Triceps Tendon Rupture

Triceps tendon rupture is the rarest of the major tendon ruptures, accounting for roughly 1-2% of all tendon injuries. According to PubMed, it occurs most often in men aged 40-60, classically during weightlifting (forced eccentric contraction at the end of a bench-press lockout) or after a fall on an outstretched hand that suddenly flexes a contracting elbow.

Key facts students should know:

• The injury is almost always an avulsion at the tendon-bone junction (enthesis) off the olecranon, not a midsubstance tear, because the enthesis is the mechanically weakest link.
• A large insurance-database cohort identified male sex, age over 60, ischaemic heart disease, rheumatoid arthritis and chronic kidney disease as risk factors for complications, and prior anabolic steroid use as the strongest predictor of needing revision surgery.
• Up to a third of cases have an associated injury (radial head fracture, olecranon bursitis, or wrist/forearm injury from the same fall) - examine the whole limb.
• Because it is so rare, the diagnosis is frequently missed at first presentation, leading to chronic, retracted tears that are harder to repair.

• Radiographs first (AP + lateral): Look for the fleck sign - an avulsed flake of olecranon cortex, pathognomonic of a triceps avulsion. Also excludes associated radial head/olecranon fractures.
• Ultrasound: Cheap, dynamic, operator-dependent; good for confirming a tear and assessing gap, useful in resource-limited settings.
• MRI: Best for equivocal cases, partial tears and surgical planning - quantifies the percentage of tendon torn, which layers are involved, gap/retraction, and muscle quality in chronic tears. Sagittal fat-saturated sequences show fluid at the footprint.

A confident clinical diagnosis (gap + antigravity loss + fleck sign) needs no advanced imaging before surgery, but MRI is invaluable when the examination is equivocal or a partial tear is suspected.

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The anatomy section notes the distal triceps is bilaminar, and the classification refers to an "MRI layered classification" — this is the framework MRI actually uses to grade the tear and plan the repair.

• The two layers. A thick superficial layer (long and lateral heads) inserts more proximally on the olecranon; a deep layer (mainly the medial head) inserts more distally and broadly. Sagittal fat-saturated MRI shows each layer separately.
• The commonest real-world pattern. The typical injury is a superficial-layer full-thickness tear with the deep layer still partly attached — which is exactly why a patient can retain weak extension and why the tear is easily under-called: the intact deep layer (plus the anconeus and lateral expansion) masks the superficial avulsion.
• Why it changes the operation. MRI quantifies (1) which layers are torn, (2) the percentage of tendon width involved, and (3) the retraction/gap. A superficial tear with a substantial intact deep layer may suit a single-row/limited repair, whereas a full bilaminar avulsion needs a footprint-restoring double-row/suture-bridge construct.
• Practical rule: when the extension weakness is worse than the tear "looks", suspect an occult superficial-layer avulsion sitting over a still-attached deep layer — image both layers before committing to partial versus complete. Systematic elbow imaging is developed in the imaging-elbow-systematic topic.

Treatment hinges on completeness of the tear and patient demand. Use the tabs below.

The classification and management repeatedly flag that a chronic tear (beyond about 6 weeks) retracts and scars so that primary footprint repair becomes impossible, requiring "V-Y turndown or Achilles allograft" — here are those reconstruction options in full.

• Why primary repair fails late. By around 6 weeks the muscle-tendon unit shortens and adheres, so dragging it back to the olecranon either fails under tension or blocks flexion. First assess muscle quality on MRI — a fatty, atrophic triceps predicts a poorer result whatever is done.
• V-Y triceps turndown (lengthening). A proximally-based inverted-V (tongue) of the scarred triceps aponeurosis is turned distally to bridge the gap and reattached to the olecranon, lengthening the musculotendinous unit so native tissue reaches bone; the donor defect is closed side-to-side. It uses the patient's own tissue with no graft.
• Tendon allograft augmentation. An Achilles tendon allograft — its calcaneal bone block fixed to the olecranon and the tendinous fan woven into the triceps — is the workhorse for a large irreparable gap; semitendinosus/hamstring or fascia lata grafts are alternatives.
• Anconeus rotation flap. The anconeus can be rotated to reconstruct a smaller distal-triceps defect.
• Counselling. Reconstruction outcomes are less reliable than acute repair (weaker extension, some extension lag, stiffness) — which is exactly why the topic stresses diagnosing and repairing within ~3 weeks. The underlying tendon-healing biology is developed in the tendon-healing topic.

Prognosis: Across systematic reviews, surgical repair gives excellent patient-reported outcomes (mean Mayo Elbow Performance Score ~92, high satisfaction), with about 92% returning to pre-injury function and essentially all patients regaining at least grade 4/5 extension strength. Outcomes are best for acute repairs; chronic, retracted tears requiring grafting do less well.

There is no large randomised trial or dedicated society guideline for this rare injury, so practice is guided by systematic reviews and expert consensus. Practice is broadly consistent worldwide.

Registry note: Unlike arthroplasty, there are no national joint-registry data for triceps tendon repair; the strongest population-level evidence comes from large insurance-claims database cohorts (e.g. Lee 2022), which inform risk-factor counselling rather than implant choice.