Triceps tendon rupture in Vienna
While pressing against high resistance or breaking a fall onto the outstretched arm, the tendon at the back of the elbow gives way: a tearing sensation, a sudden pain over the tip of the elbow, and shortly afterwards swelling and bruising. The tear is rare, but in strength sports it is a serious issue — and it is easily missed, because extension often still works at first. I operate on a complete tear in virtually all cases.
In short
A triceps tendon rupture (rupture of the tendon of the three-headed upper arm muscle) almost always affects the insertion at the tip of the elbow (olecranon). Typical are a sudden pain at the back of the elbow while pressing against high resistance or when falling onto the outstretched arm, swelling with bruising and a palpable gap above the tip of the elbow; extension against resistance is weak, though at first it often still works — which is why the tear is easily missed. I confirm the diagnosis in the conversation, in the clinical examination comparing both sides and with the ultrasound in the practice; for the extent of the tear and the retraction of the tendon I arrange an MRI, and an X-ray sometimes shows a piece of bone pulled off with it. I operate on a complete tear in virtually all cases: I fix the tendon back to the tip of the elbow, and as early as possible, because it retracts and scars. Small partial tears with preserved extension strength can be treated conservatively more readily than at the chest muscle; in patients who are active in sport the weighing-up falls in favour of a procedure earlier.
What is a triceps tendon rupture?
The three-headed upper arm muscle (musculus triceps brachii) lies at the back of the upper arm. Its three heads arise from the shoulder blade and from the humerus and converge into a strong, flat tendon that attaches at the tip of the elbow (olecranon). It extends the elbow — every pressing movement runs through it, from the bench press and the dip to pushing yourself up out of a chair. When this connection tears, it almost always affects the tendon at its insertion on the bone, less often the junction between muscle and tendon.
The mechanism is characteristic: the bent elbow is forced into further flexion against the tensed muscle — while lowering the weight, during a dip on the bars, when breaking a fall onto the outstretched arm. Those affected are predominantly men active in strength sports. The tear is rare, about as rare as a pectoralis tendon rupture, and precisely for that reason it is often taken for a bruise at first. How heavily the arm is loaded, which movements the tear makes impossible and what the break from training means, I know from my own experience with strength sports, American football and ball sports. A tear is favoured by a pre-existing irritation of the tendon insertion; repeated cortisone injections near the tendon and anabolic substances also weaken the tendon tissue. I raise this in conversation when it matters for the treatment — not to hold it against you.
A snap at the front of the armpit with bruising over the chest points rather to a tear of the chest muscle tendon, a tearing sensation in the crook of the elbow with loss of strength when turning the forearm outwards to a biceps tendon tear. The triceps tendon lies on the opposite side, at the back of the elbow. This injury is one of the tendon tears I treat in elbow surgery; other causes of complaints in this area are set out under elbow pain.
Typical symptoms
- Sudden pain at the back of the elbow — often with an audible or palpable tearing at the moment of loading.
- Swelling and bruising — over the tip of the elbow, in the days that follow often visible up into the upper arm.
- Palpable gap — above the tip of the elbow the taut cord of the tendon is missing when both sides are compared.
- Loss of strength when extending — pressing, supporting your weight and getting up out of a chair become difficult.
- Extension still possible — at first it often still works, because lateral fibres of the tendon hold. That is exactly what delays the diagnosis.
- Pain on bending — the stretched muscle pulls on the torn insertion.
How I make the diagnosis
At the beginning there is the detailed conversation: which movement, which resistance, what was there to hear and to feel? The clinical examination follows, comparing both sides. I palpate the tendon over the tip of the elbow and look for a gap, test extension against resistance and assess the muscle with the arm hanging down: if I squeeze the relaxed muscle belly, an intact tendon extends the elbow a little way by itself.
Ultrasound is available in the practice; it shows the tendon while it moves and in comparison with the healthy side, and it makes a partial tear visible as well. Where needed I arrange an X-ray — the tendon sometimes pulls a small piece of bone off the tip of the elbow — or an MRI, in order to assess the extent of the tear and the retraction of the tendon. Both examinations take place outside the building; I go through the reports with you.
Treatment: restoring the insertion
With a complete triceps tendon rupture I advise surgery early and clearly; here the rule is: operate in virtually all cases. The avulsed tendon does not grow back onto the bone by itself. It retracts further as time passes and it scars, and without a firm insertion at the tip of the elbow, extension stays weak — noticeable when pressing, when supporting your weight and with any work above your head.
In patients who are active in sport this weighing-up falls in favour of a procedure earlier still. Anyone who wants to bench press, do dips or throw again needs a tendon that carries load; an insertion that only partly holds tears further under that load. For the result of the reconstruction, every day and every week counts: while the tendon is fresh it can be led back into its bed at the tip of the elbow. With an older tear it is shortened and scarred, the procedure becomes more demanding, and at times a tendon graft is needed. That is why I assess a suspected rupture at short notice and plan the procedure promptly.
How I operate
The approach lies at the back of the elbow and it stays small: I work through a short, tissue-sparing incision, free the retracted tendon from the scar tissue, prepare its bed at the tip of the elbow and fix it with suture anchors or with sutures passed through the bone. A piece of bone that has been pulled off with the tendon I treat in the same sitting. In doing so I take care of the ulnar nerve (nervus ulnaris), which runs along the inner side of the elbow. Unlike many procedures inside the joint, this step cannot be done with elbow arthroscopy — the tendon has to be brought back into its bed under direct view.
I carry out necessary procedures at the ATOMOS Klinik Währing, the Privatklinik Döbling or the Rudolfinerhaus, and I accompany you from planning through the procedure to aftercare. The aftercare begins with a phase in a splint in near-full extension, followed by guided movement and a step-by-step build-up of strength with physiotherapy. The way back to full loading I describe under sports orthopaedics.
When a small tear can be treated without surgery
Not every finding leads to the operating theatre. Unlike at the chest muscle, small partial tears of the triceps tendon can still be treated without surgery more readily: if only a marginal part is affected, the insertion on the bone essentially holds and extension against resistance stays strong, I treat conservatively at first. The way there leads through relief from load, a splint in near-full extension, then guided movement and a step-by-step build-up of strength. Physiotherapy, exercise therapy and a chiropractor are in the same building at the Orthozentrum Döbling. I follow the course clinically and with the ultrasound; if strength does not increase or the tendon tears further, I raise the question of a procedure again. If an irritated state remains at the tendon insertion, focused shockwave therapy or an ultrasound-guided injection can be considered.
I name that limit openly: with a complete tear, the conservative route does not lead to an insertion that carries load. Loss of strength when extending and when supporting your weight then remain. Without surgery I proceed in this situation only where the demands on extension strength are very low, or where other illnesses argue against a procedure. I set this out before a decision against a procedure is taken.
My practice is a private practice, in Austria a Wahlarztordination. I do not settle directly with any public health insurer; you receive an invoice and submit it to your insurer — on request I take care of the submission for you. For an operation, direct settlement with a supplementary private insurance is possible; the details are set out under how a private practice works and bills. Whether an operation makes sense depends on the findings; the decision is taken together.
Frequently asked
Common questions about a triceps tendon rupture
Usually the moment is unmistakable: a sudden, stabbing pain at the back of the elbow while pressing against high resistance or when falling onto the outstretched arm. Afterwards the tip of the elbow and the upper arm swell, a bruise spreads, and above the tip of the elbow a gap can be felt when both sides are compared. Extension against resistance is weak, though at first it often still works.
Virtually always, once the tendon has torn away from the bone completely. It does not grow back by itself, it retracts and scars; without a firm insertion, extension stays weak. Small partial tears with preserved extension strength can be treated conservatively more readily than at the chest muscle. In patients who are active in sport the weighing-up falls in favour of a procedure earlier. Whether an operation makes sense depends on the findings; the decision is taken together.
Yes. Lateral fibres of the tendon and the small elbow muscle can take over extension at first, above all without resistance and with the help of gravity. That is exactly why the tear is often taken for a bruise and recognised late. The informative findings are extension against resistance with both sides compared, the palpable gap above the tip of the elbow and the ultrasound.
As soon as possible. A fresh tendon can as a rule be fixed back to the tip of the elbow directly; once it retracts and scars, the procedure becomes more demanding and at times needs a tendon graft. You will usually get an appointment within a week, and for acute cases I offer times outside the regular consulting hours. You do not need a referral.
Ultrasound is available in the practice and shows the tendon while it moves and in comparison with the other side. To plan a procedure I also want to know how extensive the tear is and how far the tendon has retracted; for that I arrange an MRI. I add an X-ray because the tendon sometimes pulls a small piece of bone off the tip of the elbow.
The approach lies at the back of the elbow and it stays small. Through a short, tissue-sparing incision I free the retracted tendon from the scar tissue, prepare its bed at the tip of the elbow and fix it with suture anchors or with sutures passed through the bone. This step is not possible with the arthroscopic keyhole technique. I discuss the procedure and the aftercare with you in detail beforehand.
That is exactly the aim of the aftercare: to build up movement and strength to the point where training becomes possible again. The way there leads through a phase in a splint, guided movement and a step-by-step build-up of strength with physiotherapy; pressing under heavy weight and supporting your body on the bars come last. When each step is due depends on the operative findings and on how healing progresses.
Dr. med. Martin Eigenschink
Specialist in Orthopaedics and Traumatology · Specialist in elbow, shoulder and hand surgery
Surgical and conservative treatment of the elbow, shoulder and hand, preferably minimally invasive. Practice at the Orthozentrum Döbling, 1190 Vienna. More about my background
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