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Basics ⬇

Author(s): AdamCulver, MD, AnthonyMartin, MD, CAQSM and David E.Price, MD, FAAFP, CAQSM

Description

  • Inflammation of the triceps tendon at or proximal to the insertion onto the olecranon
  • Classically an overuse injury due to repetitive extension of the elbow or extreme force placed on the tendon
  • May result from direct trauma

Epidemiology

  • Uncommon, but higher prevalence observed in certain groups (see “Risk Factors”)
  • Male predominance (1)
  • Has been described through a wide range of ages (1)

Etiology and Pathophysiology

Inflammation or swelling of the triceps tendon due to excessive force or repetitive use

Risk-Factors

  • Certain sports such as professional weight lifting, professional football (American), softball players (1)
  • Use of anabolic steroids and history of local corticosteroid injections may also predispose to injury (2).
  • Systemic disorders, including renal osteodystrophy, hyperparathyroidism, and diabetes mellitus (2)
  • Commonly associated with posterior impingement, presence of loose bodies, classic tennis elbow, history of elbow arthroplasty, high-intensity interval training (2)

General Prevention

  • Proper form when lifting weights
  • Avoid excessive weight or force when utilizing triceps.
  • Dynamic warm-up prior to repetitive use of triceps or weight lifting

Commonly Associated Conditions

  • Olecranon bursitis
  • Triceps tendon rupture (1)
  • Lateral epicondylitis (1)

Diagnosis ⬆ ⬇

History

  • Increasing pain in the posterior elbow over several weeks that worsens over course of the day and associated with occasional morning stiffness
  • Improvement can be seen with periods of inactivity.

Physical Exam

  • Pain in the posterior elbow
  • Pain on full extension/flexion of the elbow
  • Tenderness/swelling at or above the triceps insertion onto the olecranon
  • Increased pain with resisted extension of the elbow
  • Possible weakness with elbow extension (may be indicative of tendon rupture)

Differential Diagnosis

  • Olecranon fracture/stress fracture
  • Olecranon bursitis
  • Triceps rupture
  • Subtendinous bursitis
  • Cervical radiculopathy
  • Posterior interosseous neuropathy

Diagnostic Tests & Interpretation

  • Anterior/posterior and lateral plain films may be helpful if concerned for tendon avulsion (3)[B].
  • Ultrasound may be useful in distinguishing between triceps tendonitis and olecranon bursitis if the physical exam is unclear (4)[B].
  • Ultrasound may distinguish acute versus chronic pathology with increased tendon thickness, hypoechogenicity of tendon fibers, and calcific deposits within the tendon being found in chronic pathology (often called tendinopathy) (3)[B].
  • Magnetic resonance imaging (MRI) is rarely needed.

Treatment ⬆ ⬇

  • Long-term treatment:
    • Prevention is vital in high-risk populations such as weight lifters, carpenters/construction workers, or guitar players; the key to prevention is dynamic warm-up, avoiding excessive force, and taking frequent breaks within activity.
    • Injection of platelet-rich plasma (PRP) is likely effective for improving function and decreasing pain intensity in the long term (5)[A].
  • Acute treatment:
    • RICE: rest, ice, compression, elevation:
      • Rest: Avoid any that which may exacerbate symptoms.
      • Ice: Use ice packs in the painful area for 5 to 10 min 3 to 4 times/day; may also perform ice massage
      • Compression: wrapping the affected area with an elastic bandage, strap, or brace
      • Elevation: If swelling is present, elevation will help alleviate the swelling.
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) are also a mainstay of therapy.

Medication

Issues for Referral

  • If history, physical exam, or other imaging studies suggest signs of tendon rupture, including profound weakness with elbow extension, referral to orthopedic surgery is necessary for potential surgical intervention.
  • For high-risk patients, physical therapy may be beneficial to ensure proper form and stretching.

Additional Therapies

  • Special considerations:
    • Limit ice to 10 min 3 or 4 times daily to avoid cubital tunnel damage of the ulnar nerve.
  • Rehabilitation:
    • Graduated eccentric strengthening following period of rest
    • French stretch: (i) Clasp fingers together with hands above head; (ii) keep elbows close to head; (iii) reach down behind head attempting to touch back; (iv) hold, and then repeat.
    • French press: as with stretch, except holding a dumbbell
    • Towel stretch: (i) injured arm overhead with uninjured reaching behind back; (ii) one end of towel in each hand; (iii) pull, hold, and repeat.

Surgery/Other Procedures

  • Surgical intervention should be considered after a minimum of 1 yr of conservative management (3,6)[C].
  • Rare, but operative treatment described with elliptical resection of diseased tissue

Ongoing Care ⬆ ⬇

Follow-up Recommendations

Return to sport/activity when no longer tender at or above tendon insertion, strength regained, and full range of motion

References ⬆ ⬇

  1. Taylor S, Hannafin J. Evaluation and management of elbow tendinopathy. Sports Health. 2012;4(5):384–393.
  2. Keener JD, Sethi PM. Distal triceps tendon injuries. Hand Clin. 2015;31(4):641–650.
  3. Donaldson O, Vannet N, Gosens T, et al. Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies. Shoulder Elbow. 2014;6(1):47–56.
  4. Blankstein A, Ganel A, Givon U, et al. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. 2006;27(6):568–571.
  5. Fitzpatrick J, Bulsara M, Zheng MH. The effectiveness of platelet-rich plasma in the treatment of tendinopathy: a meta-analysis of randomized controlled clinical trials. Am J Sports Med. 2017;45(1):226–233.
  6. Sibley PA, Harman TW, Bamberger HB. Triceps tendinopathy. J Hand Surg Am. 2015;40(7):1446–1448.

Clinical Pearls ⬆

  • Evidence suggests that the increased risk of rupture with injection serves as a contraindication to direct tendon injection with corticosteroid.
  • Emerging evidence for PRP and its ability to promote faster healing and decrease pain may be beneficial in these types of injuries.