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Obere Extremität 2020 · 15:268–272https://doi.org/10.1007/s11678-020-00601-0Received: 30 June 2020Accepted: 21 August 2020Published online: 25 September 2020© The Author(s) 2020

Sebastian Lappen1 · Stephanie Geyer1 · Bastian Scheiderer1 · Craig Macken2 ·Augustus D. Mazzocca2 · Andreas B. Imhoff1 · Sebastian Siebenlist11 Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich,Munich, Germany

2Department of Orthopaedic Surgery, University of Connecticut, Farmington, USA

Distal triceps tendinopathies

Tendinopathy of the triceps tendon isthe rarest tendinopathy of the elbow [1].An evaluationof 801magnetic resonanceimages of elbows and upper extremitiesof 740 patients with elbow pain showedtriceps pathologies in 9.9% of the im-ages evaluated [24]. Signal alterations inthe triceps tendon without a visible dis-ruption were seen in 6% of the imageswhile triceps tendon lesions were visiblein 3.8% of the images, of which morethan 50% were partial ruptures. The av-erage age of patients with triceps tendonpathologies was 47 years.

» Triceps tendon rupturesaffect men twice as often aswomen

Triceps tendon ruptures affect men twiceas oftenaswomen [9]. While case reportsexist for patients of all age groups, ado-lescents with incompletely or recentlyclosed growth plates are particularlyaffected. Triceps ruptures are also par-ticularly common among weightliftersand American football players. Generalrisk factors include cortisone intake,anabolic steroid abuse, internal diseasessuch as chronic kidney failure, hyper-parathyroidism and type 1 diabetes,hypocalcemic tetany, Marfan syndrome,osteogenesis imperfecta, rheumatoidarthritis, and chronic olecranon bursitis[9, 10, 12].

Anatomy, histology, andpathogenesis

The triceps tendon attaches approxi-mately 12–14mm distal to the olecranontip, where it has a width of approx.40mm [29]. The bony footprint is ap-

prox. 460mm2 with an average length ofapprox. 21mm and a width of 23mm.The caput longum and mediale convergedistally and form the superficial partof the triceps tendon, which attachesdirectly to the medial aspect of the ole-cranon and laterally partially convergeswith the superficial fascia of the an-coneus muscle [9]. The exact anatomyof the deep portion of the triceps tendonremains disputed. Masen et al. describea separate lower insertion tendon of thecaput mediale [16], while Keener et al.depict histologically a confluence of themedial tendon parts with the centraltendon [12]. Ruptures can start bothfrom the medial or the lateral part of thetendon [9]. The typical injury mecha-nism is described as an eccentric force onthe contracting muscle, for example, dueto a fall on the outstretched arm, duringweight-lifting, or due to a direct traumato the elbow [9, 12, 16, 27]. Rupturesoccur in particular near the insertionof the tendon onto the olecranon, lessoften at the myotendinous junction.

» The exact anatomy of thedeep portion of the tricepstendon remains disputed

Histologically, tendinopathyshowcellac-tivationandproliferation,matrixchangesincludingdisorganizationofcollagenandneovascularization [20]. Since this re-modeling process is often not painful,tendinopathies mostly become notice-able or symptomatic only when the ten-don is ruptured. There are also differ-ences in gene expression and histologicalparameters in different tendon regionsand at different times during the healingprocess [6].

Symptoms, clinical signs, anddiagnostics

Diagnosis is often delayed due to misdi-agnosis [26]. If tendinopathy of the tri-ceps tendon is suspected, risk factors andtraumatic events including the accidentcircumstances should be inquired at first.Clinically, tendinopathy of the tricepstendon manifests in stress-related pos-terior pain, which increases with forcedextension against resistance [9, 15]. Ifthe triceps tendon is ruptured, swelling,ecchymosis, loss of strength in extension,and a palpable gap along the course of thetendon can also occur [15, 19]. However,the latter can be difficult to see due toswelling of the soft tissue. The inability offull extension can be considered as a signof complete rupture. A weaker extensionin comparison between the healthy andthe affected side can still be possible bycompensation from the anconeusmuscleor remaining parts of the triceps mus-cle. [15]. Tendinopathies often occurbilaterally. For example, rupture of theopposite extremity is almost 200 timesmore common in patients with Achillestendon rupture [3]. Bilateral clinical im-provement can often be observed afterunilateral surgical treatment, althoughthe exact mechanisms have not yet beenfully elucidated [2]. Bilateral ruptureshave also been described regarding thetriceps tendon [11].

ViegasproposedthemodifiedThomp-son test as a clinical examination sign forruptures of the triceps tendon [27]. Forthis test, the patient’s elbow is placed onthe edge of the examination table. Themuscle is compressed manually, whichleadstoapassiveextensionagainstgravitywith tendon integrity or partial rupture,with no extension in complete ruptures

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Fig. 19 Thomp-son testmodifiedaccording to Viegas

(. Fig. 1). However, the test is difficult toperform due to the large lever arm of theforearmand the relatively smallmuscle ofthe tricepsmuscle, and it is often difficultto interpret because of pain and swelling[19]. In everyday clinical practice, theextension test against resistance in theoverhead position has prevailed (. Fig. 2;[14, 15]). With the shoulder elevated at180 ° and the elbow flexed, the patient isasked to extend the arm against gravityor against resistance. If elbow extensionis not feasible, this suggests a completerupture of the triceps tendon. In par-tial ruptures, it is often still possible toextend against gravity, but only with sig-nificantly reducedextension force againstresistance in comparison with the unaf-fected side. However, information onsensitivity and specificity of this test isstill unavailable.

» Tendinopathies often occurbilaterally

X-rays should always be acquired to de-tectbonyavulsioninjuriesat the insertionarea of the triceps tendon [10]. This so-called flake of bone sign (proximaliza-tion of the torn-out fragment) can beseen in 61–88% of triceps tendon rup-tures (. Fig. 3).

In the sonographic examination, thesuperficial parts of the triceps tendon canbe seen better compared with its deepparts (. Fig. 4; [25]). The dynamic ex-amination of the tendon is advantageous;the tension of tendon parts can be ex-

amined with extension against resistanceand, in the case of a bony rupture, theproximalizing of the fragment can be vi-sualized during muscle contraction.

Magneti resonance imaging (MRI) di-agnostics are suitable for assessing the ex-tent of injury, possible tendon retraction,changes in muscle quality, and accompa-nying injuries, since both the superficialand deep areas of the tendon and itssurrounding structures can be assessedwell (. Fig. 5; [9, 14]). Tendinopathiesshow abnormal signal intensities in liq-uid-sensitive sequences, while with rup-tures a waved triceps tendon is seen asan indication of a lack of tension [9].

Treatment

Conservative management

Conservative treatment approaches canbe used for tendinopathies and partialtendon ruptures [9, 10]. The elbow is firstimmobilized in a brace andflexion is lim-ited to 30° for 4 weeks [14]. In principle,it is important that the immobilizationphase is as short as possible in order tominimize the riskof joint stiffness. Rangeof motion is then successively releasedin a movable brace after initial move-ment limitation. Unrestricted range ofmovement, which should be reached af-ter 12 weeks at the latest, is required inorder to start active training of extensionstrength. Full extension strength shouldbe restored after a period of 6–9 months[14, 30].

Fig. 28 Extension test against resistance in theoverheadposition

Publications on conservative treat-ment are limited to a few case reports.Mair et al. [17] retrospectively describea case series of 10 partial ruptures of19 National Football League players,six of whom were successfully treatedconservatively. Overall, the majority ofpatients showed good clinical outcomewith no signs of dysfunction or loss ofstrength. However, three of the patientstreated conservatively showed a lackof strength and pain at the end of theseason. A complete triceps tendon rup-ture occurred in one player, after whichtreatment was switched to a surgicalapproach.

With regard to the limited data avail-able, it is currently difficult to makerecommendations for further conserva-tive treatment options, so that in manyrespects, conservative treatment ap-proaches of other tendinopathies shouldbe considered. Nonsteroidal anti-in-flammatory drugs (NSAIDs) can beused preferably topically, although posi-tive effects have not been demonstratedfor various kinds of tendinopathy [28].

Cortisone injections—as with ten-dinopathiesofotherlocations—representa clear risk factor for ruptures [10, 12],which is why they should be used withextreme caution.

The injection of platelet-rich plasma(PRP) shows good results for the treat-ment of elbow tendinopathies in individ-ual studies [13]. However, there is a highdegree of heterogeneity in the methodsused to produce PRP, whichmakes it dif-ficult tomakeadefinitive statementabout

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the effectiveness of PRP injections. Forthe distal triceps tendon, there is onlyone case report of a partial distal tricepstendon rupture in the current literature,whichwas treatedwithPRP injectionandphysiotherapy [7]. At 2 weeks after theinjection and before the start of the phys-iotherapy, a reduction in pain was foundin a follow-up examination, and 4 weeksafter the injection, an increase in elbowstrength from 3/5 to 4/5 was seen.

Recommendations regarding phys-iotherapy and physical therapy fortendinopathies in general include ec-centric training, cross-friction, andcryotherapy[28]. Inthis regard, however,there are no explicit recommendationsfor tendinopathy of the distal tricepstendon.

Reports of extracorporeal shock wavetherapy (ESWT) in tendinopathies of theelbow show good results, but this is usu-allyrelated tothe treatmentofepicondyli-tis [28]. There are currently nodata avail-able on the treatment of triceps tendontendinopathies with ESWT.

Donaldson et al. [9] recommend reg-ular check-ups during conservative treat-ment of partial ruptures in order to de-tect an enlargement of the rupture atan early stage. If symptoms persist after6 months of conservative treatment, sur-gical treatment should be discussed. Thepatient’s age, comorbidities, and activitylevel must be taken into account whenmaking this decision [14].

Surgical treatment

Surgical treatment consists of debride-ment of the insertion region with sub-sequent anatomical refixation. Surgicalreconstruction is indicated for completeruptures. There is no uniform recom-mendation for the operative treatmentof partial ruptures. Depending on thesource, surgical refixation is recom-mended for partial tendon ruptures of50–75%, with a relevant strength deficitcompared with the healthy opposite side[9, 21].

The most widespread refixation tech-nique is transosseous triceps tendon fix-ation, which, however, has disadvantagesregarding primary stability and footprintcoverage due to the inexact anatomical

Abstract · Zusammenfassung

Obere Extremität 2020 · 15:268–272 https://doi.org/10.1007/s11678-020-00601-0© The Author(s) 2020

S. Lappen · S. Geyer · B. Scheiderer · C. Macken · A. D. Mazzocca · A. B. Imhoff · S. Siebenlist

Distal triceps tendinopathies

AbstractTendinopathy of the distal triceps representsa rare pathology in the upper extremity.Although there is scant scientific evidencepublished to date, the association with riskfactors such as internal diseases or steroiduse is commonly described in various reports.Due to traumatic incidents or sportingoveruse, partial or complete ruptures canoccur. Clinically, stress-related posterior elbowpain, swelling, ecchymosis, loss of strength inextension, and a palpable gap in the tendoncan be seen. Physical examination showsreduced extension force and increasing painwith forced extension against resistance. Ten-

dinopathies and resulting partial or completeruptures can be detected by ultrasound andmagnetic resonance imaging. Conservativetherapy with temporary immobilization isrecommended for tendinopathies or minorruptures of the triceps tendon. Completeruptures or larger partial ruptures should betreated surgically with anatomical refixationof the tendon.

KeywordsElbow · Tendon injuries · Rupture · Tricepsinsufficiency · Pain

Tendinopathien der distalen Trizepssehne

ZusammenfassungDie Tendinopathie der distalen Trizepssehneist ein seltenes Krankheitsbild, das wis-senschaftlich bisher nur wenig beleuchtetwurde. Die Trizepssehnentendinopathie isthäufig mit Risikofaktoren wie internistischenErkrankungen oder Einnahme von Steroidenassoziiert und kann sich in Form einerPartial- oder Komplettruptur aggravieren.Diese Rupturen treten insbesondere beitraumatischen Ereignissen oder in starkenBelastungssituationen auf. Klinisch könnenstressbedingte posteriore Ellenbogen-schmerzen, Schwellung, Ekchymosen,Kraftverlust in der Extension und einetastbare Dellenbildung im Verlauf der Sehnevorkommen. Die körperliche Untersuchungzeigt eine verringerte Streckkraft und eineZunahme der Schmerzen bei forcierter

Extension gegen Widerstand. Tendinopathienund daraus resultierende Partial- oderKomplettrupturen können sonographischund MRT-morphologisch nachgewiesenwerden. Nativradiologisch ist in einigen Fälleneine knöcherne Avulsion zu erkennen. BeiTendinopathien oder kleineren Teilrupturender Trizepssehne ist die konservative Therapiemit temporärer Immobilisierung empfeh-lenswert. Bei vollständigen Rupturen odergrößeren Partialrupturen ist die operativeTherapie zur anatomischen Refixation derSehne indiziert.

SchlüsselwörterEllenbogen · Sehnenverletzungen · Ruptur ·Trizepsinsuffizienz · Schmerz

reinsertion [14]. The “knotless suture-bridge repair” technique—adopted fromshoulder surgery—includes a double-row, crossing anchor fixation of thetriceps tendon [8]. Thanks to an al-most anatomical reconstruction, highbiomechanical primary stability can beachieved. On this basis, the modifiedV-shaped double-row triceps tendonreconstruction was developed in ourgroup, which has improved biomechan-ical primary stability compared with thesuture-bridge technique and is associ-ated with less tendon dislocation [23].An example of a surgically treated rup-

ture of the distal triceps tendon usingthe V-shaped double row reconstruction[22] is shown in . Fig. 6. With thistechnique, two double-hinged anchorsare placed medially and laterally at theproximal insertion area of the tricepstendon. The distal triceps tendon is thensecured medially, laterally, and centrallywith four sutures over a length of at least3 cm. Approximately 4cm distal to theolecranon tip, a monocortical boreholeis made at a 45 ° angle in a proximal di-rection to the ulna shaft. The free threadends are threaded into a button and thisis inserted transcortically. The button is

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Fig. 39 For the sono-graphic examination ofthe triceps tendon, thepatient rests their palm onthe examination table andflexes the elbow at 90° (a).The triceps tendon cannowbe assessedwith itsinsertion to the olecranonin longitudinal section (b)and in cross section

Fig. 48 “Flake of Bone”: typical sign on lateralX-ray image for triceps avulsion injuries

Fig. 68 Postoperative X-ray image of the surgically treated complete rupture of the distal triceps ten-don using a V-shapeddouble-row reconstruction [23]

then flipped in an intramedullary fash-ion by pulling on the ends of the threadsand the tendon pressure is adjusted bytensioning the threads (. Fig. 6).

Postoperatively, the elbow is immo-bilized in 90° flexion in a posterior castfor 3–4 days [14]. The patient is thenswitched to a movable brace with flexionbeing limited to 90° for 6 weeks. The pas-

Fig. 59 Completerupture of thetriceps tendon onmagnetic resonanceimaging

sive and active-assisted exercise beginson the first postoperative day with a re-striction of active extension for 6 weekspostoperatively. Sporting activities areprohibited for at least 12 weeks.

Athwal et al. [4] also describe thepossibility of arthroscopic refixation ofthe triceps tendonandwere able to reportgood clinical results in two cases.

Overall, few case series and case re-portsdescribegoodpostoperative results,with 89% of the operated patients beingable to return to the pre-traumatic ac-tivity level [10]. In the described cases,however, traumatic events are usually de-scribedas thecauseof therupturewithoutpredisposing tendinopathy. Bava et al.[5] reported good results from five sur-gically treated patients 32 months post-operatively, with the vast majority of thepatients regaining full strength and a fullrange of motion. Other cases are de-scribed in which operated patients couldbench press weights of more than 200kg[18] or return to competitive motorcy-cle races, professional football, or pro-fessional hockey [10]. Van Riet et al.[26] report 23 interventions on 22 pa-tients with eight complete and 15 par-tial ruptures. Good clinical results wereshown with an average extension loss of10° and an average flexion of 136 °. Man-ual strength tests showed a strength levelof at least 4/5 and the isokinetic peak

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Übersicht

strength averaged 82% of the unaffectedarm. In ten patients the ruptures wereinitially not recognized, and thus therewas adelaybetween injury anddiagnosis.Although the results were comparable tothose receiving early care, the recoveryprocess of patients with delayed diagno-sis was overall slower; therefore, earlysurgical treatment within 3 weeks is rec-ommended as the treatment of choiceafter post-traumatic treatment.

» Surgical reconstruction isindicated for complete ruptures

Postoperative complications include sec-ondary olecranon bursitis and a persis-tent flexion deficit of up to 20°. The re-rupture rate is low at 6% and mostly as-sociated with renewed trauma [9]. VanRiet describes results that are as good forsurgically treated ruptures as for primaryinterventions [26].

Practical conclusion

4 Tendinopathy of the triceps tendonshows reduced extension force andan increase in pain with forcedextension against resistance.

4 Ruptures occur especially aftertraumatic events or strong, suddenloads of extension.

4 Clinical examination and magneticresonance imaging are the gold stan-dard for diagnosis, while ultrasoundand X-rays can provide additionalinformation.

4 In the case of complete rupturesand larger partial ruptures, surgicaltreatmentwith anatomical fixation ofthe tendon is indicated.

Corresponding address

Prof. Dr. med.Sebastian SiebenlistDepartment of OrthopedicSports Medicine, Klinikumrechts der Isar, TechnicalUniversity of MunichIsmaningerstraße 22,81675Munich, Germanysebastian.siebenlist@tum.de

Compliance with ethicalguidelines

Conflictof interest. S.Lappen,S.Geyer,B.Scheiderer,A.B. ImhoffandS. Siebenlist declare that theyhave nocompeting interests.

For this article no studieswith humanparticipantsor animalswere performedby anyof the authors. Allstudies performedwere in accordancewith the ethicalstandards indicated in each case.

Open Access. This article is licensedunder a CreativeCommonsAttribution 4.0 International License,whichpermits use, sharing, adaptation, distribution and re-production in anymediumor format, as long as yougive appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons li-cence, and indicate if changesweremade. The imagesor other third partymaterial in this article are includedin the article’s Creative Commons licence, unless in-dicatedotherwise in a credit line to thematerial. Ifmaterial is not included in the article’s Creative Com-mons licence and your intendeduse is not permittedby statutory regulation or exceeds the permitteduse,youwill need toobtain permissiondirectly from thecopyright holder. To viewa copyof this licence, visithttp://creativecommons.org/licenses/by/4.0/.

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