At a glance......
- 1 Anatomy of Triceps Tendinitis
- 2 Causes Of Triceps Tendinitis
- 3 Symptoms Of Triceps Tendinitis
- 4 Diagnosis of Triceps Tendinitis
- 5 Treatment Of Triceps Tendinitis
- 6 Physical Therapy Management
Triceps Tendinitis is a large, thick muscle on the dorsal part of the upper arm. It often appears as the shape of a horseshoe at the back part of the arm. The main function of the triceps is for extension of the elbow joint. It is composed of three heads (tri = three, cep = head): a long head, a lateral head, and a medial head. The tendons all have different origins, but the three heads combine to form a single tendon distally. The long head originates from the infraglenoid tubercle of the scapula while both the lateral head and the medial head both originate from the humerus. The lateral intermuscular septum is what separates the dorsal part from the arm from the ventral part which is where the flexors of the arm are (biceps, brachialis, and brachioradialis). The three heads converge into a single tendon, and this tendon attaches to the proximal portion of the olecranon process (the bony prominence of the elbow) located on the upper portion of the ulna.
Triceps tendon tear is one of the least commonly recognized major tendon tears. Bilateral triceps tendon tears are especially rare. We present a case of simultaneous complete tears of bilateral triceps tendons secondary to a fall. The anatomy, etiology, image findings, and current literature are discussed.
Anatomy of Triceps Tendinitis
Long head—The origin of the long head is the infra-glenoid tubercle of the scapula. Because it attaches the scapula, the long head not only extends the elbow, but will also have a small action on the glenohumeral, or shoulder joint. With the arm adducted, the triceps muscle acts to hold the head of the humerus in the glenoid cavity. This action can help prevent any displacement of the humerus. The long head also assists with the extension and adduction of the arm at the shoulder joint. The lateral head is also active during extension forearm at the elbow joint when the forearm is supinated or pronated.
Medial head—The origin of the medial head is at the dorsal humerus, inferior to the radial groove, and connecting to the intermuscular septum. The medial head does not attach to the scapula and therefore has no action on the glenohumeral joint whether that be with stabilization or movement. The medial head is active, however during extension of the forearm at the elbow joint when the forearm is supinated or pronated.
Lateral head—The lateral head originates at the dorsal humerus as well, but unlike the medial head, it is superior to the radial groove where it fuses to the lateral intermuscular septum. This head is considered to be the strongest head of the three. It is active during the extension of the forearm at the elbow joint when the forearm is supinated or pronated.
Causes Of Triceps Tendinitis
- Mechanism of injury – The two described mechanisms for acute tears of the triceps are direct contact trauma, such as a fall or hitting fixed resistance with the posterior elbow[rx,rx,rx,rx]. Weightlifting[rx,rx,rx,rx,rx–rx] was the most common sport associated with acute tears and was often associated with a history of steroid use[rx,rx,rx]. American football[rx,rx] and general sports injuries[rx], as well as direct lacerations[rx] have all also been reported as mechanism
- Trauma – Injuries to the triceps, such as a muscle tear from placing too much force on the muscle, can lead to pain.
- Repetitive stress – Repeating the same shoulder motions, again and again, can stress your triceps muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse of tears, as well.
- Lack of blood supply – As we get older, the blood supply in our triceps brachiilessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
- Bone spurs – As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the triceps brachii muscle. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.
- Sudden forceful fall down
- Road traffic accident
- Falls – Falling onto an outstretched hand is one of the most common causes of injury.
- Sports injuries – Many Injury occurs during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
- Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
- Have osteoporosis – a disease that weakens your bones
- Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
- Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
- Wave an inadequate intake of calcium or vitamin D
- Football or soccer, especially on artificial turf
- Horseback riding
- In-line skating
- Jumping on a trampoline
Symptoms Of Triceps Tendinitis
Depending on the cause of your shoulder pain you may experience:
- Pain deep in the shoulder joint, in the back or the front of the shoulder and the upper part of the arm. Sometimes the pain in the shoulder can be described as a ‘catching pain’. The location and type of pain is likely to relate to the structure causing the pain
- Reduced movement, and pain when moving your shoulder.
- The weakness of the shoulder/upper arm. Depending on the condition, there may be a sensation of the joint slipping out and back into the joint socket, or the shoulder can become completely dislodged (dislocated)
- Sensations of pins and needles (tingling) and burning pain. This is more likely to be associated with nerves from the neck than the shoulder joint itself.
- Lack of movement after a shoulder dislocation. This is usually due to pain. Complete rotator cuff tears and injury to the axillary nerve both cause weakness in moving the arm away from the body. These problems require close clinical examination.
Symptoms Of Triceps Muscle Tendinopathy
- Pain in the muscle after impact.
- Pain and difficulty when lifting the arm to the side.
- Tender to touch the muscle.
- Bruising appears.
- There may be some swelling.
Diagnosis of Triceps Tendinitis
While histologic grading of the severity of tendinopathic changes remains separate from the clinical presentation and MRI and/or intra-operative findings, there are some noteworthy pathologic patterns associated with increasing grades of severity of tendinopathy.[rx][rx]
- Tenocytes are normal in appearance
- Myxoid degenerative material not present
- Collagen remains arranged in tight, cohesive bundles
- Blood vessels arranged inconspicuously between collagen bundles
- Tenocytes are rounded
- Myxoid degenerative material present in small amounts between collagen bundles
- Collagen remains arranged in discrete bundles, but a slight separation between bundles becomes apparent
- Capillary clustering is evident (less than 1 cluster per 10 high-power fields)
- Tenocytes are rounded and enlarged
- Myxoid degenerative material evident in moderate to large amounts
- Collagen bundles lose discrete organization as the separation between individual fibers and bundles increases
- Capillary clustering is increased (1 to 2 clusters per 10 high-power fields)
- Tenocytes are rounded and enlarged with abundant cytoplasm and lacuna
- Myxoid degenerative material abundant
- Collagen disorganized, loss of microarchitecture
- Capillary clustering is increased (greater than 2 clusters per 10 high-power fields)
Bicipital groove palpation – Direct palpation over the patient’s bicipital groove elicits a painful response in the setting of pathology.
Speed’s test – A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward elevate the shoulder against examiner resistance; the elbow is slightly flexed, and the forearm is supinated.
Uppercut test – The involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. The examiner instructs the patient to perform a boxing “uppercut” punch while placing his or her hand over the patient’s fist to resist the upward motion. A positive test is pain or a painful pop over the anterior shoulder near the bicipital groove region.
Ferguson’s test – The arm is stabilized against the patient’s trunk, and the elbow is flexed to 90 degrees with the forearm pronated. The examiner manually resists supination while the patient also externally rotated the arm against resistance. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon.
Dynamic tests for bicipital groove symptoms
- The examiner brings the patients shoulder to 90 degrees of abduction and 90 degrees of external rotation. The examiner passively rotates the shoulder at this position in an attempt to elicit the patient-reported audible “popping” or “clicking” sensations. Sometimes passively maneuvering the shoulder from the extension to cross-body plan is helpful in eliciting instability symptoms.
- At the 90/90 shoulder abduction/external rotation position, the patient is asked to “throw forward” while the examiner resists this forward motion. A positive test for groove pain must be localized to the anterior aspect of the shoulder to enhance diagnostic sensitivity and specificity.
Other Changes Associated with Tendinopathy
- Irrespective of histologic grade of tendinopathy, the surrounding bicipital sheath/synovium demonstrates varying degrees of synovial hypertrophy, hyperplasia, and proliferation
Low-Grade Degenerative Tendinopathy
- Total cellularity (cell density, cells/ mm): Minimal increase
- Apoptotic index (percent relative to the total number of cells counted): Minimal increase
Moderate Grade Degenerative Tendinopathy
- Total cellularity (cell density, cells/ mm): Peak increase
- Apoptotic index (percent relative to the total number of cells counted): Moderate increase
Severe Grade Degenerative Tendinopathy
- Total cellularity (cell density, cells/ mm): Decreases
- Apoptotic index (% relative to the total number of cells counted): Peak increase
Histologic studies have consistently reported that irrespective of patient age, the severity of symptoms, and duration of symptoms, acute inflammatory changes are rarely evident upon histologic specimen analysis.
In 2004, Habermeyer and colleagues identified 4 different subtypes of soft tissue injury groups. These types were similar to those described by Braun and colleagues, also noting 4 different types of soft tissue pulley lesions during shoulder arthroscopy.[rx]
- Type I – SGHL lesion, isolated
- Type II – SGHL lesion and partial articular-sided supraspinatus tendon tear
- Type III – SGHL lesion and deep surface tear of the subscapularis tendon
- Type IV – SGHL lesion combined with a partial articular-sided supraspinatus and subscapularis tendon tears
Bennett’s classification system subdivides biceps soft tissue pulley lesions into types I to V.[rx]
- Type I – Intra-articular subscapularis injury
- Type II – Medial band of CHL incompetent
- Type III – Subscapularis and the medial band of the CHL are both compromised; LHBT dislocates intra-articularly, medially
- Type IV – A lateral band of CHL along with a leading-edge injury of the subscapularis; Can lead to LHBT dislocation anterior to the subscapularis
- Type V – All soft tissue pulley components are disrupted
Walch classified biceps pulley lesions based on the observed LHBT instability pattern.[rx]
- Type I – SGHL/CHL injury; Superior LHBT subluxation at the proximal groove entrance; Subscapularis remains intact, preventing frank LHBT dislocation
- Type II – At least partial subscapularis injury is seen in association with the onset of pathology; Medial LHBT subluxation or dislocation
- Type III – Secondary to proximal humerus fracture; usually a lesser tuberosity fracture that is prone to malunion or nonunion
Ultrasound (US) is highly operator-dependent but is touted as a fast, cost-effective tool for diagnosing LHBT pathology. Characteristic findings include tendon thickening, tenosynovitis, and synovial sheath hypertrophy, and fluid surrounding the tendon in the bicipital groove. The ability to perform a dynamic examination increases the sensitivity and specificity for detecting subtle instability.
Magnetic resonance imaging (MRI) is useful in evaluating the LHBT, bicipital groove, and any fluid or edema that may be indicative of pathology. MRI helps define other associated shoulder pathologies, and in the setting of LHBT instability, particular attention should be given to evaluating for concomitant subscapularis injury.
Many studies have suggested MR arthrography (MRA) as the best imaging modality for the detection of triceps soft tissue pulley lesions. Walch previously described the “pulley sign” on MRA, suggesting a lesion to the soft tissue pulley structures. The “pulley sign” is an extra-articular collection of contrast material anterior to the upper subscapularis muscle. A 2012 study established MRA criteria for diagnosing biceps pulley lesions. The findings on MRA included[rx]:
- LHBT displacement relative to subscapularis tendon on oblique sagittal series; Up to 86% sensitive, 98% specific
- LHBT tendinopathy on oblique sagittal image series; Up to 93% sensitive, 96% specific
- Medial LHBT subluxation on axial image series; Up to 64% sensitive, 100% specific
- Discontinuity of the SGHL; Up to 89% sensitive, 83% specific
Treatment Of Triceps Tendinitis
- Rest – Rest, ice and heat are the initial steps to take to rehabilitate your muscles. Resting allows the muscle strain to heal, while ice reduces the inflammation and dulls your pain. Apply ice on a 15-minute on, 15-minute off schedule for the first day for grade 1 strains. Grade 1 strains are injuries that feel tight but do not produce pain or visible swelling of the shoulder area. Continue icing for several days for grade 2 and 3 strains. Strains of this severity will cause pain and hamper your mobility.
- Stretching and Strengthening – Stretching and strengthening you’re can help you recover from an injury and prevent future strains. Stretching can begin as soon as you are pain-free, and include the barbell stretch. Stand with your arms at your sides. Bring your arms up to shoulder height, keeping your elbows straight and arms out in front of you.
- Massage – Sports massage may be a part of your rehab program. A sports massage, administered by a certified professional, keeps your muscles loose and limber and warms the injured tissues. Grade 1 deltoid injuries may be massaged after the first two days of rest and icing; more severe strains or tears may require up to a week’s healing time before the massage is possible.
- Ultrasound – Grade 3 injuries can benefit from more advanced rehab techniques, including ultrasound and electrical stimulation. These types of treatments must be performed by certified professionals and may include your athletic trainer or physical therapist. Ultrasound treatments send sound waves into the deltoid muscle; electrical stimulation provides the injured tissues a low-grade electrical current. Both of these treatments can reduce pain and inflammation.
In Severe Condition of the Proximal Biceps Tendon Rupture
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating immunization.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
- Cortisone injections – First-line nonoperative management also includes the use of non-steroidal anti-inflammatory (NSAIDs) medications in conjunction with PT modalities to rapidly reduce pain.
- Muscle Relaxants – These medications provide relief from associated muscle spasms or injury
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
- Dietary supplement -to remove general weakness & healing and improved health.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Menthol – provides deep penetrating pain relief with a nice cooling sensation
- Vitamin B1, B6, B12– promotes normal nerve function
- Vitamin E – anti-inflammatory, enhances circulation, hydrates the skin
- Aloe vera – anti-inflammatory properties, soothes the skin
- Tea Tree – enhances the penetration of ingredients
- MSM – supports healthy connective tissues, anti-inflammatory
- Ilex Leaf Extract – increases circulation, skin conditioner
- Botulinum toxin injections – to her trapezius muscles, which considerably reduced pain and spasm. This clinical improvement lasted 3 months. Ongoing injections as required are planned.
Physical Therapy Management
Physical therapy has been commonly used for the treatment of tendinopathies: initially focusing on unloading followed by reloading the affected tendon.
- This may start with isometric training if the pain is the primary issue progressing into eccentric training and eventually concentric loading as with other forms of tendon rehab.
- Stretching and strengthening programs are a common component of most therapy programs. Therapists also use other modalities, including ultrasound, iontophoresis, deep transverse friction massage, low-level laser therapy, and hyperthermia; however evidence for these modalities has low quality.
- The physical therapist must consider both the patient’s subjective response to injury and the physiological mechanisms of tissue healing; both are essential in relation to a patient’s return to optimal performance.
As a preface to a discussion of the goals of treatment during injury rehabilitation, two points must be made:
- Healing tissue must not be overstressed and a very slow heavy loading program should be undertaken. During tissue healing, controlled therapeutic stress is necessary to optimize collagen matrix formation, but too much stress can damage new structures and slow the patient’s rehabilitation
- The patient must meet specific objectives to progress from one phase of healing to the next. These objectives may depend on ROM, strength, or activity. It is the responsibility of the physical therapist to establish these guidelines
Exercise therapy should include
- Restoring a pain-free range of motion – Pain-free range can be achieved with such activities as PROM, Active-Assisted Range of Motion (AAROM), and mobilization via manual therapy
- Proper scapulothoracic rhythm.
- Painful activities such as abduction and overhead activities should be avoided in the early stages of recovery as it can exacerbate symptoms
- Strengthening program consisting of heavy slow loading should begin with an emphasis on the scapular stabilizers, rotator cuff, and biceps tendon