Triceps tendonitis

1)Search strategy

First we searched for articles but this was really difficult because there is not much research about this disease. For this subject there's a serious need of research. Also we did found some articles about how to treat the Achilles tendon, maybe this could be similar with the triceps tendon. But as said earlier, there's much more research to do. We were able to find an article but we think this is not enough, so we went on with our search and found some good information about triceps tendonitis in books.

2) Definition
What is tendonitis ? Tendonitis of the triceps is an inflammation of the muscle tendon who usually occurs on the triceps tendon attachment (the olecranon) , this is often accompanied by microtraumas. And is often the result of an overload. [5]

3)clinically relevant anatomy :

The triceps consisting out of 3 heads whose origins lies in the tuberculum infraglenoidale of the scapula, distal and lateral of the sulcus of the radial nerve at the humerus. Its insertion is the olecranon of the ulna. The functions in the shoulder – arm region are retroflexion and adduction of the arm. The function in the elbow is extension. The innervation of the triceps is provided by the n.radialis and the blood flow is done by the a.profunda Brachi.

4) Epidemyologie
Tendonitis of the triceps is the consequence of a supramaximal load on the attachement of the tendon to the bone,this may be caused by excessive pitching or a direct force acting upon the surface of the tendon.Not being able to fully flex or stretch the elbow , increased brittleness of the tendon and a swelling above the olecranon are symptoms that suggest a tendonitis of the triceps tendonPeople who use steroïds,people with a reduced strength or flexibility and simply lifting heavy objects increase the risk at tendonitis of the triceps.if not treated properly,the recovery proces is lengthened [7]
5) Characteristics/Clinical representation

The patient has pain and tenderness in the triceps tendon insertion into the olecranon, this pain exacerbate by a forced extension of the elbow. It is also possible that there's swelling around the elbow. The patient is no longer able to do some activities of his daily living like for example to lift a heavy box, but also the patient can no longer participate his sports. The best way to prevent a triceps tendonitis is to make sure you'll not overuse your upper arm and elbow. Also you can use functional braces to prevent injury and warm up and stretch before an activity. It is also important to use a proper technique, if you have an improper technique a coach is an option to correct you. Other complications are that a tendon rupture could happen, if this happens surgery is needed. But there's also a loss of motion in the elbow, and a good treatment is required to make sure that the healing time will not prolonge. [7]
6) Triceps Tendinitis Associated Injuries / Differential Diagnosis
* Lateral epicondylitis
* Medial epicondylitis
* Posterior Elbow Impingement
* Elbow Arthritis
* Olecranon Bursitis
* Synovial Plica Syndrome
* Snapping triceps
* Radiocapitellar Arthritis
7) Diagnostic Procedures

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose triceps tendonitis. Occasionally, further investigations such as an ultrasound, X-ray, CT scan or MRI scan may be required to assist with diagnosis and assess the severity of the condition.
But first the physiotherapist inspects the elbow for symptoms (…..). After the inspection he does a passive- and asks for an active movement so he can see of the lateral elbow works normal. After this theirs an evaluation for the ulnar traction spurs, loose bodies in the posterior compartment of the elbow. [5]

8) outcome measures :
DASH: the dash questionnaire for disabilities of the arm,shoulder and hand.This questionnaire asks about your symptoms as well as your ability to perform certain activities.

9) Examination

To make sure that we talk about a triceps tendonitis we can evaluate for ulnar traction and look for loose bodies in the posterior compartment of the elbow. Normally and active or passive movement of the elbow also gives pain to the patient.
Also a valgus stress test can be used, the elbow is in 30° of flexion and the shoulder abducted and fully externally rotated. The patient's wrist is under the arm of the therapist, the therapist also places one hand laterally over the elbow and the other hand under the ulna and the thumb over the ulnar collateral ligament and apply valgus stress.
Another test is the milking maneuver test, the patient grasps the thumb of the affected arm and pulls downward, with the affected elbow positioned as shown, stressing the ulnar collateral ligament . Elbow pain or apprehension is positive for UCL injury.
You can also use a moving valgus stress test, with the shoulder in abduction and maximum external rotation, place the elbow in maximum flexion and apply valgus force, and extend the elbow from full flexion to full extension in an attempt to reproduce the medial pain.
If the patient has 2 positive valgus tests and posterior pain:
A positive Tinel’s sign over the cubital tunnel is an indication of ulnar neuritis.Valgus extension overload syndrome, which is caused by repetitive stress and results in osteophytes, chondromalacia of the medial olecranon fossa, tension in the UCL, and compression of the radiocapitellar joint, will also produce positive valgus stress and positive moving valgus stress tests. Keep in mind, however, that patients with valgus extension overload often have loss of full extension and posterior elbow pain with forced elbow hyperextension.[8] [1]

10) Medical management
For the medical treatment of the triceps tendonitis can the healthcare provider recommend an anti-inflammatory medicine such as ‘ibuprofen’. Further can also pain relievers may be given, if It’s deemed necessary by the healthcare provider.[2]
11) Physical Therapy Management

At the beginning of the treatment, it is better to decrease the swelling. This is done by applying cold packs + - 20 minutes 3 times a day. As a therapist, you can also apply ice massage. Freeze water in a cup and tear back the top of the cup. Rub the injured area with the ice for 5 to 10 minutes, 3 times a day. Be careful when icing your elbow. An important nerve runs just under the skin and can be damaged if you ice more than is recommended.

After this, the therapist begins with exercises for the triceps.
First one is the stretching of the triceps, this can be done in several ways:
* French stretch: Stand with your fingers clasped together and your hands high above your head. Stretch by reaching down behind your head and trying to touch your upper back while keeping your hands clasped. Keep your elbows as close to your ears as possible. Hold this position for 15 to 20 seconds. Repeat 3 to 6 times.
* Triceps towel stretch: Stand with one arm over your head holding the end of a towel. Put your other arm behind your back and grab the towel. Stretch your top arm behind your head by pulling the towel down toward the floor with hand of your bottom arm. Keep the elbow of your top arm as close to your ear as possible. Hold for 15 to 20 seconds. Repeat 3 to 6 times.
* Towel resistance exercise: Stand with one arm over your head holding the end of a towel. Put your other arm behind your back and grab the towel. Lift the top hand toward the ceiling while creating resistance by pulling down on the towel with your other hand. Keep the elbow of your top arm as close to your ear as possible. Hold for 10 seconds. Repeat 10 times.
After the triceps has been stretched, the exercises will start.
* French press: Sit grasping a small weight with both hands as if it were a baseball bat. Reach toward the ceiling. Bending your elbows, slowly lower the weight behind your head until the weight touches your upper back. Lift the weight up over your head and reach toward the ceiling again. Repeat 10 to 20 times.  Also possible with theraband

  • Triceps kick back: Lean forward with the hand of one arm resting on a table or chair for support. Hold a weight in the hand of your other arm. Keep the elbow of that arm against your side. Your arm should be bent at a 90-degree angle with your upper arm parallel to the floor. Move the forearm of your arm backward until it is straight. Repeat 10 to 20 times. Also possible with theraband

Please note that this will be done first with light weights (250 grams) in order to build up so they can increase the taxability. If you immediately start with heavy weights, it will not be effective. This is because the taxability is weakened and you have to build it up.
Afterwards we will start with the eccentric exercises , research has shows that it is very effective against tendonitis. This one also starts with light weights and then build it up.[11]

STRENGTH - Elbow Extensors
• Lie on your back. Extend your right / left elbow into the air, pointing it toward the ceiling. Brace your arm with your opposite hand.*
• Holding a weight in your hand, slowly straighten your right / left elbow.
• Allow your muscles to control the weight as your hand returns to its starting position.

Caution! 1/3 seconds for eccentric exercises ,so stretching for 3 seconds and folding for 1 second. You can do this exercise in sit, watch that the elbow don’t get in final extension
This exercise can also work with a theraband

STRENGTH - Elbow Flexors, Neutral
• With good posture, stand or sit on a firm chair without armrests. Allow your right / left arm to rest at your side with your thumb facing forward.
• Holding a weight or gripping a rubber exercise band/tubing, bring your hand toward your shoulder.
• Allow your muscles to control the resistance as your hand returns to your side.
This exercise can also be eccentric! 1 second stretching and 3 seconds folding. [5][2]
* Modified push-up: Get onto your hands and knees, with your hands directly underneath your shoulders. Slowly lower yourself toward the floor, being careful to keep your spine straight. When you can do 2 sets of 15 easily, do this with your heels in the air. Gradually progress to doing this with your legs out straight.[10]

The physiotherapist can still do extra therapies like ultrasound therapy, electrical stimulation and in chronic cases, frictions or necessary surgery [12] [6]

12) key research
We searched different article databases ( Pubmed, the VUB article Database ,Web Of Knowledge and ) we searched for Books at the library of the VUB,We searched the internet for supportive,scientific and evidence based information.
13)references :
1) Book: Physical Medicine and Rehabilitation: Principles and Practice [electronic resource] ...Joel Alan DeLisa,Bruce Michael Gans,Nicholas E. Walsh. Lippincott Williams & Wilkins, 2005
2) systematic review (level of evidence 2A) : treatment of achilles tendonitis with injections . Gross CE, Hsu AR, Chahal J, Holmes GB Jr. Injectable treatments for noninsertional achilles tendinosis: a systematic reviewDepartment of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USAFoot Ankle Int. 2013 May
3) abstract: Kjaer M, Bayer ML, Eliasson P, Heinemeier KM. What is the impact of inflammation on the critical interplay between mechanical signaling and biochemical changes in tendon matrix?Institute of Sports Medicine, Bispebjerg Hospital and Centre for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, DenmarkJ Appl Physiol. 2013

4) abstract: Dean BJ, Franklin SL, Carr AJ. The Peripheral Neuronal Phenotype is Important in the Pathogenesis of Painful Human Tendinopathy: A Systematic Review. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK, [email protected] Clin Orthop Relat Res. 2013
5) expert consultation : Matthew J.Matava MD,Americain Orthopaedic society for sports medicine. Level Of Evidence : 5
6) Henk van der Worp*, Johannes Zwerver, Inge van den Akker-Scheek and Ron L Diercks . The TOPSHOCK study: Effectiveness of radial shockwave therapy compared to focused shockwave therapy for treating patellar tendinopathy - design of a randomised controlled trial
7) Alex Scott, Sean Docking, Bill Vicenzino, Håkan Alfredson, Johannes Zwerver, Kirsten Lundgreen, Oliver Finlay, Noel Pollock,Jill L Cook, Angela Fearon, Craig R Purdam, Alison Hoens,Jonathan D Rees, Thomas J Goetz, Patrik Danielson. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012.Br J Sports Med Level of evidence : 1A
8) Physical Medicine and Rehabilitation Board Review.Cuccurullo S, editor.New York: Demos Medical Publishing; 2004. Elbow Disorders.David P. Brown, D.O., Eric D. Freeman, D.O., Sara Cuccurullo, M.D., and Ted L. Freeman, D.O
9) John N. Howell; Karen S. Cabell; Anthony G. Chila, ; David C. Eland, Stretch Reflex and Hoffmann Reflex Responses to Osteopathic Manipulative Treatment in Subjects With Achilles Tendinitis. J Am Osteopath Assoc September 1, 2006 vol. 106 no. 9 537-545
10) Scott Coleman, PT, and Phyllis Clapis, PT, DHSc, OCS, for RelayHealth. Published by RelayHealth. Triceps Tendonitis and Strain.Central States Orthopedic specialists.
11) Brett M. Andres, MD and George A. C. Murrell, MD, Dphil.Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon Clin Orthop Relat Res. 2008 July; 466(7): 1539–1554. Published online 2008 April 30 level of evidence : 2A
12) abstract : Ewa M. Roos.Mikael Engström.Annika Lagerquist.Bengt Söderberg. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up. Scandinavian Journal of Medicine & Science in SportsVolume 14, Issue 5, pages 286–295, October 2004

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