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.

 

 

Pitcher’s Elbow

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Today’s youth sports are more demanding than ever.  Seasons are longer and the practice and game schedule is intense.  Though with proper training and the ability to understand what pain may be signaling, a career ending injury can be avoided.

One of the more common overuse sports injuries we see affects the elbow and is known as Pitcher’s Elbow.

Throwing a baseball, particularly repeatedly as a pitcher does, puts a tremendous amount of stress on the inside of the elbow.  This stress is concentrated on a ligament known as the ulnar collateral ligament (UCL).

Lateral Collateral Ligament / Ulnar Collateral Ligament

When there is pain on the inside of the elbow it may mean that the ligament has either been stretched or has micro-tears.  The goal is to avoid throwing to the point of such pain, as it may indicate that the damage is already done!

There are many factors that can lead to the injury of a young player’s elbow ligament.  The main problem is throwing too much.  Often times this player is young, talented and needed in much of the game in order for the team to win.  The player then gets “overplayed,” until the elbow pain prevents further throwing.  The team must then find another pitcher and the cycle repeats.

Below are some suggestions that will hopefully help young pitchers – enabling them to mature and develop their full potential before an injury cuts their season short:

1. Pitch Count

The definitive pitch count guideline generally adopted comes from the 1996 American Sports Medicine Institute (ASMI) study.  This guideline includes maximum pitches per day, and days of rest between pitching.  Below are websites that include more information on this.

2. All Season Baseball

As our youth become more competitive, they begin to play year round.  This includes spring…..and now also summer and fall.  The elbow never gets a chance to rest and re-strengthen.  Ideally, the young athlete would pursue a different sport during the off-season – engaging different muscles, ligaments and tendons.  If baseball is the only sport, the pitcher must limit the amount of pitching during the off-season and work on some of the other influencing factors listed below.

 3. Pitching Mechanics

The mechanics of pitching are often left to the weekend warrior coach.  It may be worthwhile to find a professional pitching coach who can not only see the subtle corrections that need to be made, but also find a way to help the player make these adjustments as they throw at ever increasing velocity.  Consider that the player is developing as he gets older.  This means that the lessons from last year may no longer apply.  Players are not only getting taller, but developing more muscle.  This will impact their pitching mechanics.  A player should be re-evaluated every year or two.

 4. The Shoulder

Pitching is a rotation sport!  The windup starts in the body and gets transmitted to the hand via the shoulder and elbow.  If the shoulder is weak, the elbow must compensate.  This leads to injury.  It is important to strengthen the shoulder, chest and back in order to support this movement.  Specifically, it is important to strengthen the shoulder muscles that rotate the shoulder called the rotator cuff.  It is also important to strengthen the muscles that control the shoulder blade (scapula).  Young players have open growth plates in their bones, and injury to these growth plates are avoided by keeping the weight low.  The goal is not to build bulk but rather to build strength and stamina.  Weight training is best done in the off-season.   Smaller muscles like the rotator cuff can be exercised two or three times per week.  More than three times a week will weaken and not strengthen these muscles.  Finally, it is important to stretch the shoulder joint, especially the posterior capsule.  This is done by bringing the arm across the body and feeling the stretch on the back of the shoulder.

5. Fatigue

There is a difference between strength and fatigue.  As the game progresses, the muscles become fatigued.  The player, in their effort to maintain speed, start to use other muscles and change their throwing mechanics.  This then leads to increased strain on the elbow and ultimately to injury.  This may be avoided by strengthening the upper muscles in the off-season and by watching the pitch count during the season.

6. Addressing an already painful elbow

Pain in the elbow could indicate that the elbow is injured.  The first step is to stop playing baseball and seek the assessment of an orthopedic specialist.

–  Once pain is resolved and the tenderness is completely gone, initiate a strengthening program focusing on muscles of the chest, back and shoulders

– After the strengthening program is well on its way, the player should seek an evaluation by a professional pitching coach.

-Gradually the player will increase pitching distance and speed – with particular focus on proper mechanics

– After completing these steps, players can return to the regular season.

Typically, once a player has elbow pain they generally require about six months to complete the steps above.  Since the pain often occurs at the start or middle of a pitching season, this usually means that they will lose out on the remainder of that season.  Though, this is preferable to permanently damaging the arm and eliminating any chance of playing another season.

Helpful Websites:

www.qcbaseball.com

www.WebBall.com

www.littleleague.org   (pitch count regulation)

www.pitchsmarter.com