DISTAL TRICEPS TENDON RUPTURE DUE TO OLECRANON OSTEOPHYTE AVULSION: A CASE SERIESABSTRACT
Objective: To report a case series of distal triceps tendon rupture associated with olecranon osteophyte avulsion, a rare condition with few reports in the literature.
Methods: This study analyzed patients who underwent surgical treatment between 2011 and 2022 for distal triceps tendon rupture associated with olecranon osteophyte avulsion. Clinical and radiographic characteristics, pain levels, and functional outcomes were assessed using the Q-DASH and MEPS scores.
Results: There was a significant reduction in pain between the 1st and 12th weeks (mean VAS from 5.8 to 0.8; p<0.001). The mean Q-DASH score improved from 1.9 to 0.2 between the 6th and 12th months (p=0.003). The MEPS remained high throughout the follow-up period (final mean: 100). Patients operated on within 7 days from trauma had less residual pain (p=0.02). Smokers had worse functional scores at 6 months (p=0.04). Previous elbow pain was associated with worse pain score in the first week post op (p=0.048), but no difference in final outcomes.
Conclusion: Surgery for triceps tendon rupture with olecranon osteophyte avulsion led to significant improvements in pain and function. Factors such as time to treatment, smoking, and age influence recovery. Level of Evidence IV; Case Series.
Keywords:
Tendons; Tendon Injuries; Osteophyte; Elbow; Orthopedic Procedures; Case Reports
RESUMO
Objetivo: Relatar uma série de casos de ruptura do tendão distal do tríceps associada à avulsão de osteófitos do olécrano, condição rara, com poucos relatos na literatura.
Métodos: Esse estudo analisou pacientes submetidos a tratamento cirúrgico entre 2011 e 2022 por ruptura do tendão distal do tríceps associada à avulsão osteofitária do olécrano. Foram avaliadas características clínicas, radiográficas, dor e desfechos funcionais por meio dos escores Q-DASH e MEPS.
Resultados: Houve redução significativa da dor entre a 1ª e a 12ª semana (EVA média de 5,8 para 0,8; p<0,001). O escore Q-DASH melhorou de 1,9 para 0,2 entre o 6° e o 12° mês (p=0,003). O MEPS manteve-se elevado ao longo do seguimento (média final: 100). Pacientes operados há menos de 7 dias do trauma apresentaram menor dor residual (p=0,02). Tabagistas apresentaram piores escores funcionais no 6° mês (p=0,04). Dor prévia no cotovelo associou-se a pior escore de dor na primeira semana pós-operatória (p=0,048), mas não houve diferença no desfecho final.
Conclusão: A cirurgia para ruptura do tríceps com avulsão de osteófito do olécrano resultou em melhora significativa da dor e da função. Fatores como o tempo até o tratamento, o tabagismo e a idade influenciam a recuperação. Nível de Evidência IV; Série de casos.
Descritores:
Tendões; Traumatismos dos Tendões; Osteófito; Cotovelo; Cirurgia Ortopédica; Relatos de Casos
INTRODUCTION
The rupture of the distal triceps tendon is a rare injury, accounting for less than 1% of all upper-limb tendon ruptures1. This condition predominantly affects middle-aged men and is usually associated with direct trauma to the elbow or vigorous eccentric contraction, as occurs in falls onto an outstretched hand or during weightlifting2,3. In many cases, the initial diagnosis is overlooked, as the extension of the elbow may be partially preserved due to the integrity of the lateral expansion of the tendon, masking the complete functional deficit4,5.
The distal insertion of the triceps at the olecranon has complex anatomical features and is subject to degenerative changes from chronic use and repetitive overload6. In these cases, the formation of enthesophytes, also known as olecranon spurs, is common; these are bony projections arising from chronic traction at the tendon enthesis7,8. Although often asymptomatic, these spurs can predispose to tendon avulsion in traumatic events, especially when associated with degeneration of the tendon tissue9.
Despite reports of triceps rupture in patients with olecranon osteophytes, the direct association between these two conditions is rarely described in the literature. Additionally, isolated fracture of the spur as a mechanism of tendon avulsion is rarely recognized on initial diagnosis10,11. Confusion with other elbow pathologies, such as bursitis or epicondylitis, contributes to delays in appropriate treatment5,12.
This study aims to describe a series of cases of distal triceps rupture associated with avulsion of olecranon osteophytes and to characterize the clinical, radiographic, and surgical aspects of this poorly documented entity. The analysis aims to provide relevant clinical and anatomical data to support early diagnosis and appropriate management of these cases.
MATERIALS AND METHODS
This is a series of cases of patients diagnosed with distal triceps tendon rupture with avulsion of the olecranon osteophyte, treated by the shoulder and elbow surgery team at the Sports Trauma-Orthopedics Center of the Federal University of São Paulo between 2011 and 2022. The study was approved by the institutional ethics committee under registration CAAE 55501222.2.0000.5505. All patients signed the informed consent form.
After reviewing electronic medical records, cases of traumatic rupture of the distal triceps tendon associated with avulsion of the insertional osteophyte were identified. Cases of purely tendon injuries, ruptures with olecranon fracture, chronic injuries (>14 days), and cases with other concomitant elbow injuries were excluded.
All patients had the diagnosis of the injury made through clinical evaluation (local pain, bruising, and palpable gap) and confirmed by ultrasound or magnetic resonance imaging. For complete tendon injuries, surgical treatment was indicated. For partial injuries, the patient was given the option to choose between conservative or surgical treatment, depending on work and sports demands.
Demographic characteristics of the patients were evaluated, such as sex, age, body mass index (BMI), dominant limb, physical activity, comorbidities, and habits (smoking, alcoholism, use of anabolic steroids). Data related to the injury were also analyzed, including the type of injury (partial or complete), the mechanism of trauma, the presence of prior symptoms, the treatment (surgical or conservative), the time to surgery, the complications, and the time to return to work and sports activities. The evolution of pain complaints was assessed using the Visual Analog Scale (VAS). Elbow function was evaluated using the Quick-Disabilities of the Arm, Shoulder and Hand (Q-DASH) scores and the Mayo Elbow Performance Score (MEPS). At the end of treatment, patients rated their satisfaction with the treatment on a scale from 0 to 10 (0 = dissatisfied, 10 = completely satisfied).
Surgical Technique
Under general anesthesia, in a prone position, the injured limb was supported on a brace, with the forearm hanging down. A distal posterior incision of about 6 centimeters was made on the arm. The tendon stump was identified and its mobility tested by moving it to its insertion on the olecranon. The avulsed bone fragment, as well as the remaining part still attached to the olecranon, were resected. The tendon repair was performed with two bioabsorbable SwiveLock anchors (Arthrex, Naples, Florida, USA), fixed to the olecranon and spaced 2 centimeters apart. The range of motion of the elbow was assessed to confirm appropriate repair tension, and the incision was sutured.
Post-operative
After surgery, patients kept their elbows immobilized in slings at 90 degrees for 3 weeks. Starting from the fourth week, under physiotherapeutic supervision, passive exercises were initiated to recover elbow flexion and extension. Patients were encouraged to achieve a full range of motion by the 8th week post-operatively. From weeks 9 to 12, the focus was on isometric and isotonic exercises. Starting in the 12th week, concentric and eccentric exercises with progressively increasing loads were initiated to achieve gradual strengthening. Work and sports activities that did not require load on the upper limbs were permitted starting from the 2nd month post-operation. Return to sports for more strenuous activities was allowed when the patient achieved a range of motion and strength clinically similar to the contralateral side, and when it was deemed safe for sports practice.
Statistical Analysis
Descriptive analysis of the data was performed using Stata software version 17.0 (StataCorp LLC, College Station, TX, USA), and tables were created in Excel software version 365 (Microsoft Corporation, Redmond, WA, USA). Continuous variables were represented by mean and standard deviation, while categorical variables were represented by absolute numbers and relative frequency. The normality of continuous variables was verified using the Shapiro-Wilk test. Given the small sample size (n = 12), all comparisons between independent groups were performed using the Mann-Whitney U test. For paired comparisons in longitudinal measures, the Wilcoxon test was used. The assessment of pain over time was conducted using the Friedman test, complemented by pairwise comparisons with the Wilcoxon test. To investigate associations between age and clinical outcomes, the Spearman correlation coefficient was used. The level of statistical significance was set at 5% (p < 0.05).
RESULTS
Twelve elbows in nine patients were analyzed with a mean age of 51.5 years (± 7.4) and a mean BMI of 26.5 kg/m² (± 1.0). All patients engaged in regular physical activity, with weightlifting, running, and CrossFit being the most prevalent. The rupture was complete in nine cases and partial in three. Three patients presented with bilateral injury. The average time between trauma and surgery was four days. Two patients with partial injury were treated conservatively. Most injuries occurred in the dominant limb. Previous pain was reported in six cases, comorbidities in three, use of anabolic steroids in four, and smoking in two patients. The main characteristics of the sample are presented in Table 1, and the individual characteristics of each patient are in Table 2. Figures 1 to 4 illustrate clinical and radiographic images of the lesions.
Clinical images from the physical examination of two patients. A) Bruising on the elbow around the injury. B) Palpable gap at the site of the tendon rupture.
Lateral radiographs of the elbow showing the injury. A and B) The arrows point to the avulsed bone fragment from the osteophyte. C) The arrow points to the olecranon osteophyte, already showing signs of incomplete fracture, on the verge of rupture.
Ultrasound image of the elbow. The left arrow points to the avulsed bone fragment and the right arrow points to the remaining osteophyte that is still attached to the olecranon.
Sagittal cuts from magnetic resonance imaging highlighting the injury with arrows pointing to the bone fragment avulsed by the triceps tendon. A) T2 weighting. B) T1 weighting.
Throughout the follow-up, progressive clinical improvement was observed (Table 3). Pain showed a statistically significant reduction between the first and the 48th week (p < 0.001). Comparisons between consecutive weeks showed continuous improvement through the 12th week, followed by stabilization between the 12th and 24th weeks, with further reduction through the 48th week. The Q-DASH score showed a significant improvement between 6 and 12 months (p = 0.039), whereas the MEPS score remained high throughout the follow-up period, with no statistically significant difference between the same periods (p = 0.157). The average patient satisfaction was 9.9 on a scale from 0 to 10.
In comparisons between subgroups, no significant differences were observed in functional outcomes, pain, or satisfaction between patients with total and partial injuries (Table 4). Similarly, patients with bilateral injuries and those treated conservatively did not differ statistically compared to others. However, it was observed that patients who underwent surgery early, within seven days after the trauma, had lower residual pain scores at 12 months (VAS 48S), with statistical significance (p = 0.031). Smoking patients showed worse functional performance at six months (MEPS6, p = 0.0016) and greater dysfunction at 12 months (Q-DASH12, p = 0.044). The use of anabolic steroids, the presence of previous pain, and the dominance of the injured limb did not significantly influence the functional outcomes. The presence of comorbidities was associated with a trend towards worse functional performance on the MEPS at six months (p = 0.103), without a statistically significant impact on other outcomes.
There was a negative correlation between age and MEPS at six months (p = 0.082) and a positive correlation between age and Q-DASH at the same time point (p = 0.087), suggesting that older patients had slightly inferior functional recovery in the early stage of follow-up, although this was not statistically significant. No relevant correlations were observed between age and pain or satisfaction.
DISCUSSION
The results of this study demonstrated a favorable clinical evolution in patients with distal triceps tendon rupture associated with olecranon osteophyte avulsion. Progressive improvement in pain was observed throughout the follow-up period, with clinical stabilization beginning in the 12th week. Upper limb function, assessed by the Q-DASH, showed consistent improvement between the sixth and twelfth months, while MEPS scores remained high throughout the follow-up. Most patients reported high satisfaction with functional outcomes. Among the subgroups, early surgery was associated with less residual pain, and smoking patients showed worse functional outcomes in intermediate assessments. Age also showed a tendency for slightly inferior initial functional performance. These findings reinforce the relevance of clinical and behavioral factors in the functional prognosis of this rare injury.
The good functional results observed corroborate previous findings in case series and systematic reviews, which show significant improvement in pain and function after surgical repair of the triceps, especially when performed early1,2. In contrast, delays in diagnosis, common in injuries with preserved extension, are associated with worse outcomes, as reported by Sharma et al. and Downey et al.4,5. This emphasizes the importance of early diagnosis, especially in patients with persistent pain and a history of eccentric effort.
The association with avulsion of osteophytes from the olecranon, present in all cases in this series, is rarely described in the literature but has been reported in anatomical studies and isolated cases7–9. These spurs may represent mechanical weak points at the triceps insertion, predisposing to rupture even with low-energy trauma. The fracture of the spur can be subtle or mistaken for benign calcifications, delaying recognition of the condition10.
Surgical treatment proved effective, regardless of the technique used. Techniques with anchors, transosseous methods, or suture bridges are widely used, and the results of the present series are consistent with the good outcomes described by Furuhata et al. and Bernardi et al.11,12. The failure reported by Neumann et al. with isolated anchors highlights the importance of assessing bone quality and adapting the technique as needed3.
Clinical variables, such as smoking and age, influenced the outcomes, reflecting patterns already observed in other orthopedic conditions. Although not always directly addressed in studies on the triceps, factors such as compromised vascularization and reduced tendon healing capacity help explain these differences13–16. Thus, the findings of this series reinforce the importance of individualized approaches and early attention to clinical signs suggestive of this rare entity.
Limitations
This study presents methodological limitations that must be considered. The small number of patients limits the statistical power to detect differences between subgroups and compromises the generalization of the findings. However, since it is a rare clinical condition, this series represents one of the largest ever published, providing descriptive relevance to the work. The retrospective design may introduce selection bias and limitations in the standardization of data collection. Nevertheless, all patients were treated at a single specialized center, under homogeneous clinical protocols, which favors the consistency of the data. The absence of a control group limits causal inference, particularly regarding the effectiveness of conservative treatment. However, the prospective collection of functional data at multiple time points over 12 months enabled a robust evolutionary analysis of patients’ clinical and functional recovery.
CONCLUSION
The rupture of the distal triceps tendon associated with the avulsion of an olecranon osteophyte is a rare condition, but with an excellent functional prognosis when diagnosed early and treated appropriately.
DATA AVAILABILITY DECLARATION
The underlying contents of the research text are contained in the manuscript.
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