Triceps Tendon Repair & Reconstruction
Specialized anatomical repair of distal triceps tendon ruptures using transosseous bone tunnels or double-row suture bridges, with meticulous ulnar nerve neurolysis and graft reconstruction for retracted tears.
Understanding Triceps Tendon Ruptures
The triceps brachii is the powerful three-headed muscle on the back of the upper arm responsible for extending and locking the elbow straight. Its three muscle bellies (long, lateral, and deep medial heads) coalesce into a broad, robust tendinous plate that inserts directly onto the olecranon process (the prominent bony tip of the elbow).
Distal triceps tendon ruptures represent the least common of all major tendon avulsions (accounting for less than 1% to 2% of upper extremity tendon injuries). They typically occur when a forceful eccentric deceleration load is suddenly applied against an actively contracting triceps—such as bracing against a fall on an outstretched hand, catching a heavy falling object, or during maximum bench press and weightlifting maneuvers.
Clinical Hallmarks of a Triceps Tear: A sudden painful "pop" at the back of the elbow, rapid swelling and bruising, a palpable gap or divot just above the bony olecranon tip, and inability to extend the elbow against gravity (such as straightening the arm overhead or pushing up from a seated position).
On diagnostic plain radiographs, a classic "flake sign" (a small fleck of bone avulsed from the olecranon cortex) is visible in up to 80% of complete tears. High-resolution 3T MRI and dynamic musculoskeletal ultrasound are utilized to differentiate full-thickness tears from partial-thickness enthesopathy, assess tendon retraction distance, and evaluate muscle belly quality.
Download Rehabilitation Protocol
Official milestone-driven physical therapy protocol detailing hinged brace unlock angles, protected passive flexion arcs, and eccentric triceps strengthening:
Download Triceps Protocol (PDF) ↓Precision Anatomical Footprint Reconstruction
Because the triceps footprint is broad and subjected to immense tensile forces during pushing and weight bearing, surgical repair must achieve rigid anatomical fixation to the olecranon bone bed while safeguarding the adjacent ulnar nerve.
Transosseous Bone Tunnel Repair
The time-tested gold standard technique for primary acute avulsions. High-tensile, non-absorbable braided sutures (such as FiberWire) are placed through the retracted tendon stump using locking Krakow or Bunnell stitch configurations.
- Three parallel or crossed precision drill tunnels created through the olecranon cortex.
- Tendon stump brought directly down into a decorticated bone trough to promote rapid osteotendinous healing.
- Sutures secured over a sturdy dorsal bone bridge, ensuring high pullout strength.
Double-Row Knotless Suture Anchors
A contemporary anatomical reconstruction utilizing high-strength knotless suture anchors inserted into the articular margin and distal olecranon footprint, replicating natural anatomy.
- Compresses the broad tendon footprint evenly over the entire bone bed.
- Eliminates bulky subcutaneous suture knots under the thin skin of the posterior elbow.
- Significantly reduces microscopic gap formation under early cyclical motion.
Reconstruction for Retracted Tears
When presentation is delayed past 3 to 4 weeks, the tendon may retract into the posterior arm with marked muscle contracture, preventing direct repair without excessive joint stiffness.
- Achilles tendon allograft with a calcaneal bone block to reconstruct structural length.
- V-Y quadriceps-style turndown flap (van Gorder technique) to advance native tendon tissue.
- Restores full extensor leverage and functional motion arc without excessive tension.
Ulnar Nerve Neurolysis & Protection
The ulnar nerve courses immediately medial to the triceps insertion within the retrocondylar cubital tunnel. Its meticulous preservation is an indispensable component of every surgical repair.
- Formal surgical identification and gentle vessel-loop mobilization away from drill paths.
- Protects against accidental nerve entrapment, traction neuropraxia, or suture impingement.
- Prevents post-operative ring and small finger numbness, weakness, or cubital tunnel syndrome.
Phased Rehabilitation Milestones
Hinged Brace Protection & Edema Control
Hinged elbow brace worn 24/7, locked at 30° to 45° of flexion for 2 weeks to eliminate tension on the olecranon repair. Weeks 3 to 4: brace unlocked to allow passive flexion from 0° to 45°. Strictly NO active elbow extension. Immediate active hand, wrist, and shoulder motion to maintain peripheral circulation and prevent upper extremity deconditioning. Cryotherapy for posterior elbow swelling.
Protected Motion Progression & Brace Weaning
Brace settings unlocked progressively: 0° to 60° at week 4, 0° to 90° at week 6. Discontinue brace between weeks 6 and 8. Active unassisted elbow flexion and gravity-assisted active extension. Gentle passive end-range stretching without forceful manipulation. Submaximal isometric triceps sets initiated at 60° flexion by week 8.
Progressive Strengthening & Muscular Re-Education
Active extension against gravity throughout the full available range. Initiate light resistance bands and 1 to 2 lb dumbbell triceps extensions. Closed-chain wall pushups, upper body ergometer, and functional reaching drills. Full active range of motion symmetrical to the contralateral elbow expected by week 12.
Advanced Conditioning & Return to Heavy Loading
Progressive eccentric triceps strengthening, overhead resistance drills, and closed-chain pushup progressions. Clearance for heavy vocational lifting, heavy bench pressing, dips, and competitive sports at 5 to 6 months once isokinetic triceps strength reaches at least 85% to 90% of the unaffected arm.
Frequently Asked Questions
Triceps tendon repair (surgically reattaching the muscle at the back of the arm to the elbow bone) is an outpatient procedure.
A hinged elbow brace is typically worn for 6 weeks following surgery. It is initially locked and progressively unlocked to protect the repair from tension.
Therapy carefully restores elbow bending over 6 weeks. Active pushing strength is avoided until the tendon heals solidly to the bone.
Driving requires the brace to be removed or fully unlocked, typically at 6 weeks. Desk work can resume in 1 to 2 weeks.
Heavy pushing movements such as bench pressing, dips, push-ups, and contact athletics are resumed between 5 and 6 months post-operatively.
An untreated full-thickness tear causes persistent loss of extension power against gravity. Patients struggle to push up from chairs or perform pushing exercises.
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Dr. Christian Veillette provides comprehensive subspecialty care for the full spectrum of elbow conditions, tendon avulsions, and joint reconstruction.