Distal Tr iceps Tendon

Injuries
Jay D. Keener, MDa,*, Paul M. Sethi, MDb

KEYWORDS
 Triceps tendon injury  Triceps rupture  Elbow  Distal triceps  Treatment

KEY POINTS
 Distal triceps ruptures are uncommon injuries.
 Advanced imaging is required for an accurate diagnosis.
 Complete tendon injuries are best managed surgically, whereas some partial tears can be treated
conservatively.
 Surgery is successful in restoring function.

INTRODUCTION triceps, the evaluation and treatment of triceps

tendon injuries, and the clinical outcomes of
Distal triceps tendon injuries are rare and, often, treatment.
initially unrecognized. In the largest published se-
ries of tendon injuries, Anzel and colleagues1 ANATOMY
noted triceps tendon injuries to be the least com-
mon, accounting for 1% of tendon injuries. The tri- The triceps muscle is pennate and composed of 3
ceps brachii is the chief extensor of the elbow and distinct muscle bellies: the long, lateral, and medial
is critical for normal upper extremity function. The heads. The triceps is innervated by the radial
anatomy of the triceps muscle and tendon archi- nerve, which is the terminal branch of the posterior
tecture has been well described and in recent cord of the brachial plexus. The radial nerve is
years renewed interest has occurred in developing composed of branches of the sixth, seventh, and
surgical repair techniques with better recreation of eighth cervical nerve roots. The long head of the
anatomy and improved biomechanical strength. triceps has a broad origin at the infraglenoid tuber-
Triceps tendon injuries may occur in a variety of cle of the scapula and inferior glenohumeral joint
clinical scenarios and are most often associated capsule.2 The lateral head has a proximal origin
with a distinct event recognized by the patient. from the humerus just lateral to the teres minor
There are several well-recognized risk factors insertion extending distally from the lateral aspect
that predispose to triceps injuries, both systemic of the spiral groove and lateral intermuscular
and localized. Like other tendon injuries, triceps septum. The medial head originates from the hu-
tendon ruptures may be partial or complete. The merus distal to the spiral groove and the medial
unique anatomy of the elbow extensor mechanism aspect of the intramuscular septum.
allows some preservation of strength even in the The insertion of the triceps tendon can be
presence of a complete tendon rupture, which divided into the central tendon insertion into the
can lead to a missed diagnosis and delay in proper olecranon process and the lateral triceps expan-
treatment. Treatment can be successful both sion. The central tendon is thicker medially where
conservatively and surgically in properly selected a distinct rolled edge is formed by a confluence
patients. This article reviews the anatomy of the of the medial and long head tendons (Fig. 1).3
[Link]

a
Department of Orthopaedic Surgery, Washington University, CB# 8233, 660 South Euclid Avenue, St Louis,
MO 63110, USA; b The ONS Sports and Shoulder Service, 6 Greenwich Office Park, Greenwich, CT 06831, USA
* Corresponding author.
E-mail address: keenerj@[Link]

Hand Clin 31 (2015) 641–650

[Link]
0749-0712/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
642 Keener & Sethi

Fig. 1. Deep view of triceps muscle and tendon. The Fig. 3. Insertional footprint of the central triceps
deep muscle has been elevated revealing the central tendon. The insertion of the central tendon into the
triceps tendon. Note the well-developed rolled edge olecranon is broad and dome shaped.
on the medial side of the deep tendon (4 asterisks).

a three-dimensional modeling system suggested

that the mean insertion was 646 mm2.8
The deep surface of the tendon is covered by mus- The lateral triceps expansion serves as an
cle fibers from the medial head (Fig. 2). Although important reinforcement of central tendon and
some investigators think that the medial head can maintain active elbow extension in the pres-
tendon has a distinct insertion,4–6 others have ence of a central tendon rupture. The lateral tri-
shown that the medial tendon blends with the re- ceps expansion is thinner than the central tendon
maining tendon, forming a single tendon conflu- covering the anconeus muscle and blends with
ence.3 The total width of the triceps tendon the extensor carpi ulnaris and dorsal antebrachial
insertion is 4.0 to 4.2 cm.3,7 The thickness of the fascia, eventually inserting into the dorsolateral
central tendon just proximal to the olecranon tip ulna (Fig. 4). The mean width of the lateral expan-
is 6.8 mm.3 The olecranon footprint tendon inser- sion is between 14.4 and 16.8 mm, which is
tion is wide and dome shaped (Fig. 3). The triceps approximately 70% of the width of the central tri-
insertion begins 12 to 14 mm distal to the tip of the ceps tendon.3,7
olecranon and has a mean width of 20.9 mm and
length of 13.4 mm, with dimensions correlating RISK FACTORS AND INJURY MECHANISM
with the size of the boney olecranon.3 One study
showed that the mean area of the footprint inser- Triceps tendon injuries are most common in weight
tion was 466 mm2,7 whereas another study using lifters and athletes; football players may be at partic-
ular risk.9 Triceps injuries are most common in
men.10 Chronic anabolic steroid11 and corticoste-
roid use are considered risk factors given their dele-
terious effect on tendon strength. Likewise, triceps
injuries have been linked to local corticosteroid
injections for triceps tendonitis or olecranon
bursitis.11,12 A variety of systemic disorders,
including renal osteodystrophy, hyperparathyroid-
ism, and diabetes mellitus, can predispose to triceps
injuries.
Triceps tendon ruptures usually occur as a result
of a forceful eccentric contraction of the triceps,
such as a fall on the outstretched hand or during
weight lifting. Usually the injury occurs at the level
of the tendon insertion into bone; however, mus-
culotendinous ruptures can occur. Direct blunt
trauma to the posterior arm is a less common
Fig. 2. Deep view of the distal triceps tendon. Muscle mechanism and generally requires high energy.
fibers covering the deep layer of the tendon originate Even less commonly, lacerations can lead to direct
primarily from the medial head of the triceps. transection of the tendon.
 Distal Triceps Tendon Injuries 643

Fig. 4. Superficial appearance of the triceps tendon insertion. (A) The lateral triceps expansion is continuous with
the anconeus muscle and lateral antebrachial fascia inserting distally into the dorsolateral ulna. (B) The lateral
triceps expansion is broad and thinner than the central tendon, and is approximately 70% of the width of the
central tendon.

CLINICAL EVALUATION avulsion fracture from the olecranon process (flake

sign) is pathognomonic of a triceps rupture (Fig. 5).
Most injuries result from a recognizable event by Advanced studies such as MRI, computed to-
the patient, often accompanied by a painful pop mography scan, or ultrasonography (US) are usu-
or tearing sensation. A subjective loss of elbow ally necessary to confirm the diagnosis and can
extension strength is common. Acute injuries are give some idea of the chronicity of injury. Both
accompanied by variable amounts of swelling of MRI and US can distinguish partial from complete
the olecranon bursa and localized bruising. Phys- tendon injuries.9,15–19 MRI can be particularly help-
ical examination usually reveals localized tender- ful to identify associated soft tissue injuries. The
ness and swelling and often a palpable defect in triceps tendon is best visualized on the sagittal im-
the tendon confirming the diagnosis. Usually full ages (Fig. 6). Complete discontinuity of the central
elbow range of motion is present, and posterior tendon from the olecranon indicates a full-
pain may be present with terminal flexion motion. thickness tear, often associated with a fluid gap
Inability to extend the elbow against gravity is a on T2 imaging. Partial tears appear as an area of
sign of a complete rupture; however, the converse increased T1 and proton density signal within the
is not always true. Because of the integrity of the tendon and, when acute, have increased T2 signal
lateral triceps expansion complete central tendon intensity.17 Partial tears may include either the
rupture often preserves antigravity elbow exten- deep or superficial layers. Partial tears may be
sion. Therefore, accurate diagnosis can be
misleading by clinical examination alone. One
study showed that approximately half of acute tri-
ceps tendon ruptures were initially misdiag-
nosed.13 Both partial and full-thickness rupture
has loss of elbow extension power compared
with the opposite extremity.
A modification of the Thompson calf squeeze
test has been proposed to rule out complete tri-
ceps tendon ruptures.14 During this test the upper
arm is placed on a table surface with the patient
prone and the forearm allowed to hang freely
over table edge. The triceps muscle is manually
squeezed with the arm relaxed. Similar to the ankle
during the Thompson test, when the muscle is
squeezed the elbow should extend slightly.

DIAGNOSTIC IMAGING
Fig. 5. Flake sign. Lateral radiograph of an elbow
Plain radiographs should be obtained on presenta- with a triceps tendon tear. Note the displaced avulsion
tion and include anteroposterior, lateral, and obli- of an osteophyte from the olecranon tip indicating a
que views of the elbow. The presence of a small triceps tendon injury.
644 Keener & Sethi

by progressive elbow flexion mobilization.15,20,21

Progression of elbow motion is allowed as tolerated
beyond 4 weeks.
There is little literature regarding outcomes of con-
servative treatment of partial triceps tendon injuries.
Mair and colleagues9 reported the results of 10 par-
tial triceps injuries in football players treated conser-
vatively. The tears involved between 30% and 75%
of the tendon. Four elbows eventually required
surgery, 3 because of residual weakness and 1
because of early full tendon rupture. The remaining
6 elbows recovered with no residual symptoms.

Surgical Treatment
Most complete triceps tendon injuries should be
managed with surgical repair.15,22 The exceptions
include very low demand patients or those not
medically fit for surgery. Partial tendon injuries
that are high grade (involving >50% of the tendon),
associated with tendon retraction and extension
weakness, or that have failed conservative treat-
ment are also recommended for surgical repair
(Fig. 7). These indications are particularly appli-
cable in active individuals and athletes. Ideally,
Fig. 6. Sagittal T2-weighted MRI of a displaced acute surgery should be performed within 2 to 3 weeks
triceps tendon injury; a complete rupture with only a
for acute complete tears with tendon retraction.
few fibers of the deep central triceps tendon intact.
Primary repair can be performed in a delayed
more common at the medial aspect of the
tendon.6,9

TREATMENT RECOMMENDATIONS
Because there exists no classification system for
triceps tendon ruptures, injuries are generally
described by severity and location: partial versus
complete ruptures and tendon versus musculoten-
dinous injuries. Most triceps tendon injuries occur
at the tendon insertion. Advanced imaging is usu-
ally necessary to confirm the severity of injury and
the recommended treatment is dictated by the
injury severity and the age and physical demands
of the patient. In general, partial tears with minimal
strength loss can be managed nonsurgically and
complete ruptures are treated with surgical repair.

Conservative Treatment
Tears of the triceps occurring within the muscle or
musculotendinous junction are thought to have
good healing potential and are generally treated
conservatively. Partial tears of the tendon are more
controversial. In sedentary individuals, all partial
tears can be managed conservatively. When partial
tears are not associated with tendon retraction, Fig. 7. Sagittal MRI of high-grade partial tear of the
strength is usually preserved and conservative treat- distal triceps tendon. The superficial tendon is torn,
ment is preferred. Treatment includes a brief period whereas the deep tendon remains intact. Arrow point
(3–4 weeks) of immobilization at 30 flexion followed to retracted superficial tendon and surrounding fluid.
 Distal Triceps Tendon Injuries 645

fashion and may be more feasible with injuries 3 parallel tunnels23 (Fig. 9) have been described.
associated with less tendon retraction. The sutures are then tied over the olecranon as a
bone bridge with the elbow held in near full exten-
sion. Alternatively, the triceps may be reattached
SURGICAL TECHNIQUE with the use of suture anchors placed within the
A variety of techniques have been described for tri- olecranon tip.21,24–26 With these techniques,
ceps tendon repair. There is no clear superior tech- side-to-side sutures are recommended to rein-
nique in terms of clinical outcomes but each has force the edges of the repair.
theoretic advantages. All techniques focus on reat- Modified repair techniques have recently
tachment of the torn central tendon to the olecranon. become more popular in attempts to restore a
In addition, any disruption of the lateral triceps larger, native anatomic footprint and improve the
expansion should be performed and helps to mechanical strength of the repair. The strength of
augment the primary repair. In cases in which there the native triceps tendon has been shown to rival
is a significant amount of olecranon bone attached that of the patellar tendon at roughly 1700 N in ca-
to the displaced triceps tendon, it may be favorable davers.27,28 Yeh and colleagues7 showed signifi-
to reattach the bone fragment with either heavy su- cantly greater repair strength (under cyclical
tures or anchors rather than to excise the bone. loading) with a transosseous-equivalent repair
Perhaps the most historically popular triceps compared with both traditional bone tunnel
repair technique involves the creation of bone tun- and suture anchor repairs. In addition, the
nels in the olecranon. Purchase of the central transosseous-equivalent repair gave a better rec-
tendon is achieved with high-tensile, braided su- reation of the native triceps footprint qualitatively
tures in a running, locked (Krackow) fashion or compared with the other techniques, although
with use of a Bunnell-type suture configuration. this was not quantified. With the transosseous-
The strands of suture are threaded through bone equivalent repair, 2 anchors are positioned in the
tunnels; both crossing tunnels13 (Fig. 8) and proximal olecranon approximately 12 mm from

Fig. 9. Modified bone tunnel repair of the triceps

Fig. 8. Traditional bone tunnel repair of the triceps tendon. Krackow-type suture configuration in the tri-
tendon. Bunnell-type suture configuration securing ceps tendon. The tendon is secured through 3 parallel
the central triceps tendon through crossing tunnels tunnels passed through the olecranon tip. (From Si-
in the olecranon. (Reproduced with permission from erra RJ, Weiss NG, Shrader MW, et al. Acute triceps
the Mayo Foundation of Medical Education and ruptures: case report and retrospective chart review.
Research, Rochester, MN.) J Shld Elbow Surg 2006;15(1):131; with permission.)
646 Keener & Sethi

the olecranon tip. Sutures from these anchors are repair, 2 core high-tensile, braided sutures are
then passed through the tendon creating horizon- woven through the central triceps tendon, creating
tal mattress stitches. These sutures, along with the 4 repair strands (2 medial and lateral suture ends)
tails of a Krackow-type suture weaved through the (Fig. 11). A shuttle suture is passed through the
triceps tendon, are then secured to 2 anchors distal tendon on both the medial and lateral as-
placed more distally on the dorsal aspect of the pects of the tendon as well. Two parallel bone tun-
ulna (Fig. 10).7 This arrangement effectively com- nels are created at the medial and lateral aspects
presses the distal tendon footprint against the of the olecranon, exiting the dorsal aspect of the
bone, creating a larger area of boney apposition ulna. The 3 strands of suture are passed through
and better recreating the large area of the native the olecranon bone tunnel on both the medial
triceps footprint. Alternatively, medial mattress and lateral sides. Next, each shuttle suture is
stitches from anchors can be combined with a used to repass the free ends of the Krackow suture
central tendon Bunnell-type suture secured back through each of the bone tunnels, creating a
through crossing bone tunnels.29 cruciate repair (1 limb from the medial and lateral
Knotless repair constructs have recently been sides are crossed into the opposite tunnel). All
studied and show favorable biomechanical slack is taken out of the 4 Krackow strands and
strength.30,31 In addition, this type of repair can the elbow is extended. All 4 strands are then
be performed with 1 anchor, thereby creating secured to an interference fit–type anchor placed
less expense than transosseous repair tech- after predrilling into the dorsal apex of the olec-
niques. Clark and colleagues31 studied an ranon, angled away from the articular surface.
anatomic knotless repair compared with a tradi-
tional cruciate bone tunnel repair in cadaveric el- POSTOPERATIVE CARE
bows. The knotless repair showed significantly
less displacement under cyclic loading and better Most protocols recommend immobilization of the
peak load to failure and yield strength than the elbow at 30 to 45 for a short period (1–2 weeks)
traditional repair. With the anatomic knotless to allow skin healing and protect the repair.15,22
Gentle active elbow flexion and passive or
gravity-assisted extension starts at 2 weeks and
continues until full range of motion has returned.
Active elbow extension is initiated at 4 weeks.
Light strengthening begins at 6 weeks with slow
progression until 3 months. Heavy lifting and
weight training should be delayed until 4 to
6 months following surgery.13 With the advent of
stronger repair constructs, some investigators
have recommended a more accelerated rehabilita-
tion protocol. We prefer to place the arm in a sling
rather than a splint and begin immediate active
and passive range of motion of the elbow and fore-
arm unrestricted. Patients should avoid lifting
more than 2.3 kg (5 pounds) during this phase.
Light triceps strengthening is initiated 6 weeks af-
ter surgery and advanced as tolerated. Direct
comparisons between rehabilitation timelines
have not been performed, therefore the advan-
tages and safety of accelerated rehabilitation pro-
tocols have not been established.

REVISION, CHRONIC, OR DIFFICULT ACUTE

REPAIRS
In some instances, primary repair of the tendon
Fig. 10. Double-row triceps tendon repair. Repair of can be difficult either because of a fixed retracted
the triceps tendon with a double-row technique. position of the tendon, which may be seen in cases
(From Yeh PC, Dodds SD, Smart LR, et al. Distal triceps of chronic rupture (>6 weeks), or in cases of defi-
rupture. J Am Acad Orthop Surg 2010;18(1):31–40; cient or poor-quality tissue, such as a revision
with permission.) repair. In cases in which direct primary repair is
 Distal Triceps Tendon Injuries 647

Fig. 11. Knotless repair construct. (A) The central tendon is secured with 2 separate sutures passed through the
tendon in a Krackow configuration creating 4 separate strands (2 medial and 2 lateral sutures). In addition, a
shuttle suture is passed through the medial and lateral aspects of the distal tendon. Three strands of suture
are passed through a medial and lateral longitudinal bone tunnel in the olecranon. (B) Each shuttle suture is
used to repass the free ends of both the medial and lateral Krackow sutures back through each of the bone tun-
nels, creating a cruciate repair. (C) A bone tunnel is created distal to the olecranon tip on the dorsal surface of the
bone, away from the articular surface. (D) The 4 limbs of suture are passed through an interference fit–type an-
chor to be secured into the bone tunnel. Note the extended position of the elbow to facilitate reduction of the
tendon. (E) Secured knotless cruciate repair of the triceps tendon.

suspected to be difficult, potential tendon primary repair. Petre and colleagues27 compared
augmentation should be discussed with the pa- the biomechanical strength of the intact triceps
tient before surgery. A variety of tendon augmen- tendon with direct tendon repair and repairs
tation procedures have been described and augmented with flexor carpi radialis tendon.
include allograft or autograft hamstring tendon Although neither repair construct was a strong as
augmentation, rotational anconeus flap, Achilles the native tendon, the augmented repairs were
tendon augmentation, and ligament augmentation nearly twice as strong as the repairs without
devices.15,32–34 The method of reconstruction in augmentation. In scenarios with deficient or
these cases depends on several factors, including poor-quality tissue, hamstring augmentation can
surgeon preference, tendon mobility and tissue be used to reinforce the repair or gain tendon
quality, and a variety of host factors. length. The tendon is woven in a Bunnell fashion
Repair augmentation with tendon can substan- through the residual tendon (Fig. 12). A transverse
tially improve the repair strength compared with bicortical tunnel is drilled 1 cm from the olecranon
648 Keener & Sethi

Fig. 12. Triceps tendon repair with graft augmentation. The triceps tendon is reinforced with a hamstring graft
woven through the tendon in a Bunnell-type manner (A). The tendon is fixated through the olecranon through a
transverse bone tunnel (B). (From Yeh PC, Dodds SD, Smart LR, et al. Distal triceps rupture. J Am Acad Orthop Surg
2010;18(1):31–40; with permission.)

tip. The free ends of the graft are passed through in 5 acute tears repaired with suture anchors at a
the tunnel from opposite directions. An interfer- mean 32 months following surgery. Function was
ence screw is placed, securing the graft within nearly normal in these patients with a mean
the tunnel with the elbow in extension. DASH (Disabilities of the Arm, Shoulder, and
Hand) score of 1.4, American Shoulder and Elbow
CLINICAL OUTCOMES AND COMPLICATIONS Surgeons elbow score of 99.2, and a mean Mayo
Elbow Performance Index of 95.8. The results of
The clinical results of acute distal triceps tendon more anatomic repair constructs are largely un-
repairs are generally good; however, reruptures known. Kokkalis and colleagues29 reported the re-
have been described to occur in up to 20% of sults of 11 acute triceps tendon tears repaired with
cases.13 Successful repair is more predictable a double-row technique at a mean of 21 months
when performed within 2 to 3 weeks of injury. following surgery. All repairs were performed
One series noted that a primary repair was within 3 weeks of injury. The mean visual analog
feasible in only 6 of 15 cases when surgery scale pain score decreased from 8.5 preopera-
was performed more than 25 days after the tively to 2.4 at follow-up. The mean loss of elbow
injury.13 Most studies reporting the outcomes of extension was 7 and the mean arc of elbow mo-
triceps tendon repair are retrospective and tion was 136 . Elbow extension strength was
consist of small case series without control significantly improved but not quantified. Nine of
groups or direct comparisons of various repair the 11 patients were completely satisfied with the
constructs. In addition, outcomes are not re- surgery and had returned to full activity.
ported in a consistent fashion and often lack vali- Results of repairs of chronic ruptures often lack
dated scales of upper extremity function. quantitative data and objective outcome mea-
Van Riet and colleagues13 showed peak sures. However, Van Riet and colleagues13
strength of 92% (range of 75%–106%) and loss measured the outcomes of 9 chronic ruptures
of extension of 8 compared with the uninjured (average of 163 days before surgery) that under-
side at 1 year postoperatively in 14 acute tears went reconstructions. These patients showed, on
(average of 63 days before surgery) that were pri- average, 66% peak elbow extension strength
marily repaired using the transosseous cruciate (range of 35%–100%) and loss of elbow extension
technique. Mair and colleagues9 treated 11 acute of 13 . Despite the wide range of peak strength,
complete triceps tears in professional football this report shows that reconstructions of chronic
players with immediate repair. All but 1 missed tears are inferior to primary repairs of acute tears.
an entire season. There was 1 tendon rerupture. The results of repairs and reconstructions from 3
The remaining patients were doing well at 3 years recurrent rupture cases by van Riet and col-
postoperatively with no pain or subjective weak- leagues13 were functionally equivalent to results
ness. Bava and colleagues24 noted good results of first-time primary repairs.
 Distal Triceps Tendon Injuries 649

Common complications of triceps tendon re- 8. Capo JT, Collins C, Beutel BG, et al. Three-dimen-
pairs include olecranon bursitis, localized soft tis- sional analysis of elbow soft tissue footprints and
sue irritation from sutures or wires, residual mild anatomy. J Shld Elbow Surg 2014;23(11):1618–23.
elbow flexion contracture, and elbow extension 9. Mair SD, Isbell WM, Gill TJ, et al. Triceps tendon rup-
weakness. In addition, rerupture remains a tures in professional football players. Am J Sports
concern, especially with poor-quality tissue or de- Med 2004;32(2):431–4.
layed repairs performed under tension. 10. Stucken C, Ciccotti MG. Distal biceps and triceps in-
juries in athletes. Sports Med Arthrosc 2014;22(3):
153–63.
SUMMARY
11. Sollender JL, Rayan GM, Barden GA. Triceps
Acute triceps ruptures are an uncommon entity, tendon rupture in weight lifters. J Shld Elbow Surg
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elbow trauma. Accurate diagnosis is made clini- tendon associated with steroid injections. Am J
cally, although MRI may aid in confirmation and Sports Med 1993;21(3):482–5.
surgical planning. Acute ruptures are classified 13. van Riet RP, Morrey BF, Ho E, et al. Surgical treat-
on an anatomic basis based on tear location and ment of distal triceps ruptures. J Bone Joint Surg
the degree of tendon involvement. Most complete Am 2003;85-A(10):1961–7.
tears are treated surgically in medically fit patients. 14. Viegas SF. Avulsion of the triceps tendon. Orthop
Partial-thickness tears are managed according to Rev 1990;19(6):533–6.
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response to conservative treatment. Surgical rupture. J Am Acad Orthop Surg 2010;18(1):31–40.
repair offers predictable return of function with a 16. Downey R, Jacobson JA, Fessell DP, et al. Sonogra-
small risk of loss of elbow motion. Even surgical phy of partial-thickness tears of the distal triceps
treatment of chronic tears has shown improved brachii tendon. J Ultrasound Med 2011;30(10):
elbow extension strength and patient satisfaction. 1351–6.
We favor an anatomic footprint repair of the triceps 17. Wenzke DR. MR imaging of the elbow in the injured
to provide optimal tendon-to-bone healing and, ul- athlete. Radiol Clin North Am 2013;51(2):195–213.
timately, functional outcome. 18. Thornton R, Riley GM, Steinbach LS. Magnetic reso-
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