Triceps Tendon Trauma – Rare but Serious

In our last blog we discussed biceps tendon ruptures, which occur when the biceps tendon (located in front of the upper arm) is torn from the bone at the point of tendon attachment – either at the shoulder or the elbow.

In contrast, rupture of the triceps tendon (representing the opposing muscle group to the biceps and located at the back of the elbow) is an injury that occurs most commonly from the forced bending of the elbow during a forceful pushing activity, causing the triceps tendon attachment to separate from the bone.

The triceps muscle tendon is responsible for elbow straightening/extension and strength. A triceps tendon that has ruptured prevents the muscle’s normal function and results in weakness and restricted elbow extension.

Triceps Tendon Rupture Diagnosis

Triceps tendon ruptures are rare, accounting for just 0.8% of tendon ruptures, and therefore often misdiagnosed in the emergency department (1,2).

Symptoms may include:

  • Swelling and tenderness to touch at the back of the elbow (where tendon attaches)
  • Weakness/loss of strength when elbow is extended against resistance
  • Inability to follow through with certain movements

This type of injury generally occurs in a sports-related trauma or harsh impact and are more frequently diagnosed in men aged 30 -50.  They are more likely to occur when the biceps and triceps muscle groups are not equally strengthened and pushed to an extreme.

Additional Risk Factors:

  • Excessive weight/power lifting, body building
  • Systemic illness (hyperparathyroidism, renal osteodystrophy)
  • Anabolic steroid use
  • Local steroid injection
  • Fluoroquinolone use
  • Chronic olecranon bursitis
  • Previous triceps surgery
  • Marfan syndrome (2,3)

If this injury is missed or neglected, the individual/athlete may experience weakness with elbow extension and an inability to support a block in football, lift weights, or perform push-ups.

Triceps Tendon Rupture Treatment

While the severity of the injury will determine treatment, surgery is usually indicated in cases of complete rupture and entails tendon repair using bone suture anchors or bone tunnels. Surgery is then followed by a rigorous rehabilitation program that moves from isometric extension exercises to weight-resisted and eventually throwing exercises.

Delayed repair becomes technically demanding and yields treatment results that are inferior to acute repair (2). Early diagnosis and repair will lead to the best possible outcome.

Preventing Injury

While a triceps tendon rupture caused by trauma may be difficult to avoid, those involved in power lifting and body building should be cognizant of such repercussions from the load sport and affiliated supplements.  Equal training of opposing muscle groups, regular stretching and adequate muscle rest have also been found to reduce risk of many different types of musculoskeletal injuries (4).

References

  1. Ahn L., Ahmad CS. Triceps Rupture. American Shoulder and Elbow Surgeons, Orthobullets.com, 2019. Retrieved from https://www.orthobullets.com/shoulder-and-elbow/3071/triceps-rupture
  2. Kocialkowski C, Carter R, Peach C. Triceps Tendon Rupture: Repair and Rehabilitation. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734527/.
  3. Nikolaido ME., Banke IJ., Laios T., et al.Synthetic Augmented Suture Anchor Reconstruction for a Complete Traumatic Distal Triceps Tendon Rupture in a Male Professional Bodybuilder with Postoperative Biomechanical Assessment. Case Rep Orthop. 2014; 2014:962930. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965944/.
  4. Tucker A. Why it Matters if One Side of Your Body is Stronger than the Other – and How to Fix It. Self, 2017. Retrieved from https://www.self.com/story/muscle-imbalances.

 

 

Biceps Tendon Tears – When Not to Push Through the Pain

From a young age we’ve heard; “no pain, no gain.”  Some even see it as a personal challenge.  And while a youthful body can be forgiving when pushed beyond its limits, an adult one is not.

Pain is our body’s warning to either stop or proceed with caution.  Ignoring this or “pushing through” could come at a cost, particularly as we get older.

As working professionals workouts are less frequent and muscle mass, correspondingly, less sufficient to sustain the same weights and reps.

Additionally, as we age, our musculoskeletal system changes.  Joints, tendons and ligaments are feeling the cumulative effects of decades of activity.  To ensure decades more, we need to be smart in our workout routines and the challenges we’re willing to take on.

One injury we often see in men ages 40 – 60 are biceps tendon tears and ruptures.  This often happens when the biceps tendon experiences chronic wear as a result of lifting excessive weights or participating in aggressive contact sports.  It can also occur in those performing repetitive overhead lifting or work in occupations requiring regular heavy lifting.

The Biceps Muscle and the Difference between a Tear and a Rupture

The biceps muscle is located in the front of the upper arm and helps to bend and rotate the arm. It has two tendons; 1.) the long head and the short head of the biceps, which attach the muscle to the shoulder, and 2.) the distal biceps tendon, which attaches at the elbow/forearm.

The terms biceps tear and biceps rupture are often used interchangeably and occur when the biceps muscle is torn from the bone at the point of tendon attachment, either at the shoulder or the elbow.  A tear could represent either a partial or a complete tear.

Biceps tendon tears most often occur at the long head of the biceps at the upper arm bone.  It rarely occurs at the elbow, unless trauma from a sudden accident occurs.

While biceps tears do not repair themselves and can limit full function of the arm unless surgically repaired, those occurring at the elbow cause greater arm weakness than those occurring more commonly at the shoulder/upper arm.

Indications of a Biceps Tendon Tear or Rupture

  • A “pop” or snap at the shoulder or elbow.
  • Sharp pain in the upper arm.
  • Bruising and swelling in the affected area.
  • Weakness and tenderness in the shoulder or when bending the elbow, rotating the forearm, or lifting the arm overhead.
  • A deformity/bulge in the lower part of the biceps referred to as “Popeye arm.”

Treatment of a Distal Biceps Tendon Tear

Following a physical examination and functional testing, the severity of the injury will be determined.  While physical therapy may suffice for elderly patients with low upper body demands, surgery is generally indicated for younger patients.  This may entail either a nonanatomic repair to the brachialis or, most commonly, an anatomic repair to the radial tuberosity [1].

The surgical approach has evolved from an anterior approach to a two-incision approach and most recently to a single-incision approach with a bone anchor or ENDOBUTTON™.

Advantages of this approach include anatomical reinsertion, flexion restoration and supination strengthening [2].

Preventing Biceps Tendon Rupture

  • Maintain equal strength throughout the arm – biceps/triceps, elbow and forearm – and in the shoulders.
  • Avoid repetitive overhead lifting of excessive weight.
  • Use the entire upper body when lowering heaving objects to the ground.
  • Avoid steroid use and smoking, as they weaken muscles and tendons and inhibit muscle recovery and growth.

References

  1. Ward JP, Shreve MC, Youm T, Strauss EJ. Ruptures of the distal biceps tendon. Bull Hosp Jt Dis (2013). 2014;72(1):110–119. Article Summary in PubMed.
  2. Tarrallo L, Lombardi M, Zambianchi F, Giogini A, Cantani F. Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach.BMC Musculoskelet Disord. 2018;19:364. Full articles online.