TRICEPS TENDINOPATHY

What is Triceps Tendinopathy?

• Triceps tendinopathy is a condition marked by pain and dysfunction at the triceps tendon. Injuries to the triceps tendon typically occur at its insertion on the olecranon of the elbow and are among the rarest tendinopathies around the elbow [Donaldson, et. al, 2014].

  • The triceps brachii muscle is a large, thick muscle on the back of the
    upper arm that is composed of three heads (tri = three, cep = head).
    Each of the three heads originates in a different location, but all
    three combine to form a single tendon that inserts into the posterior
    elbow [Tiwana, et. al., 2023].
    

• Triceps tendinopathy is often the result of overuse or repetitive strain, leading to microtears and subsequent degenerative changes within the tendon.
  

  • Histologically, the tendon is characterized by collagen disorganization, increased microvasculature, and sensory nerve innervation, as well as dysregulation of the extracellular matrix homeostasis [Millar et al, 2021].

• Rupture of the triceps tendons is rare and accounts for less than 1% of all upper extremity tendon ruptures and 2% of all tendon injuries [Sharma et al, 2005].
  

What are the symptoms of triceps tendinopathy?

• Triceps tendinopathy is characterized by posterior elbow pain, which is typically exacerbated by activities involving elbow extension, such as pushing or lifting against resistance.
  

• Patients may also experience weakness in elbow extension, making it difficult to perform tasks that require forceful extension of the arm [Tom et al, 2014; Molloy et al, 2013].
  

How is triceps tendinopathy diagnosed?

Triceps tendinopathy is diagnosed through a combination of clinical evaluation and imaging studies.

• Clinically, the diagnosis of triceps tendinopathy begins with a detailed history and physical examination.
  
  • Key symptoms include posterior elbow pain, weakness in elbow extension, and tenderness at the triceps tendon insertion on the olecranon. A palpable defect or gap in the tendon may also be noted during the physical examination [Tom et al, 2014; Walker & Noonan, 2020].
• Imaging studies play a role in confirming the diagnosis and assessing the extent of the injury, but the severity of symptoms in triceps tendinopathy does not always correlate directly with imaging findings. Studies have shown that structural changes observed in imaging, such as tendon thickening, partial or complete tears, and hypoechogenicity, do not consistently align with the clinical severity of symptoms [Docking et al, 2015; Bley & Abid, 2015; Clarke et al, 2010; Koplas et al, 2011]..
  • Plain radiographs are often the initial imaging modality used to rule out bony abnormalities and may reveal a Flake sign, indicative of an avulsion fracture at the tendon insertion [Tom et al, 2014; Walker & Noonan, 2020].
  • Diagnostic musculoskeletal ultrasound (US) is a valuable imaging modality, offering a dynamic evaluation of the tendon. It can detect partial and complete thickness tears and assess tendon integrity. US is less expensive and more accessible than MRI, making it a useful tool in the initial assessment and follow-up of tendinopathy [Thomas et al, 2022; Potter, 2000].
    
  • Magnetic Resonance Imaging (MRI) is particularly useful for evaluating soft tissue injuries, including tendinopathy. MRI can distinguish between partial and complete tendon tears and identify tendinopathic changes including tendon thickening, enthesopathy, and reactive bone marrow changes [Fritz & Steinbach, 1996; Kheterpal & Bredella, 2019; Gabel, 1999; Koplas et al, 2011].

How is triceps tendinopathy treated?

For those with triceps tendinopathy, treatment options are categorized into operative and non-operative.

Conservative Management

• Physical Therapy: There is evidence to support the efficacy of physical therapy for triceps tendinopathy, particularly through the use of eccentric exercises, progressive strengthening, and activity modification to reduce pain and improve function [Cooper et al, 2023; Irby et al, 2020; Ortega-Castillo et al, 2022].
• Corticosteroid Injections: Steroid injections can provide short-term pain relief, but are not recommended for long-term use due to potential adverse effects, including tendon rupture [Irby et al, 2020; Andres & Murrell, 2008; Hegmann et al, 2013].
  
• Extracorporeal Shockwave Therapy (ESWT) has been studied for its efficacy in treating various tendinopathies, although direct studies on triceps tendinopathy are limited.
  • A systematic review by Karanasios et al. demonstrated that ESWT significantly reduced pain intensity and improved grip strength in patients with lateral elbow tendinopathy, suggesting potential benefits for triceps tendinopathy as well [Karanasios et al, 2021].
  • Pellegrino et al. found that both radial and focused ESWT were effective in managing lateral elbow tendinopathy, with focused ESWT providing earlier pain relief and fewer minor adverse events [Pellegrino et al, 2023].
• Platelet-Rich Plasma (PRP) Injections: There is limited direct evidence for the use of platelet-rich plasma (PRP) in the treatment of triceps tendinopathy. However, evidence from studies on other tendinopathies can provide insights into its potential efficacy [Finnoff et al, 2021; Fitzpatrick et al, 2017; Filardo et al, 2018].
  • Cheatham et al. presented a case report and rehabilitation strategy used following a PRP injection for a patient with a partially torn distal triceps tendon. The patient returned to light weight training and coaching activity after completing 15 visits over a 3 month period. One month after discharge, the patient reported pain-free activities of daily living and a return to previously performed gym activities, suggesting that PRP presents a viable treatment option for individuals who are recalcitrant to conservative interventions yet elect to avoid more invasive surgical measures [Cheatham et al, 2013].
    

Surgical Intervention

Surgery is typically reserved for cases where conservative treatments fail or in the presence of significant tendon tears. Surgical treatments for triceps tendinopathy include both traditional open surgical approaches and minimally invasive techniques such as minimally invasive tenotomy (Tenex procedure).

• Minimally Invasive Tenotomy: Minimally invasive tenotomy involves the use of small incisions with the goal of reducing recovery time and minimize complications compared to traditional open surgery. The procedure is typically performed under local anesthesia and guided by ultrasound to ensure precision. The Tenex procedure use a specific type of tenotomy device that uses a proprietary device to microresects the pathological tendon tissue while preserving healthy tissue.
  
  • Stover et al. reported significant improvements in pain and function or various elbow tendinopathies, including triceps tendinopathy at both short- and long-term follow-ups [Stover et al, 2019].
  • Sussman et al. reported a series of 5 patients with triceps tendinopathy and partial tearing treated with a tenotomy under ultrasound guidance with a significant improvement in pain [Sussman et al, 2019].
    
  • Hall & Woodroffe presented a case report of a strongman with chronic triceps tendinosis treated with a tenotomy under ultrasound guidance with excellent result up to a 3-year follow-up [Hall & Woodroffe, 2017].
• Open surgery is typically reserved for cases of complete tendon rupture or when conservative treatments have failed. It involves an open incision with direct visualization and repair of the tendon that involves reattaching the tendon to the bone (olecranon). Open surgery is associated with longer recovery times, higher risk of complications, and a more invasive nature compared to minimally invasive techniques.
  • A systematic review by Shomal Zadeh et al. found that minimally invasive tenotomy provides similar outcomes to surgical tenotomy, with significant improvements in pain and function [Shomal Zadeh et al, 2023; Shomal Zadeh et al, 2023].

What are potential complications if triceps tendinopathy is left untreated?

Untreated triceps tendinopathy can lead to tendon rupture, chronic pain, functional impairment, secondary complications, and potentially more complex surgical interventions with prolonged recovery times.

• Progression to Partial or Complete Tendon Rupture: Chronic tendinopathy can lead to progressive degeneration of the tendon, increasing the risk of a partial or complete tendon rupture [Tom et al, 2014; Walker & Noonan, 2020].
  
• Chronic Pain and Functional Impairment: Persistent posterior elbow pain can become chronic, impacting quality of life and the ability to perform daily activities. Weakness in elbow extension can lead to functional limitations, making it difficult to perform tasks that require pushing or lifting [Gabel, 1999; Hegmann et al, 2013].
• Secondary Complications: Untreated tendinopathy can lead to compensatory mechanisms and altered biomechanics, potentially causing secondary issues such as shoulder or wrist problems due to overuse or improper mechanics [Gabel, 1999]
• Surgical Intervention: Delayed treatment may necessitate more complex surgical interventions. Acute tendon injuries, if not addressed promptly, may require more involved surgical reconstruction rather than simpler primary repairs [Gabel, 1999].
• Prolonged Recovery: The longer the condition remains untreated, the more extended the recovery period may be, even with eventual intervention. This can delay return to normal activities and sports [Tom et al, 2014; Hegmann et al, 2013].

Resources:

• Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008 Jul;466(7):1539-54.
  

• Bley B, Abid W. Imaging of Tendinopathy: A Physician's Perspective. J Orthop Sports Phys Ther. 2015 Nov;45(11):826-8.
  

• Cheatham SW, Kolber MJ, Salamh PA, Hanney WJ. Rehabilitation of a partially torn distal triceps tendon after platelet rich plasma injection: a case report. Int J Sports Phys Ther. 2013 Jun;8(3):290-9.
  

• Clarke AW, Ahmad M, Curtis M, Connell DA. Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability. Am J Sports Med. 2010 Jun;38(6):1209-14.
  

• Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess. 2023 Oct;27(24):1-389.

• Donaldson O, Vannet N, Gosens T, Kulkarni R. Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies. Shoulder Elbow. 2014 Jan;6(1):47-56.

• Demirhan, M., & Ersen, A. (2017). Distal triceps ruptures. EFORT open reviews, 1(6), 255–259. https://doi.org/10.1302/2058-5241.1.000038

• Docking SI, Ooi CC, Connell D. Tendinopathy: Is Imaging Telling Us the Entire Story? J Orthop Sports Phys Ther. 2015 Nov;45(11):842-52.
  

• Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc. 2018 Jul;26(7):1984-1999.
  

• Finnoff JT, Awan TM, Borg-Stein J, Harmon KG, Herman DC, Malanga GA, Master Z, Mautner KR, Shapiro SA. American Medical Society for Sports Medicine Position Statement: Principles for the Responsible Use of Regenerative Medicine in Sports Medicine. Clin J Sport Med. 2021 Nov 1;31(6):530-541.
  

• 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 Jan;45(1):226-233.
  

• Fritz RC, Steinbach LS. Magnetic resonance imaging of the musculoskeletal system: Part 3. The elbow. Clin Orthop Relat Res. 1996 Mar;(324):321-39.
  

• Gabel GT. Acute and chronic tendinopathies at the elbow. Curr Opin Rheumatol. 1999 Mar;11(2):138-43.
  

• Hall MM, Woodroffe L. Ultrasonic Percutaneous Tenotomy for Recalcitrant Calcific Triceps Tendinosis in a Competitive Strongman: A Case Report. Curr Sports Med Rep. 2017 May/Jun;16(3):150-152.

• Hegmann KT, Hoffman HE, Belcourt RM, Byrne K,Glass L, Melhorn JM, Richman J, Zinni P 3rd, Thiese MS, Ott U, Tokita K, Passey DG, Effiong AC, Robbins RB, Ording JA; American College of Occupational and Environmental Medicine. ACOEM practice guidelines: elbow disorders. J Occup Environ Med. 2013 Nov;55(11):1365-74.
  

• Irby A, Gutierrez J, Chamberlin C, Thomas SJ, Rosen AB. Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Scand J Med Sci Sports. 2020 Oct;30(10):1810-1826.
  

• Karanasios S, Tsamasiotis GK, Michopoulos K, Sakellari V, Gioftsos G. Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis. Clin Rehabil. 2021 Oct;35(10):1383-1398.

• Kheterpal AB, Bredella MA. Overuse Injuries of the Elbow. Radiol Clin North Am. 2019 Sep;57(5):931-942.
  

• Koplas MC, Schneider E, Sundaram M. Prevalence of triceps tendon tears on MRI of the elbow and clinical correlation. Skeletal Radiol. 2011 May;40(5):587-94.
  

• Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, Murrell GAC, McInnes IB, Rodeo SA. Tendinopathy. Nat Rev Dis Primers. 2021 Jan 7;7(1):1.
  

• Molloy JM, Aberle CJ, Escobar E. Triceps tendon tear in a middle-aged weightlifter. J Orthop Sports Phys Ther. 2013 Nov;43(11):848

• Ortega-Castillo M, Cuesta-Vargas A, Luque-Teba A, Trinidad-Fernández M. The role of progressive, therapeutic exercise in the management of upper limb tendinopathies: A systematic review and meta-analysis. Musculoskelet Sci Pract. 2022 Dec;62:102645.
  

• Pellegrino R, Di Iorio A, Filoni S, Mondardini P, Paolucci T, Sparvieri E, Tarantino D, Moretti A, Iolascon G. Radial or Focal Extracorporeal Shock Wave Therapy in Lateral Elbow Tendinopathy: A Real-Life Retrospective Study. Int J Environ Res Public Health. 2023 Feb 28;20(5):4371.

• Potter HG. Imaging of posttraumatic and soft tissue dysfunction of the elbow. Clin Orthop Relat Res. 2000 Jan;(370):9-18.
  

• Sharma SC, Singh R, Goel T, Singh H. Missed diagnosis of triceps tendon rupture: a case report and review of literature. J Orthop Surg (Hong Kong). 2005 Dec;13(3):307-9.
  

• Shomal Zadeh F, Shafiei M, Hosseini N, Alipour E, Cheung H, Chalian M. The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review. Skeletal Radiol. 2023 May;52(5):875-888.

• Shomal Zadeh F, Shafiei M, Shomalzadeh M, Pierce J, Thurlow PC, Chalian M. Percutaneous ultrasound-guided needle tenotomy for treatment of chronic tendinopathy and fasciopathy: a meta-analysis. Eur Radiol. 2023 Oct;33(10):7303-7320.
  

• Stover D, Fick B, Chimenti RL, Hall MM. Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow: a retrospective review. J Shoulder Elbow Surg. 2019 Dec;28(12):2386-2393.

• Sussman WI, Fanuele J, Hackel JG. Ultrasonic Percutaneous Tenotomy for the Treatment of Recalcitrant Triceps Tendinopathy. J Surg Tech Proced. 2019;3(2):1028.

• Tiwana MS, Sinkler MA, Bordoni B. Anatomy, Shoulder and Upper Limb,
  Triceps Muscle. [Updated 2023 Aug 28]. In: StatPearls [Internet].
  Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/b...

• Tom JA, Kumar NS, Cerynik DL, Mashru R, Parrella MS. Diagnosis and treatment of triceps tendon injuries: a review of the literature. Clin J Sport Med. 2014 May;24(3):197-204.
  
• Thomas JM, Chang EY, Ha AS, Bartolotta RJ, Bucknor MD, Caracciolo JT, Chen KC, Flug J, Kumaravel M, Raizman NM, Ross AB, Silvis ML, Surasi DS, Beaman FD. ACR Appropriateness Criteria® Chronic Elbow Pain. J Am Coll Radiol. 2022 Nov;19(11S):S256-S265. d
• Walker CM, Noonan TJ. Distal Triceps Tendon Injuries. Clin Sports Med. 2020 Jul;39(3):673-685.

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Other Elbow Conditions

• Elbow Arthritis
• Distal Biceps Tendinopathy
• Tennis Elbow (Lateral Epicondylitis)
• Thrower’s Elbow
• Ulnar or radial neuritis (PIN lesions)
  
• Ulnar Collateral Ligament (UCL) partial tears