Distal Triceps Tendon Rupture

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What is it?

The triceps brachii muscle group is located on the back (posterior) side of the upper arm. The triceps group consists of three “heads” or distinct muscle bellies: the medial, long and lateral heads.

All three heads form a large, thick tendon at the elbow and attach to the point of your elbow, known as the olecranon process. They all work together to extend or straighten the elbow and are therefore extremely important for weight bearing activities of the arms such as push-ups, getting out of a chair and lifting heavy objects above head height.

A distal triceps tendon rupture often results from an eccentric extension load to the elbow. It refers to an injury where this tendon is ruptured or torn at or close to its insertion to the bony  prominence at the back of the elbow. Intramuscular and muscle-tendon injuries also occur, but they are even less common than avulsion injuries. Tears can be either partial or complete.

Dr Sumit Raniga - Shoulder and Elbow Surgeon - distal triceps tendon rupture & Elbow Stiffness

Who is affected?

Distal triceps tendon rupture is a rare injury. At its very essence, the triceps tendon can fail when a very high amount of force is applied to the tendon.

This may be seen in a fall onto an outstretched hand or when lifting heavy weights at the gym in movements such as bench or overhead press. The vast majority of these injuries occur in male patients.

Those who have sustained a previous triceps tendon rupture, have health conditions associated with poor tendon health, a smoking history and those with a history of prolonged steroid use are more at risk of tendon rupture.

 Other related conditions include chronic renal failure with secondary hyperparathyroidism, hypocalcemic tetany, rheumatoid arthritis, osteogenesis imperfecta, systemic anabolic steroid use, local corticosteroid injections, and possibly insulin-dependent diabetes.

This injury can also be seen after elbow joint replacement where the triceps tendon may be detached, to assist the surgeon to replace the joint, and then subsequently repaired.

What are the symptoms?

When the distal triceps tendon is torn, there is often a popping or tearing sensation felt at the back of the elbow.

This may initially be quite painful however this pain normally subsides over the course of a few days or perhaps even a week or so. The elbow and arm may become very swollen and bruised.

As the pain and swelling subsides, the most noticeable symptom of a distal triceps tendon rupture is a feeling of weakness, particularly in those movements that the triceps is responsible for, being extension of the elbow and weight bearing.

How is the diagnosis made?

Distal triceps tendon rupture can be detected by physical examination of the elbow. A palpable gap is often present at the triceps insertion.

Although confirmation of the injury is made with diagnostic imaging techniques x-ray and ultrasound or MRI. 

The extent of the tear and the degree of proximal retraction can be visualized and graded by MRI. If <75% of the tendon thickness is involved, the injury is considered a partial tear. When >90% of the tendon is involved, the injury is considered a full-thickness tear. It is also very important to rule out other injuries to the arm that can be sustained in an injury like a fall.

What is the prognosis?

Management of distal triceps tendon rupture is dependent on the extent of the injury, partial or complete, the general health of the patient and the desires of the patient with regards to future physical activity.

A smaller sized partial thickness rupture can be successfully rehabilitated without need for surgery. Larger-sized partial thickness and full-thickness ruptures of the tendon often require surgical repair. 

If a large partial thickness or full thickness tear of the distal triceps is not repaired, patients will likely suffer from severe weakness at the elbow in activities and movements that involve elbow extension such as weight-bearing and lifting heavy objects above head height.

Non surgical treatment

Immediately after the injury, it is important to manage pain and swelling with rest and/or immobilisation in a plaster cast or splint that keeps the elbow slightly flexed.

Wearing a light compressive garment and intermittently applying an ice pack to the elbow (i.e. apply ice for 20-30mins before taking it off for 20-30mins) can assist in managing pain and swelling. Non-steroidal anti-inflammatory medications may also be helpful however we recommend that these should only be taken under instruction from your doctor or pharmacist.

For small sized partial thickness tendon tears, physiotherapist-led rehabilitation normally consists of a period of immobilisation (approx. 6 weeks) to help the tendon heal, followed by exercises to restore normal elbow range of motion and strength of the triceps muscle. Rehabilitation and return to pre-injury activities can take approximately 6 months in total.

For larger partial thickness tendon tears and full thickness tears that are left unrepaired, the principles of rehabilitation are similar, however it is to be expected that there will almost always be limitations on the capacity for use of the affected arm for weight-bearing due to weakness. A physiotherapist can help guide a return to suitable physical activity and prescribe appropriate strengthening exercises for the arm to maximise function.

Surgical treatment

Acute, full-thickness, or partial-thickness ruptures in high-demand individuals are treated operatively with good results and low re-rupture rates.

Surgical repair of a distal triceps tendon involves reattachment of the tendon to its bony insertion. This procedure is completed by making an open incision in the back of the elbow. Repair techniques often utilize either suture anchors or bone tunnels with similar clinical outcomes

It is vital a strict adherence to the post-surgical rehabilitation program to reduce the risk of re-rupture, restore range of motion and return to work and/or recreation. The rehabilitation process can take approximately 6 months and usually involves:

  • Protecting the repair in a brace for the first 6 weeks after surgery
  • Range of motion exercises to restore normal motion to the elbow
  • Commencement of a strengthening program 3 months after surgery
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