Return to play and performance in Division I collegiate pitchers following ulnar collateral ligament surgery: a retrospective case series

Background: The purpose of this study was to evaluate return to play, postoperative performance, and career advancement in National Collegiate Athletic Association (NCAA) Division I baseball players following ulnar collateral ligament (UCL) surgery. Methods: NCAA Division I pitchers undergoing UCL surgery between 2015 and 2024 were identified using the Tommy John List. Outcomes included return to play, level of return to play, advancement to professional baseball, and pre- and postoperative earned run average (ERA), walks and hits per innings pitched (WHIP), strikeout-to-walk ratio, and innings pitched per season. Comparisons were made between performance outcomes from all preoperative seasons versus all postoperative seasons for pitchers who returned to Division I. Results: A total of 264 pitchers were included, with 239 (90.5%) returning to play following UCL surgery. Return-to-performance analysis included 156 pitchers who returned to play at the Division I level. The only significant difference in pre- and postoperative performance for the full cohort was an increase in innings pitched per season (median difference, 6.25; P=0.002). Subgroup analysis of Power 5 pitchers demonstrated significantly higher postoperative ERA (median difference, 0.42; P=0.01) and WHIP (median difference, 0.05; P=0.03), along with a significant increase in innings pitched per season (median difference, 7.94; P=0.01). Conclusions: Division I pitchers returned to play at high rates following UCL surgery. Among those who returned to Division I, no significant differences were observed in postoperative ERA, WHIP, or strikeout-to-walk ratio for the full cohort. However, Power 5 conference pitchers displayed small but statistically significant increases in postoperative ERA and WHIP. Level of evidence: IV.