Rare injury: Triceps tendon ruputure

[andreasthell]

Hello!

I´m an orthopedic surgeon from Austria.

An olecranon spur was diagnosed about 1 year ago which causes intermitted pain during weight training at the tip of my right olecranon. About 3 months ago, the spur was fractured due to a direct blow on the ellbow. It was very painful and I paused training (weight training & judo) for 3 weeks.

But the pain didn´t release and so I got a trop of cortisone (about 1 mg of triamcinolone) injected directly into the fracture which released pain immediately. Unfortunately, I didn´t follow the usual advice to pause training after injection of cortison in or around a tendon.

Performing a throw during warm-up of the judo training, I suddenly felt a severe pain at the back side of the whole right upper arm which made me to stop training immediately. There was a palpable depression directly superior to the olecranon tip and I could not extend the ellbow against gravity.

At our hospital, a complete tear of the triceps tendon was diagnosed and I underwent immediate surgery. First, the spur was removed completely. The part of the tendon near to the olecranon was kind of yellow-coloured and soft. It was also removed and the tendon was refixated on the olecranon using suture anchors and non-resorbable sutures.

As we have never seen this injury before, I am wondering about the best postoperative procedure. For the moment, the ellbow is placed in a splint at 60° of flexion. At this position, I have no feeling of tension and no pain (even without NSAID´s).

Any experience or any ideas?

[andreasthell]

As I see, there are no big experiences with this kind of tendon rupture. So I want to report what I´ve done during the last 9 weeks.

Week 1: splint fixed on 60° flexion
Week 2: splint set to S-0-20-70, active flexion, passive extension
Week 3 to 6: increase flexion for 10 - 20° each week
Week 7: splint removed, at end of week 7 I reached full ROM despite 5° of extension deficit which I have had before the rupture
Week 8: active flexion against very light resistance (about 2 - 3 kg, 3 sets of 20 reps, 3 times per day)

Today, approx. 9 weeks after surgery, I had sonographic examination of the tendon. Apart from a little edema at the point of the suture, the tendon seems to have a very good structure. Unfortunately, NMR is not possible because the suture anchors are made from steel.

I will give you the next report at the middle of may (=planned start of regular resistance training).

[injuryupdate]

This is a rare injury although I think there are some cases in the literature. Because it is a prime mover without major agonists and you are active then surgical repair is a good move. Will probably fix your tendinopathy you originally had.

Watch out that you don't do the other side at some stage.

[Rod Whiteley]

I'd agree that this is a rare injury, and I've only seen two in clinical practice. Both were high level rugby league players, both had surgical repair, and both went on to full recovery. (I also had queries with both of them as to the aetiology of the injury, and I suspect there may have been something in the way of a "chemical precursor" for each of them - clearly this isn't the case with the current injury). The rehabilitation programme you describe is very similar to what we did for our two guys, except that we began (light) resistance training at the 7 week mark. This was then progressed as symptoms dictated, and whilst I was always worried about the possibility of a recurrence of triceps tendonopathy during rehabilitation, particularly due to the thickening that was present after the surgery, this proved to be no problem.
Our criteria for return to play was full range of motion toward flexion, instrumented resistance testing of triceps >75% of the contralateral side, ability to 'fall' onto the injured arm confidently (initially falling to the wall, then from knees to the floor, then from standing to the floor) and finally return to full training (including contact drills). The timing of both the surgeries meant we missed about 9 months until they returned the following season.
Good luck with this.

[andreasthell]

Our criteria for return to play was full range of motion toward flexion, instrumented resistance testing of triceps >75% of the contralateral side, ability to 'fall' onto the injured arm confidently (initially falling to the wall, then from knees to the floor, then from standing to the floor) and finally return to full training (including contact drills). The timing of both the surgeries meant we missed about 9 months until they returned the following season.


I think, the stuff with the "confident fall" onto the injured arm will be a very good predictor when to start with judo training again. I agree with you that it will take at least 9 months after surgery for full-power ballistic loads on the tendon.

Because I am very curious, could you tell me how exactly the refixation of the tendon was done in the cases you know? Transosseal? Suture anchors (how much? material?). Where there any radiologic examinations like sonography or NMR after surgery?

[andreasthell]

Hi!

During rehabilitation, we noticed that the triceps tendon healing is better than originally expected. I am now at week 14 post surgery. Apart from being near as twice as thick as the contralateral tendon, it has a completely normal appearance at sonography. During activities of daily life, I feel little or no pain. I started a well dosed resistance training three weeks ago.

Now I am able to perform 3 x 20 push ups with narrow grip (puts more load on the triceps than on the pecs & delts), 3 x 20 bench dips and 3 x 20 lying triceps extensions (="French press" or "Skull crusher") with a 10 kg barbell. All the exercises cause me no pain. And the girth of my right upper arm is at 41cm now (which was at 43 cm before the injury).

I am now quite confident that I can return to Judo in about half a year.

The only drawback is that a part of the olecranon spur was not fully removed and caused a chronic elbow bursitis. By now, the bursitis is not really an -itis because there are no inflammation signs and there is no pain. Maybe I need another little surgery for removing the bursa and the rest of the spur later.