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Triceps Tendon Rupture

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Ovid: 5-Minute Sports Medicine Consult, The


Triceps Tendon Rupture
Mark H. Mirabelli
Ramsey Shehab
Basics
Description
  • Triceps tendon ruptures are defined as a partial or complete tear of the triceps muscle or tendon at one of several sites, including the musculotendinous junction or the tendinous insertion into the bone. The latter scenario occasionally includes a piece of bone from the olecranon insertion (1). There also have been several cases of tears of the muscle belly (2).
  • Synonym(s): Triceps tendon rupture; Triceps tendon avulsion; Triceps tendon tear; Avulsion fracture of the olecranon; Triceps muscle tear
Epidemiology
  • Triceps tendon ruptures are rare and have been described as the least common of all tendon injuries.
  • This injury is more commonly seen in men and affects individuals in the age range of 7–70 yrs.
  • Least common of all major tendon injuries (1.9% of all tendon ruptures) (3)
  • Equal predominance in both sides, and no correlation with dominant or nondominant hand
Risk Factors
Several predisposing factors have been described (4):
  • Hyperparathyroidism secondary to chronic renal failure
  • Anabolic steroid use
  • Both local and systemic corticosteroid injection; the former sometimes secondary to olecranon bursitis (5)
  • Chronic tendinosis at the area may also be a risk factor.
  • Recent use of fluoroquinolones is also a risk factor for all types of tendon ruptures.
Etiology
  • Usual mechanism of injury involves a fall on an outstretched arm (causing a deceleration-type injury).
  • Direct blow to the posterior arm or elbow, especially if flexed
Commonly Associated Conditions
  • Olecranon fracture (intra-articular)
  • Triceps tendinosis
  • Triceps contusion
  • Avulsion fracture of the olecranon
  • Radial head fracture
  • Olecranon bursitis
Diagnosis
History
  • Injury history is of an acute trauma, usually from direct blow or fall.
  • There may be antecedent history of problems with the elbow.
  • Patients usually complain of pain and swelling of the posterior elbow.
  • May have ecchymosis over area of triceps insertion
  • Can also have decreased active elbow extension
Physical Exam
  • Presentation includes swelling, pain, bruising over posterior arm and elbow
  • Activities can be significantly limited, including those requiring pushing and reaching overhead.
  • Begin with a general exam of upper extremity and contralateral side, including shoulder and wrist exams, to exclude other concomitant injuries and establish a basis for comparison.
  • Specifically examine affected side and compare to contralateral.
  • Patients have localized swelling at the posterior elbow.
  • Tenderness in the area of the triceps tendon insertion is typical.
  • Sometimes a palpable defect can be appreciated just proximal to the olecranon.
  • Test triceps function; pain and weakness with resisted elbow extension should be noted.
  • Verify integrity of neurovascular status.
  • Modified Thompson test can help determine the integrity of the musculotendinous unit. This test is best accomplished with the upper arm supported, the elbow flexed to 90 degrees, and the forearm and hand hanging relaxed. This can be done by allowing the forearm to hang over the side of a table or the back of a chair. Upon squeezing the triceps muscle belly, the elbow should reflexively extend if the tendon is intact. If there is a complete rupture of the tendon, the elbow will not extend.
Diagnostic Tests & Interpretation
Imaging
  • Radiographs occasionally show 1 or several bony flecks from the tip of the olecranon that have been avulsed with the tendon.
  • Sometimes a larger fracture of the olecranon can be seen.
  • Associated injuries and findings may include radial head or neck fractures, as well as wrist fractures (probably secondary to the common mechanism of injury, a fall on an outstretched hand).
  • US can be used to diagnose triceps tendon ruptures, but may be operator-dependent (6).
  • MRI can be helpful in the diagnosis and can differentiate between complete and partial tendon ruptures (7).
Differential Diagnosis
  • Olecranon fracture (intra-articular)
  • Triceps tendonitis or strain
  • Triceps contusion
  • Avulsion fracture of the olecranon
  • Radial head fracture
  • Olecranon bursitis

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Treatment
  • Ice and NSAIDs are the mainstay of acute therapy.
  • If injury is associated with a larger olecranon fracture or radial head or wrist fracture, narcotic pain medication may be warranted.
  • Arm should be placed in sling with ≤90 degrees of flexion initially after the injury. A posterior splint may be used if necessary.
Additional Treatment
  • When a triceps tendon rupture is diagnosed, it is imperative to determine whether the tear is partial or complete. This will determine whether operative or nonoperative therapy is appropriate. As noted, MRI is useful for making this determination when correlated with clinical findings.
  • Loss of elbow motion and triceps strength (the inability to extend the elbow against even minor resistance) is consistent with a complete tendon rupture. The treatment for this is surgery.
  • If there is some active elbow extension, particularly against resistance, the more likely diagnosis is a partial tendon rupture.
  • Although some clinicians suggest surgical repair for both partial and complete tears because of its low morbidity and high success rate, others support nonsurgical treatment of partial tendon ruptures with close clinical observation.
  • Platelet-rich plasma and autologous whole blood injections are currently investigational adjuvants in both operative and nonoperative treatment.
  • If nonoperative treatment is appropriate, the elbow should be immobilized in a posterior splint in ∼30–40 degrees of flexion for up to 6 wks.
  • After a period of immobilization (for either operative or nonoperative cases), patients should be sent to physical therapy for increased range of motion and progressive strength recovery.
  • Pain control modalities and shoulder, forearm and wrist range of motion (ROM) exercises may be started immediately.
  • Passive elbow ROM should be started after 2–3 wks.
  • Active assist and then full active ROM exercises should be initiated after completion of immobilization period.
  • Recovery is often slow.
  • Unrestricted activity should be considered no sooner than 3–4 mos (dependent upon recovery from either operative or nonoperative intervention) due to risk of rerupture.
  • Full recovery may take up to 1 yr.
Surgery/Other Procedures
  • This is the recommended treatment for complete rupture (8).
  • Surgical repair can be more easily accomplished during the 1st 2 wks after the injury.
  • There are several methods of repairing triceps tendon ruptures that yield excellent results.
  • A common repair technique reattaches the tendon with wire or suture through drill holes in the olecranon.
  • For ∼3–4 wks postoperatively, the elbow is splinted in 30–40 degrees of flexion.
Ongoing Care
Prognosis
  • Prognosis is generally good for complete tears treated surgically and incomplete tears treated either nonoperatively or operatively.
  • Athletes can expect to return to their previous level of activity with preserved motion and normalized strength.
References
1. Viegas SF. Avulsion of the triceps tendon. Orthop Rev. 1990;19:533–536.
2. Aso K, Torisu T. Muscle belly tear of the triceps. Am J Sports Med. 1984;12:485–487.
3. Anzel SH, Covey KW, Weiner AD, et al. Disruption of muscles and tendons; an analysis of 1,014 cases. Surgery. 1959;45:406–414.
4. Bach BR, Warren RF, Wickiewicz TL. Triceps rupture. A case report and literature review. Am J Sports Med. 1987;15:285–289.
5. Stannard JP, Bucknell AL. Rupture of the triceps tendon associated with steroid injections. Am J Sports Med. 1993;21:482–485.
6. Kaempffe FA, Lerner RM. Ultrasound diagnosis of triceps tendon rupture. Clin Orthop Rel Res. 1996;332:138.
7. Tuite MJ, Kijowski R. Sports-related injuries of the elbow: an approach to MRI interpretation. Clin Sports Med. 2006;25:387–408, v.
8. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg [Am]. 2009;34:566–576.
Additional Reading
Farrar EL, Lippert FG. Avulsion of the triceps tendon. Clin Orthop Rel Res. 1981;161:242.
Pantazopoulos T, Exarchou E, Stavrou Z, et al. Avulsion of the triceps tendon. J Trauma. 1975;15:827–829.
Strauch RJ. Biceps and triceps injuries of the elbow. Orthop Clin North Am. 1999;30:95–107.
Codes
ICD9
  • 727.60 Nontraumatic rupture of unspecified tendon
  • 841.8 Sprain of other specified sites of elbow and forearm
Clinical Pearls
Physician responses to common patient questions:
  • When can I resume my usual work/play activities? Treatment for triceps tendon rupture commonly yields excellent return of motion and strength. Rehabilitation, after the period of immobilization, is the key to attaining full recovery, and patients should be able to resume full activity in 3–4 mos.


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