December 22, 2019
triceps tendon injuries cover

Triceps Tendon Injuries: An Uncommon Clinical Entity

Triceps tendon injuries, which can be described as a spectrum of disease ranging from strain, tendinopathy, partial and complete tears, is a rare clinical phenomenon. Triceps tendon injuries tend to occur in men in their 40s and is the last common tendinopathy of the elbow. The three heads of the Triceps Brachii coalesce to form a common insertional tendon onto the olecranon process of the ulna and posterior capsule of the elbow joint capsule.
Typically, tendinopathy occurs as a result of an overuse or repetitive loading of the tendon. Partial ruptures can occur and complete rupture is considered the terminal event of tendinopathies, although acute ruptures are reported in case reports [1]. Approximately half of acute tears are from falls while the other half are seen in bodybuilders and professional weight lifters [2]. Triceps tendonitis is associated with olecranon bursitis and the two can be difficult to distinguish clinically. Risk factors include overhead and throwing athletes, chronic kidney disease, hyperparathyroidism, and anabolic steroid use.
History may reveal an insidious or acute onset with the patient describing an extension load on the elbow. Patients report pain with active elbow extension. On exam, they will be tender along the olecranon and with resisted elbow extension at 90० and 180०. This can be distinguished from posterior elbow impingement by reproducing pain with active triceps extension short of complete elbow extension. Evaluation often involves initial radiographs which may be normal or show a olecranon bone spur. Ultrasound and MRI can be used to evaluate injuries as well [3].
Elbow XR Olecranon enthesophyte, olecranon bursitis

Image 1. Olecranon bursitis with small enthesophyte

Elbow XR Olecranon avulsion fracture

Image 2. Avulsion fracture of the olecranon. Also noted is elbow joint O and history of ORIF of proximal radius.

Tendinopathies are managed nonoperatively with a high success rate. Interventions include activity avoidance and relative rest from offending sports or exercises, physical therapy, NSAIDS, splinting at 45०. Platelet rich plasma can be considered in refractory cases. In the case of partial tears, management is more controversial. Among a series of 10 NFL players managed conservatively, 1 sustained a complete rupture requiring surgical repair while the rest were allowed to return after an average of 5 weeks of missed playing time [4]. Of the rest, 3 more underwent delayed surgical repair after the season. For complete repairs, surgical management is indicated.

In summary, triceps tendon injuries are not well studied or described in the literature. Tendinopathies can usually be managed conservatively. Partial tears should be seen by an orthopedic surgeon although surgical indications are not well defined. Complete tears are surgical and require intervention. 

Citations

1. Foulk DM, Galloway MT. Partial triceps disruption: a case report. Sports Health 2011; 3:175–8.
2. Donaldson, Oliver, et al. “Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies.” Shoulder & elbow 6.1 (2014): 47-56
3. agliafico A, Gandolfo N, Michaud J, Perez MM, Palmieri F, Martinoli C. Ultrasound demonstration of distal triceps tendon tears. Eur J Radiol 2012; 81:1207–10.
4. Mair SD, Isbell WM, Gill TJ, Schlegel TF, Hawkins RJ. Triceps tendon ruptures in professional football players. Am J Sports Med 2004; 32:431–4.