Distal Triceps Rupture
Jacksonville, FL
A pop at the back of the elbow followed by inability to straighten the arm — that's a distal triceps rupture. Complete tears require urgent surgical repair. R. David Graham, MD at JOI repairs acute triceps avulsions with anchor-based locking stitch technique. No cortisone at the triceps insertion — ever. PRP for partial tears and chronic tendinosis.
- Complete tear = cannot actively extend elbow against gravity
- Partial tear = function maintained — PRP + activity modification
- No cortisone at triceps insertion — PRP is the injection of choice
- Acute complete tears repaired urgently within 2–4 weeks
- Delayed/chronic: reconstruction with allograft when needed
Distal triceps ruptures are rare — rarer than distal biceps ruptures — but equally disabling when complete. The no-cortisone rule at the triceps insertion is the same as at the distal biceps: the risk of precipitating a complete rupture in degenerated tendon tissue is not acceptable.
Understanding the Condition
Distal Triceps Rupture —
The Rarest Major Tendon Tear
The distal triceps tendon attaches to the tip of the olecranon — the bony prominence at the back of the elbow. The triceps is the primary elbow extensor, and when its distal attachment tears, the patient loses the ability to actively extend the elbow against gravity. Distal triceps ruptures are the rarest of the major tendon ruptures (far less common than distal biceps or rotator cuff) but produce a significant functional deficit when complete.
Complete tears occur most often from a fall on an outstretched hand with an eccentric load on the contracting triceps — the muscle contracts forcefully while being stretched by the fall, producing an avulsion at the olecranon insertion. Direct blows to the posterior elbow can also produce triceps avulsion. Risk factors include systemic steroid use, local corticosteroid injection (the no-cortisone rule applies specifically here — cortisone injection into the triceps insertion is not performed), fluoroquinolone antibiotic use, and anabolic steroid use.
Partial tears — where the triceps is still attached but partially disrupted — are managed conservatively when function is maintained. PRP injection to the repair site is offered for partial tears and chronic tendinosis as an alternative to the cortisone injection that is avoided at this location.
In Dr. Graham's experience, complete tears in any patient who needs functional elbow extension — which is essentially all working-age patients — require urgent surgical repair. The repair window is not as dramatically time-sensitive as distal biceps repair, but early repair (within 2–4 weeks) before significant tendon retraction makes surgery significantly more straightforward.
- ✓ Complete tear = inability to actively extend elbow against gravity
- ✓ Partial tear = maintains function, managed conservatively
- ✓ Positive "triceps drop test" — arm overhead, elbow passively extended, patient cannot hold it
- ✓ No cortisone injection at triceps insertion — PRP preferred
- ✓ Acute complete tears: urgent repair within 2–4 weeks
- ✓ Chronic/delayed: reconstruction with allograft if retraction prevents primary repair
Unable to Extend Elbow
The defining clinical finding — the patient cannot actively push the elbow into extension against gravity or resistance. They can extend passively (the arm falls into extension) but cannot contract the triceps to actively extend. The triceps drop test confirms this: with the arm elevated to 90°, the elbow drops into flexion rather than remaining extended.
Posterior Elbow Pain & Swelling
Acute rupture produces sudden posterior elbow pain, often with an audible or felt pop at the moment of injury. Significant swelling and ecchymosis develop over the olecranon within hours. A palpable gap may be felt at the triceps insertion, though swelling often obscures this.
MRI Confirms & Characterizes
MRI distinguishes complete from partial tears and assesses tendon retraction and tissue quality — all of which influence surgical planning. The "flake sign" on lateral elbow X-ray (a small avulsion fragment of bone from the olecranon) is pathognomonic for distal triceps avulsion when present.
Treatment
Urgent Repair for Complete Tears — PRP for Partial
Why No Cortisone at the Triceps Insertion
Cortisone injection at the distal triceps insertion — for triceps tendinosis or partial tears — carries an unacceptable risk of tendon rupture. The triceps tendon inserts directly onto the olecranon with minimal surrounding soft tissue, and the injection is necessarily placed close to or within the tendon substance. Corticosteroids weaken tendon collagen, and in this anatomically constrained location, the risk of precipitating a complete rupture is not acceptable.
PRP is the preferred injection-based intervention for distal triceps tendinosis and partial tears. PRP delivers growth factors that promote collagen synthesis and tendon healing without the tissue-weakening effect of cortisone. It is offered alongside splinting and activity modification as the primary non-operative treatment when injection therapy is appropriate.
Anesthesia & Setup
Outpatient at Baptist Beaches Hospital or Horizon Surgery Center. Regional block with sedation. Prone position with arm over a bolster, or lateral — both provide access to the posterior elbow. Tourniquet on the upper arm.
Posterior Approach & Tendon Retrieval
Longitudinal posterior incision over the olecranon. The retracted triceps tendon is identified and mobilized — tendon retraction assessed and the tendon freshened at the repair end. In delayed presentations, the tendon may be significantly retracted and adherent to surrounding tissue.
Olecranon Footprint Preparation
The olecranon insertion site is debrided to bleeding bone to prepare a vascular bed for tendon healing. Suture anchors are placed in the olecranon to receive the repair sutures — the same anchor-based technique used for distal biceps repair on the medial side.
Locking Stitch & Repair
A locking stitch (Krackow technique) is placed through the distal triceps tendon, distributing repair tension along the tendon length. The tendon is advanced to the olecranon footprint and secured through the suture anchors. Repair integrity tested by taking the elbow through flexion — the repair should hold securely with the elbow at 90° of flexion.
PRP & Closure
PRP applied to the repair site before closure to support biological healing and tendon-to-bone integration. Splint applied at 30–45° of elbow flexion — the position that minimizes tension on the repair.
Recovery
After Triceps Repair
Splint & Protection
Splint at 30–45° flexion, protecting repair from full extension stress. Grip and finger motion maintained. No active extension against resistance.
Progressive Extension
Splint adjusted to allow progressive extension. Active-assisted range of motion through formal therapy. Gravity-only extension exercises begin before resisted extension.
Strengthening
Progressive triceps strengthening under formal therapy supervision. Return to light pushing and overhead activities. Heavy resistance deferred.
Full Return
Full return to pushing, pressing, and manual labor at 4–6 months. Strength fully restored in most patients by 6 months. Heavy bench press and power activities cleared last.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Cannot extend your elbow after a fall —
this is urgent.
Inability to actively extend the elbow against gravity after posterior elbow trauma is a distal triceps rupture until proven otherwise. Early repair within 2–4 weeks is significantly simpler than delayed reconstruction. Walk-ins seen same day for acute injuries via JOI Now, Monday–Friday.
Jacksonville Beach, FL 32250
Walk-ins for acute elbow injuries seen same day via JOI Now.