Chronic Tendonitis of the Triceps Tendon (Triceps Tendinopathy)

Terminology

• Disorganization and degeneration of collagen fibers
• Infiltration by macrophages, plasma cells, and lymphocytes (not neutrophils)
• Increased vascularity (neovascularization)
• Absence of significant acute inflammatory changes

Anatomy

Epidemiology and Risk Factors

• Advancing age (decreased tendon blood supply, reduced tensile strength)
• Male sex
• Obesity (in weight-bearing joints)
• Systemic disease: diabetes mellitus, chronic renal failure (renal osteodystrophy), rheumatoid arthritis, systemic lupus erythematosus
• Smoking

• Anabolic steroid use (bodybuilders - well-documented association)
• Multiple local corticosteroid injections (predisposes to eventual tendon rupture)
• Fluoroquinolone antibiotic use (ciprofloxacin and others have direct deleterious effects on tendon tissue)
• Chronic olecranon bursitis

• Repetitive overuse - overhead pressing, triceps dips, skull crushers, javelin/ball throwing
• Training errors (too rapid progression in load, volume, or intensity)
• Muscle imbalance or weakness

Clinical Presentation

• Posterior elbow pain, typically at or just proximal to the olecranon tip
• Pain with elbow extension against resistance (triceps dips, push-ups, overhead pressing)
• Pain at the beginning of activity that may warm up and ease, then worsen again post-exercise
• Morning stiffness in the posterior elbow

• Point tenderness directly over the triceps tendon insertion on the olecranon
• Pain on resisted elbow extension
• Possible posterior elbow swelling
• Palpable crepitus over the tendon with motion
• With chronic disease: thickening or nodularity of the tendon may be palpable
• Elbow extension strength should be tested: intact in pure tendinopathy; reduced with partial tears
• Approximately 50% of distal triceps injuries are initially missed on first clinical assessment

Imaging

• Usually normal in pure tendinopathy
• May show calcification within the tendon (calcific tendinopathy)
• A bone flake or irregular olecranon surface suggests enthesopathy or avulsion
• Olecranon bone spur may be present in chronic insertional disease

• Increasingly favored: portable, real-time, cost-effective, dynamic assessment
• Detects changes in tendon tissue composition and integrity
• Can identify: tendinopathy (hypoechoic areas, tendon thickening), partial tears, complete tears, calcifications, and bony enthesophytes
• Useful for monitoring healing progression and guiding injection therapy
• The distal triceps tendon and its insertion onto the olecranon are well-visualized sonographically

• Gold standard for soft tissue detail
• Demonstrates intratendinous signal change (T2 hyperintensity = tendinosis or partial tear)
• Essential when surgical planning is required or diagnosis is uncertain

Differential Diagnosis

Management

Conservative (First-Line)

• Relative rest (not complete immobilization): reduce the aggravating activity while maintaining overall movement
• Ice application to the posterior elbow (15-20 min, several times daily)
• NSAIDs - useful for short-term analgesia but do not significantly alter tendinopathic pathophysiology; avoid prolonged use in elderly, diabetics, or those with renal risk
• Counterforce bracing or elbow support if required

• Progressive loading program - central to tendinopathy recovery
• Isometric exercises initially (e.g., isometric elbow extension at varying angles): provide analgesia and begin tendon loading
• Isotonic strengthening: progressed to full-range eccentric-concentric loading
• Address contributing factors: scapular control, shoulder strength, sport technique correction
• Range of motion restoration

• Corticosteroid injection: may relieve pain for short periods but should not be repeated frequently as it is associated with tendon rupture. Not appropriate for tendinopathy lasting more than 90 days without reassessment
• Extracorporeal shockwave therapy (ESWT): an option for refractory cases, particularly calcific tendinopathy; satisfactory results but may be less effective than PRP
• Platelet-Rich Plasma (PRP) injection: growing evidence supports PRP over corticosteroid or shockwave therapy at 6 and 12 months in chronic cases; biologic rationale is delivery of growth factors to stimulate collagen remodeling

Surgical Management

1. Conservative management fails after 6 months, OR
2. Strength deficits are present on examination (suggesting significant partial or complete tear)
3. High-grade partial tear (>50% of tendon width)

• Open tenotomy with debridement of degenerated tissue and longitudinal tendon incisions to stimulate healing response
• Bone drilling/curettage of the olecranon enthesis to provoke a healing response
• Augmentation for chronic ruptures: anconeus rotation flap, plantaris or hamstring tendon augmentation, Achilles rotation flap, ligament augmentation devices

• Transosseous tunnel repair (though studies show higher rerupture rates vs. anchors)
• Suture anchor fixation (preferred by many surgeons - anatomic footprint repair with suture bridge)
• Anchor fixation has lower rerupture rates and lower reoperation rates than transosseous tunnels

Complications of Untreated Chronic Tendinopathy

• Progression to partial or complete tendon rupture
• Chronic pain and elbow dysfunction
• Weakness of elbow extension, impacting pushing activities
• In chronic cases, gap between tendon ends makes repair technically more difficult, requiring augmentation grafts

Key Points Summary

• Miller's Review of Orthopaedics 9th Ed, p. 725
• Campbell's Operative Orthopaedics 15th Ed, p. 2988
• Rosen's Emergency Medicine, pp. 551-552
• Tintinalli's Emergency Medicine, p. 3405
• Imaging Anatomy Vol 3, p. 543
• Casadei K et al. "Triceps Tendon Injuries." Curr Sports Med Rep 2020;19(9):367-372 [PMID: 32925376]
• Manske RC et al. "Diagnostic MSK Ultrasound in the Evaluation of the Triceps Tendon." Int J Sports Phys Ther 2025 [PMID: 40469652]