Rupture of the Triceps Brachii muscle

Introduction

The triceps is a large, thick muscle located on the back of the upper arm. It usually appears as a horseshoe on the back of the arm. The main function of the triceps is extension of the elbow joint. [1]

Triceps rupture is a rare injury of the extensor mechanism of the elbow, most commonly caused by sudden forced elbow retraction in weightlifters or older men with underlying systemic disease [2].

Etiology

Triceps tendon tears are a relatively rare injury, with distal triceps rupture being the rarest rupture in the upper extremity (less than 1% of all upper extremity tendon injuries) [3][4].

• Rupture is usually related to a pre-existing systemic condition or medication, including topical or systemic steroids or systemic endocrine dysregulation, renal failure, anabolic steroids, and local steroid injections.
• Patients tend to be athletic men between the ages of 30 and 50.
• Injuries are usually due to direct damage to the resistance of the elbow by the outstretched hand during a fall [5], and may sometimes follow surgical procedures to reattach the triceps muscle. For example, several case reports have demonstrated triceps rupture after total elbow arthroplasty.

Clinical Presentation

Clinical signs and symptoms vary according to:

• Lesion type (tendon avulsion or intramuscular)
• The degree of extension (partial or total).
• The time (acute or chronic).

In general, triceps injuries are characterized by

• Tendon pain or tenderness and a palpable defect proximal to the olecranon can be seen [6][7].
• Patients describe frequent, unexpected “pops” or subsequent extremity pain and weakness.
• You can expect a complete rupture of the triceps when the patient is unable to extend the arm against gravity. Palpable imperfections are not always present, but can sometimes be found in the hindarm.
• Swelling and ecchymoses (bruises) are other nonspecific findings. [8]

Examination

Inspection

• Painful swelling and bruising on the back of the elbow
• may have palpable defect

Motion

• Unable to extend elbow against resistance
• Not always present – some patients are able to extend the elbow against resistance if the lateral expansion or anconeus compensation is intact

Provocative tests

Modified Thompson squeeze test: With the patient prone, the elbow at the end of the table, the forearm drooping, the triceps muscle is squeezed so hard that the elbow cannot be extended against gravity, indicating complete disruption of the intrinsic triceps and lateral extension. [2]

Imaging Studies

Magnetic resonance imaging is widely accepted as the gold standard for assessing tear size and extent: triceps injuries typically occur at the tendon insertion and result in a partial or complete tear.

Complications

1. Elbow stiffness/weakness
2. Ulnar nerve injury
3. Failure of repair[2]

Differential Diagnosis

• Fracture[3]
• Joint dislocation[3]
• Intramuscular tears [3] debilitating due to neurogenic radial nerve problems and triceps tendonitis, but reported in the literature as uncommon [6] [9]

Treatment

Non-operative: splint immobilization

Indications

• Partially torn and able to stretch against gravity
• low demand patients in poor health

Technique: Immobilize the elbow joint at 30 degrees of flexion for 4 weeks. Fixation is followed by range of motion and strengthening exercises. Six months after injury, full strength and ROM should be achieved. [10]

Operative: primary surgical repair

Indications

• acute complete tears
• Partial tear (>50%) with significant weakness

Technique: Delayed reconstruction may require tendon graft

Physical Therapy Mangement

Treatment after triceps surgery consists of several steps:

Protected phase 

1.Splinting following triceps repair:

Since the elbow is initially immobilized in a long arm splint following surgical repair of the triceps, the elbow is in 30 – 45° elbow flexion, the forearm is in a neutral position, and the wrist is usually supported. Management recommendations vary widely after surgery. But the postoperative position is at the discretion of the surgeon based on the tone and quality of the tendon repairing other injuries and the patient’s medical history. This location is also unique to each patient. [3][11]

Hinge splints can be used after triceps repair if early control of motion is desired. The splint prevents elbow flexion on the one hand and allows dynamic/gravity-assisted elbow extension on the other. The goal is to progressively flex the elbow by advancing the range of motion blocks each week. so The splint allows passive elbow flexion and active elbow flexion within a defined range. When the patient is not exercising, the splint locks in one position. Patient education is also important at this stage. Patient Information No Active Elbow Movement Prolongation, as this may cause avulsion or rupture of the repaired tendon. For example: pushing yourself out of a chair may not be possible with the surgical arm. [3][12] When the patient has difficulty relaxing the repaired muscles, or when he is performing In this case, we use a dynamic traction splint for a protective splint exercise. [3]

2. Therapy program

At this stage, we can start with Early Controlled Movement (ECM), whether the patient is in a static hinged splint or a dynamic splint. When using a static splint on a patient, it is absolutely imperative that the patient is secure. We can prevent this problem by using hinge cleats, because then there will be blocks Placed to limit end range, it also facilitates dynamic movement. [3] There is not really a consensus in the literature regarding the optimal time frame for initiating early controlled exercise. In this paper, ECM was started from postoperative day 10 to 14. This has some advantages, such as: Reduces pain and edema. As you can see in the photo below, the ECM program consists of four exercises, namely [3]:

A) Full passive elbow extension B) Active and/or passive elbow flexion to 30 °C) Use of template splints to prevent the extent of active flexion D) Passive forearm rotation with elbow extended can assist exercise performance in home programs by gravity . Increase Flexion was allowed for each consecutive week. Week 6 allows for a fully active range of motion in the elbow and forearm. Patients often experience edema in their hands after surgery. We can explain this by the fact that the hand is in a dependent position for most of the day due to immobilization Elbows are in an extended position. Therefore, it is highly recommended to start some exercises immediately after surgery, such as: hand pumping elevated above heart level using compression gloves or wraps. [3]

Additional therapeutic interventions include: thermal agents; therapist-assisted movement within range limitations; edema control; pain management; scar mobilization

If necessary: Isometric reinforcement of rotational abduction and adduction of the hands and shoulders. [3] The end range of elbow flexion combined with shoulder elevation is important as this will emphasize triceps repair. full-time fixed for If the patient does not follow the ECM procedure, it takes three to four weeks because more prosthetic protection is needed. [3]

Progressive motion phase

Six weeks after surgery, the patient began to actively contract the triceps. Definitely emphasize elbow extension against gravity to encourage active motor recruitment rather than using gravity to assist in the extension. There are techniques to restore active end-of-range Proposal such as [3]:

*Place and hold exercise at available end range*PNF = Proprioceptive Neuromuscular Facilitation Mode of Movement*Neuromuscular Electrical Stimulation

Treatment for capsular tightness or joint contractures may be required. This treatment consists of [3]:

*Thermal agent*Joint mobilization*Continuous positioning*Splits for increased range of motion

C) Strengthening phase:

This phase begins 10-12 weeks after surgery. It may take months to regain strength. At the beginning of this phase, it is very important that the active range of motion equals the passive range of motion. Can be healed as long as the passive limit is still present Improve. The fact that this phase begins after 10 to 12 weeks ensures that the tendon is sufficiently healed to withstand the stress of strengthening exercises. [3]

Strengthening begins with a 50% isometric contraction of the muscle-tendon unit. Force exertion was determined by measuring the maximal voluntary contraction (MVC) of the non-operated side with a hand-held ergometer and having the patient exercise up to 50% of the MVC. Shrinkage is Starts in the mid-range and progresses to the sporty end-of-range. If the patient is not in pain, the effort is increased to maximum. These are exercises to strengthen the triceps. Note the position of the forearm in supination, neutral and pronation to address all three heads. triceps. [3] The strengthening plan was eventually advanced to:

Isotonic concentric exercises use: • Free weights, such as dumbbells • Elastic bands • PNF Diagonal pattern eventually advancing to eccentric muscle contractions

These two photos at R demonstrate the completion of the stabilization and mobilization exercises. A : Demonstrate weight bearing and scapular control exercises to facilitate total limb repair

B: Demonstration of swordsmanship. The Bodyblade uses vibration and inertial forces to rapidly contract your muscles at a rate of 270 beats per minute, stimulating your nervous system and transforming your body. [13]

If pain develops at the surgical site, the intensity of the strengthening program is reduced immediately. Start specific sports and work specific activities 16 weeks after surgery. [3][14]