, ATC; and Mr Mark O’Neal, ATC, athletic train-
ers with the St Louis Cardinals baseball team during the
time of this study.
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