How to Know if You Strained Your Tricep

Getting direct to the point on triceps tendon injuries

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Chris Mallacexplores another 'uncommon injury,' triceps tendinopathy and rupture. In addition to considering injury pathology, he also discusses imaging and diagnosis, along with management guidelines for rehab.

Tendinopathies of the triceps tendon, and the potential serious sequalae of fractional and complete ruptures, are a relatively rare only debilitating condition that can touch on power athletes^(ane). For the power athlete participating in a 'push' based sport such equally powerlifting, contact football, and martial arts/combat sports, triceps tendon pathology tin can cause meaning symptoms and be functionally limiting^(two-4).

The more common tendon injuries include the lateral and medial epicondyle tendons (extensor origin and flexor origin) and the distal bicep tendon^(v). It has been estimated (using magnetic resonance imaging [MRI]) that only 3.8% of tendinopathies touch on the triceps tendon^{(half dozen)}. Along the triceps tendon injury continuum, partial tears are the most mutual triceps injury comprising around 23% of the distal triceps tendon injuries.

Every bit the average historic period of those injured is effectually 46 years, this suggests that developing tendon degeneration is a necessary precursor to partial or complete rupture⁽⁶⁾. The serious end-stage pathology is a tendon rupture; however, this has been estimated to be extremely rare (in less than 1% of serious tendon injuries to the upper limb)⁽¹⁾.

It is more mutual for serious injuries such every bit tendon rupture to affect males between the ages of 40-l at a ratio of 11:1 ratio of males to females^{(6,10,eleven)}. The incidence of chronic triceps tendinopathy is unknown; many cases of triceps tendon pain may go unreported as oft, gym goers just modify the choice of exercises to avert tendon pain.

Anatomy

The master function of the triceps is to extend the elbow, and the long head of the triceps can also assist in shoulder extension movements. The exact anatomy of the distal triceps insertion may therefore be important for the surgeon to empathise when repairing the distal triceps tendon.

The triceps brachii is composed of three muscle bellies (see figures one and 2)^(seven):

1. The long head arises off the infraglenoid tubercle of the scapula. Equally this muscle crosses ii joints, it is bi-articular and is influenced past the shoulder flexion angle.
2. The medial caput originates off the posterior aspect of the humerus distal to the spiral groove.
3. The lateral caput originates off the lateral intermuscular septum and the posterolateral aspect of the humerus above the spiral groove.

Effigy 1: Anatomy of the triceps muscle

The exact beefcake of the insertion of the triceps remains controversial. Agreement tends to exist equally to the verbal beefcake of the superficial portion of the insertion. This tendon is believed to be fabricated up of the lateral and long heads that converge, and then insert medially straight into the medial aspect of the olecranon. Laterally, the fibres insert at an bending and then go along to blend with the superficial fascia of anconeus (sometimes referred to as the lateral expansion).

The anatomy of the medial head tendon of the triceps is more contentious:

1. Madsen et al believe the medial head to have a split, deep insertion from the primal tendon (from cadaveric studies⁽⁸⁾).
2. In another cadaveric study, Keener et al described a thickening of the medial aspect of the tendon that was non distinct from the fundamental tendon with fibres from the medial and long heads of triceps⁽⁹⁾. The insertion was not split from the central tendon.
3. In another dissection report, it was found that approximately half of the specimens had a discrete tendinous portion of the medial triceps that was deep to the long and lateral heads of the triceps. The long head and lateral head course a tendon that is superficial to this detached medial portion⁽¹⁰⁾. In the other half of the specimens, a mutual combined tendon insertion was found; withal these nonetheless had medial fibres that were deep to the long and lateral head fibres.

Figure 2: Anatomy of the triceps muscle (showing the position of the iii heads)

Injury types

*Tendinopathy

This most normally occurs at the tendon attachment to the os at the olecranon⁽¹²⁾, merely can occur within the tendon substance or at the musculotendinous junction. In athletes, the archetype systemic risk factors that weaken tendons are not equally common equally in the general population. However, these may include metabolic conditions and endocrine disorders such as diabetes mellitus and hypoparathyroidism^(13-fifteen). What may be more relevant for the athlete are the local factors that may weaken or traumatise the tendon, such every bit corticosteroid injections⁽¹⁶⁾, anabolic steroids⁽¹⁶⁾, overtraining, and olecranon bursitis (which has also been implicated in tendon rupture)⁽¹²⁾.

Tendon pain in gym athletes is typically felt during exercises such equally lying triceps extensions and overhead triceps extensions. However, pain is usually manageable if the lifter performs triceps pressdowns and dips. It is theorised that positions of increasing shoulder flexion identify the long head of the triceps under greater stretch. This greater stretch and greater tensile load – coupled with the compressive load of the tendon pressing against the olecranon – may be plenty to precipitate a tendinopathy.

*Acute tears

Astute tears of the triceps tendon may occur in a number of ways:

1. A fall on an outstretched hand when a sudden deceleration stress is put on a contracted triceps muscle, such every bit a breaking a fall with an extended elbow. This would be common in a football game player or martial artist.
2. Stiff triceps contraction during gym exercises such as bench press.
3. Hitting a stock-still resistance with the posterior elbow such as landing straight on the point of the elbow^(10,17-20).

The most common sport associated with tendon tears is weightlifting^{(6,10,16,18,21-23)}, which has also oft been associated with a history of steroid use^{(vi,sixteen,22)}.

*The 'snapping triceps' tendon

This dynamic phenomenon tends to occur in younger athletes (average historic period of 32 years) and with a slightly reduced male to female person ratio of half-dozen.5:1^(24-27). It is characterised by a snapping awareness during both flexion and extension, with both agile and passive movement of the elbow²²⁸⁾.

This miracle is acquired by a 'dislocating' triceps tendon either on the medial or lateral side of the elbow. Medial snapping is more common, and it may be painless or cause snapping with elbow pain and ulnar nerve neuropathy on the medial side^{(28, 29)}. It is common to take concurrent snapping of the tendon with dislocation of the ulnar nerve⁽²⁸⁾. It has been postulated that a snapping ulna nerve and snapping triceps could be differentiated by the angle at which the snapping occurs. The ulna nerve is thought to snap at 70-ninety degrees of flexion, whereas the triceps is thought to snap at around 115 degrees of flexion⁽²⁸⁾.

A number of causes of medial snapping tendon have been proposed:

1. A medial vector placed on the tendon with the elbow in a valgus position⁽³⁰⁾or sure muscle activation patterns⁽²⁷⁾. This medial vector is a function of the T bending, where the T bending is the angle between the subtended line of pull of triceps (humeral shaft with extended elbow) and the longitudinal line of proximal ulna⁽²⁷⁾.
2. A complexity of displaced supracondylar fractures^(31,32).
3. Inherited as an accessory medial triceps or abnormal insertion⁽²⁸⁾.
4. Hypertrophy of the medial triceps in athletes^(28,31).
5. Associated with hypermobility of the ulna nerve⁽²⁹⁾.

Signs and symptoms

Triceps tendinopathy is a characterised as a chronic status resulting from overuse and repetitive heavy lifting. Swelling and palpable tenderness of the triceps tendon may be present on examination. The provocative sign will exist resisted extension in positions of stretch (such as lying triceps extension), only strength is usually maintained. Tenderness to palpation occurs at the triceps insertion on the olecranon. In the setting of chronic repetitive injury, patently radiographs may reveal a traction osteophyte on the olecranon.

Along the triceps injury continuum, a chronic tendinopathy may also then endure strains and tears. Patients with spontaneous acute tears of the unabridged tendon typically nowadays with ecchymosis, hurting, swelling, extension lag and a decreased agile range of motion at the elbow, while a palpable defect is commonly constitute and nowadays in up to lxxx% of patients^{(19,22,28,33)}. Similar to Achilles tendon injuries, pain may often be absent prior to rupture of the tendon.

Fractional tears may be confusing and not be as easy to diagnose initially. They may be easily missed as patients may lack power in elbow extension, while retaining a expert range of active motion^(x,34-36). Force testing will testify weakness of elbow extension. However, information technology is important to note that the ability of a patient to extend his or her elbow does non exclude triceps rupture, considering elbow extension can be preserved in cases of partial tears though the lateral expansion of the triceps fascia. Furthermore, weakness in extension with the elbow flexed greater than 90° may be diagnostic of a partial extensor mechanism disruption (specifically, medial caput triceps).

A complete inability to extend the elbow against gravity may represent a more significant injury to the triceps mechanism. Viegas has described a modification of the Thompson test (used to detect Achilles tendon ruptures) in which squeezing the triceps muscle belly does non produce expected elbow extension⁽³⁷⁾.

Imaging

It is common for disruption injuries of the triceps tendon to exist complete avulsions off the olecranon; this is found intra-operatively in 33-73% of patients who suffer tendon tears. These correlate well to imaging findings of consummate tears on Ten-ray and MRI. With acute tendon tears, a bony fleck proximal to the olecranon on radiographs is commonly identified^(20-22,33), which is strongly suggestive of a triceps avulsion injury. This 'bony fleck' sign may also exist demonstrated on ultrasound (run across figure 3 below)^(38,39).

Figure 3: The 'bony fleck' sign

Bony bit is shown circled.

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The remainder of patients who don't accept complete avulsion injuries off the olecranon will have a rupture at the bone tendon junction^(xx,34). These triceps ruptures can be missed on X-ray, every bit the archetype 'bony fleck' sign volition not be present⁽²⁰⁾. Both ultrasound (United states of america) and MRI have been used to diagnose complete tears and fractional tears that do not involve the olecranon attachment^{(xviii,20,21,38)}. Usa has been reported to exist as accurate equally MRI for both consummate and partial ruptures, including identifying the location of partial rupture⁽³⁹⁾.

The superficial location of the triceps tendon does yet allow like shooting fish in a barrel evaluation using ultrasonography compared to imaging other subconscious tendons such every bit the distal biceps tendon. Ultrasound is performed with the elbow in flexion, and shows reduced echogenicity and occasional calcification in tendinopathy. Fractional tears of the superficial or deep insertion of the triceps tin besides be readily seen⁽³⁹⁾.

MRI is used to visualise tendinopathy, and these scans may demonstrate an aberrant betoken intensity on fluid sensitive sequences consistent with all forms of tendinopathy. The insertions of the superficial and deep portions of the tendon are also easily evaluated. In terms of diagnosing the snapping triceps tendon, US, MRI, computer tomography (CT) and sonoelastography have all been used for diagnosis^(24-26,40). Ultrasound is the imaging modality of option for some, as it tin be used as a dynamically to differentiate between a snapping medial triceps and an ulnar nerve that is subluxing⁽²⁴⁾.

Injury management

*Managing tendinopathy

The cognition in the management of triceps tendinopathy is not well developed or understood compared with the other common tendinopathies such as achilles, patella, upper hamstring, gluteals and wrist extensor tendons. The clinician tin simply extrapolate the ideas used in the direction of these common tendinopathies and apply the principles to the triceps tendon. These basic principles are every bit follows⁽⁴¹⁾:

1. When reactive or 'reactive on degenerative' (when the tendon is angry), loftier load isometrics can be used to reduce hurting via corticospinal inhibition. This is hands done using a single arm triceps pressdown hold in a mid-position (approximately 45 degrees elbow flexion). This should be done as heavy every bit possible then that:
   1. 45 seconds is sustainable without shaking.
   2. Pain levels are no more than 3/10 on the Visual Counterpart Scale (VAS).
   3. Five sets of x 45 seconds with a two-minute recovery tin can be tolerated.
   4. Weight can be progressed for isometrics, or the sufferer can progress onto heavy isotonics (run across beneath).
2. Heavy isotonics used when the hurting is nether control. This needs to exist performed initially away from positions of high tendon pinch (such as overhead triceps extensions or lying triceps extensions). The exercises most likely to be useful here are elementary rope triceps pressdowns. These tin can be performed in the traditional four sets of 6 repetitions.
3. Heavy eccentric loads such every bit single arm triceps pressdowns using ii hands to push the weight down and using only one on the eccentric. Again, this needs to be in high volume, such equally three sets of 15 repetitions.
4. High tensile forces that store energy such as clap push ups are used for athletes who demand high reactive forcefulness and power in elbow extension.

*Managing tendon tears

Surgical repair is oft recommended for consummate tears or partial tears with meaning weakness of elbow extension. Small partial tears tin can be successfully managed non-operatively. Even in patients with loftier functional demands (such as contact athletes), good results with non-operative treatment accept been reported for the treatment of partial tears.

Patients are commonly braced in a position of slight flexion (30 degrees) for approximately four weeks⁽⁷⁾, and heavy lifting/pushing/resisted extension are avoided for upward to 12 weeks^(xl). Adjunct treatments such as platelet rich plasma (PRP) injection have also been successfully used for the treatment of partial tears^(18,42). Cheatham et al reported the results of a single patient treated with PRP with resolution of pain and return to gym four months later on a PRP and physiotherapy authorities⁽⁴²⁾.

For an astute tear of more than l% shown on MRI together with significant loss of triceps power (power less than 60% of that pre-injury), operative repair of the torn tendon is recommended⁽⁴³⁾. Surgical repair is usually successful with minimum morbidity.

The management of chronic tendon ruptures is a challenge. For chronic ruptures with meaning tendon retraction, reconstruction with a graft may be required. A number of grafts have been used to augment a primary repair such equally achilles allograft ^(44,45), semitendinous tendon⁽³³⁾, aconeus⁽³³⁾, latisimus dorsi⁽³³⁾, plantaris⁽³³⁾and palmaris longus⁽³³⁾.

In cases of acute triceps avulsion, timely surgical repair is advocated. Cases of incomplete tears where bourgeois measures take failed should likewise be treated operatively. Surgical technique involves master repair of the avulsed triceps tendon using a Krakow suture pattern to the olecranon via bone tunnels⁽³³⁾. In general, surgical repair yields good results and return to action.

The largest example series report to engagement from the Mayo Clinic utilised an Achilles tendon allograft in three cases of triceps tendon rupture or an anconeus musculus flap in iv cases⁽⁴⁴⁾. From these seven cases, one rotation flap failed 6 months after operation. The remaining vi patients had slight or no pain, restored functional range of move and simply slightly decreased extension power at 33 months follow up.

A few studies have attempted to evaluate the biomechanical backdrop of repaired triceps tendons. In an intact triceps tendon, the peak load to failure is at an average of 1714 Newtons⁽⁴⁶⁾. Direct repairs and augmented repairs fail at lower forces of 317 and 593 Newtons respectively. Unlike type of techniques such as trans-osseous cruciate sutures and bone tunnel and knotless suture techniques have also been studied for respective failure rates^(7,33,46,47).

*Managing the 'snapping tricep' tendon

Initial conservative treatment can be attempted by avoiding the provoking activity for 3-6 months⁽⁴⁰⁾. Surgery can be tried if conservative treatment fails and this includes resection of the triceps border, transposition of the tendon, transposing an associated ulnar nervus and correction of cubitus varus^(40,48). Transposition involves transferring the medial third of the tendon to the lateral position^(36,49).

Summary

Triceps tendon problems such every bit degenerative tendinopathy and fractional/full tears are an uncommon and unusual injury in the athlete. If they do occur, they near likely occur due to direct contact onto the triceps tendon or falling and breaking he fall with an outstretched arm, when the triceps contracts strongly to pause the fall. This injury is more than common in 'button' based sports and contact athletes such as weightlifting, rugby/NFL and martial arts. Direction of tendinopathies follows the same guidelines as other more common tendinopathies. Pocket-size partial tears can be managed conservatively whereas bigger partial tears and full thickness tears will require surgical reconstruction.

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Source: https://www.sportsinjurybulletin.com/triceps-tendon-injuries/

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