25
Elbow Tendinopathies and Tendon Ruptures
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25.1 Endobutton Single-Incision Repair of the Distal Biceps Tendon
LATERAL EPICONDYLITIS
History
In 1873, Runge described a condition associated with lateral humeral
condylar tenderness and difficulty writing; Morris referred to it in 1882
as “lawn tennis arm.” Eventually, this entity became known as tennis
elbow or lateral epicondylitis.1
Multiple treatments have been proposed for epicondylitis affect-
ing the elbow, ranging from benign neglect to physiotherapy, bracing
modalities, injection of various substances, and surgery; the optimal
treatment remains controversial. Boyer and Hastings2 suggested that
“there is much witchcraft and pseudoscience involved in the treatment
of patients with lateral tennis elbow.” In 1936, Cyriax3 suggested “that
the condition usually clears up in eight to twelve months without any
treatment except perhaps avoidance of the painful movements for a
time,” although cases “lasting much longer…are encountered.” Few
conditions elicit as much frustration and controversy regarding cause,
treatment, and outcomes among patients and physicians.
Etiology, Associations, and Pathophysiology
Boyer and Hastings2 reported that “lateral tennis elbow is most com-
monly an idiopathic or a work-related condition. A distinct pathoeti-
ology has not been definitively identified.” Lateral epicondylitis likely
represents a multifactorial condition with elements of repetitive micro-
trauma in a physiologically susceptible individual. The imaging and
clinical history and findings associated with lateral epicondylitis are
associated with increasing age; it has been suggested to be a “benign,
self-limited condition of middle age.”4-9
The pathology associated with lateral epicondylitis is believed to
involve the attachment of the extensor carpi radialis brevis (ECRB) at
the lateral humeral epicondyle. It is suggested that the extensor dig-
itorum communis (EDC) is involved in approximately one-third of
cases, and rarely the extensor carpi radialis longus (ECRL) or extensor
carpi ulnaris (ECU) is involved.10,11 The ECRB and EDC origins are
indistinguishable at the level of the lateral epicondyle. They only visibly
become separate muscle-tendon units several centimeters distal to the
elbow.
Lateral epicondylitis has been associated with forceful repetitive
activities and smoking.6,12,13 The peak prevalence is at age 45 years,
with most patients 35 to 54 years old5,6 and the dominant arm usu-
ally affected.5 There is an equal distribution between the genders.5 Of
patients followed for 18 months after initial presentation to a general
practitioner with the diagnosis of lateral epicondylitis, more than half
exhibited a recurrence of symptoms.5
It is now recognized that lateral epicondylitis is a degenerative ten-
dinopathy or tendinosis, rather than an inflammatory tendinitis.10,11,14-22
Nirschl11 described the histologic findings as an angiofibroblas-
tic tendinosis, with a gross appearance of a gray friable edematous
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tendon structure.10,11,23 The first three stages of epicondylitis include an
inflammatory stage that is restricted to the early course of the disease,
followed by angiofibroblastic degeneration in stage II and structural
failure in stage III. The fourth stage has a hallmark of fibrosis or calcifi-
cation in the setting of components of stage II or III.24,25
Repetitive contraction of the extensors is believed to cause micro-
trauma to the tendons, eventually resulting in lateral epicondyli-
tis.15,26-28 Other authors have suggested that impingement of the ECRB
tendon against the lateral edge of the capitellum causes abrasion and
wear of the tendon during elbow motion, which eventually results in
the condition.29
In the diseased state, the normally avascular tendon attempts to
repair itself with fibroblastic elaboration of collagen and fibrovascular
proliferation.10,14,15,18 Continued mechanical trauma in the setting of
an inadequate healing response leads to tendinosis.
Histopathologic findings include fibrocartilaginous formation16,17,22
or mucoid or hyaline degeneration,16,17,20,21 fibrovascular proliferation,
16,17,20-22 and focal calcifications.16,17,19,20,22 Milz and colleagues19 inves-
tigated the gross and histologic and molecular features of the com-
mon flexor and extensor origins in cadaveric specimens to attempt to
describe the ranges of normal and pathologic findings at these loca-
tions. The tendon insertions medially and laterally showed confluence
with the underlying collateral ligaments, resulting in a complex inte-
grated structure. Fibrocartilage, which had previously been thought
to represent a pathologic condition, was found frequently in all age
groups, suggesting that it may be present under normal conditions. In
addition, degeneration of tendon structure at the epicondylar inser-
tions was present in elderly specimens, indicating that the presence of
degenerative changes at the epicondyle may be associated with age.
Although most of the evidence suggests the changes in tendon are
pathologic and represent the cause of pain, some suggest that the pain
generator is intraarticular, related to the capsule and/or synovial region
at the lateral aspect of the elbow.30
Presentation
In lateral epicondylitis, patients typically complain of pain localized
to the lateral epicondyle and at the ECRB origin, just slightly dis-
tal and anterior to the lateral epicondyle; the pain is exacerbated by
wrist extension. On clinical examination, pain is elicited with resisted
wrist extension with the forearm pronated and elbow fully extended.
Additionally, resisted supination with the wrist flexed can precipitate
the pain of lateral epicondylitis. The “chair test,” in which the patient
is asked to lift a chair with the arm in forearm pronation and wrist
flexion, typically causes pain.31 There is an overlap with radial tun-
nel syndrome in patient complaints and physical findings with use
of provocative tests.32 Pain occurs with resisted finger extension and
resisted forearm supination in both processes, so these are not defini-
tive tests for either diagnosis.
If the history is vague and pain is poorly localized or unrelated to
activity, other conditions should be considered. This is especially true
if the physical examination fails to localize the area of tenderness as
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1026 PART IV Elbow and Forearm
described previously. Chondromalacia, arthritis, periarticular tumors,
loose bodies, radiocapitellar plica, osteochondral defects, cervical
radiculopathy, or ligamentous instability should be considered. Radial
tunnel syndrome (supinator syndrome) may be concomitantly present
(with an estimated incidence of 5%).32,33
Diagnosis
The diagnosis of lateral epicondylitis is based on the clinical history
and examination findings of pain centered over the origin of the com-
mon extensor mechanism, particularly the area of the ECRB and EDC.
Radiographic evaluation of the elbow is typically not helpful in lateral
epicondylitis but is helpful to exclude other disease entities. There
might occasionally be some ossification of the soft tissues, but whether
this is a result of treatment from multiple injections or is a natural pro-
cess of the disease is uncertain.
Frequently, magnetic resonance imaging (MRI) studies are obtained
in patients with elbow pain, often ordered by the referring physician or
requested by the patient. MRI findings consistent with lateral epicon-
dylitis include increased signal on T1 and T2 sequences.20,34 MRI can
show frank tearing and separation of muscle from the bone,20,22 and it
has been suggested that there is good correlation between MRI find-
ings and intraoperative findings.20
Frequently, asymptomatic patients have false-positive findings
with signal enhancement.34,35 In addition, enhancement may per-
sist in symptomatic individuals even after the clinical resolution of
symptoms.35
In practice, just about every patient with mild pain over the lateral
aspect of the elbow seems to have signal changes on MRI, particularly if
the patient has had a series of injections. MRI is not significantly help-
ful in making the diagnosis or dictating treatment but can be used as
an adjunct to look for other causes of potential pain around the elbow.
Ultrasonography is increasingly being used in the evaluation of
musculoskeletal pain and may be obtained in order to evaluate lat-
eral elbow discomfort. Findings typically seen in the setting of lateral
epicondylitis include thickening of the common extensor tendon, the
presence of calcifications, hypoechogenicity of the common extensor
origin, neovascularity, and bone cortical irregularity. However, ultra-
sonographic findings must be interpreted with caution; patients with
pain frequently have similar findings to those without lateral epicon-
dylar pain, as expected changes occur with age. Further, as with MRI,
ultrasonographic findings that might be suggestive of epicondylitis are
known to persist even following resolution of pain.8,9,36,37
MEDIAL EPICONDYLITIS
Presentation
Medial epicondylitis is much less common than lateral epicondylitis,
with a prevalence of 0.4% compared with 1.3% in one study.6 Other
studies have found an estimated prevalence of 3.2% to 8.2% in patients
employed in repetitive labor tasks.13,38,39 Medial epicondylitis is sug-
gested to constitute 10% to 20% of all epicondylitis cases.40-42
Risk factors are similar to those in lateral epicondylitis and seem to
include obesity, physical loads, and smoking; some studies suggest a
female preponderance, whereas others do not.6,12,38,43,44
There seems to be an association of medial epicondylitis with
other work-related or overuse musculoskeletal disorders.38,45 As in
lateral epicondylitis, patients are typically middle-aged (fourth to fifth
decades) and the dominant arm is usually involved.40,45 An exception
is young throwing athletes who may experience medial-sided elbow
pain.46
The history typically involves the insidious onset of pain at the
medial aspect of the elbow. Tenderness exists at the medial epicondyle
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and distally over the pronator teres (PT) and flexor carpi radialis (FCR).
Pain is worsened with resisted pronation and resisted wrist flexion.40
Etiology and Pathogenesis
It has been suggested that the cause of epicondylitis is related to over-
use or repetitive motions leading to microtrauma to the muscular ori-
gins at the medial epicondyle; most commonly, to the PT and FCR,
but also occasionally to the palmaris longus, flexor digitorum super-
ficialis, and flexor carpi ulnaris origins.10,11,24,41,45,47,48 As implied by
the layperson’s term golfer’s elbow, repetitive use and microtrauma can
precipitate the condition, and it has been associated with repetitive
valgus loads in golf, racquet sports, football, baseball, weight lifting,
and archery, in addition to occupational exposures requiring repeti-
tive motions of the hand, wrist, elbow, or forearm.40,41,45,49-51 One of
the oldest references is that of Morris,52 who described a condition
in rowers occurring after “long and vigorous sculling,” with pain at
the “inner part of the elbow,” which resolved with rest and avoidance
of pronosupination. Although usually associated with a chronic over-
use type of phenomenon, occasionally a single sudden traumatic epi-
sode can cause avulsion of the flexor pronator origin and lead to this
condition.24
As in lateral epicondylitis, pathologic findings include a degenera-
tive tendinosis rather than an inflammatory tendinitis, and it has been
suggested that this is due to the repetitive microtears in the setting of
an inadequate healing response and, eventually, altered biomechanics
of the elbow joint.48 In pitchers, the stresses are conferred to the medial
structures of the elbow, including the flexor pronator muscles and
medial collateral ligament (MCL).48
Acceleration and valgus forces may exceed the tensile strength
of the medial constraints of the elbow, leading to tears with a spec-
trum of pathologic findings ranging from epicondylitis to MCL
insufficiency.40,45
The pathologic change found in medial epicondylitis is indistin-
guishable from that found in lateral epicondylitis with angiofibroblastic
tendinosis.45
In 23% to 60% of patients, ulnar neuritis is present.45,48,51,53,54 The
pathophysiologic mechanism has been suggested to be a combination
of traction injury with entrapment and compression.40
Diagnosis
The differential diagnosis of epicondylitis includes neurologic con-
ditions (ulnar nerve neuritis, cervical radiculopathy, pronator syn-
drome); intraarticular pathologic conditions such as elbow synovitis,
arthritis, or osteochondral defects; and ligamentous deficiency (MCL
insufficiency).48 Typically, the diagnosis is made on clinical grounds.
Radiographs may reveal calcification adjacent to the medial epicondyle
or traction spurs or calcifications, particularly in throwing athletes.24,48
As in lateral epicondylitis, radiographs are not typically necessary for
the diagnosis, but they may exclude alternative causes of elbow pain.
Some authors have investigated use of other imaging modalities, and
ultrasonography has been noted to be highly specific and sensitive.
Typically, a focal hypoechogenic or anechogenic area is shown,55
although ultrasound is usually not necessary to make the diagnosis.
MRI may be useful to rule out other conditions, such as MCL
insufficiency or intraarticular pathologic conditions such as osteo-
chondral defects. In the setting of medial epicondylitis, MRI may show
increased signal intensity on T1 and T2 series,50 but it is again typi-
cally not required to make the diagnosis and it is not specific because
signal changes can be seen in asymptomatic individuals.50 It has been
suggested that these signal changes in asymptomatic patients may
represent senescent changes or prior epicondylitis that has become
quiescent.50
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures
Because of a high rate of concomitant ulnar neuritis, the clinical
examination should include evaluation of the ulnar nerve, including
provocative maneuvers such as a cubital tunnel Tinel sign, a cubital
tunnel compression test, and an elbow flexion test.40,48 Electrodiagnos-
tic testing is of limited utility because it is normal in 90% of patients
with ulnar nerve symptoms.48
The status of the MCL should be assessed to rule out ligamentous
insufficiency. Valgus stress should be applied to the elbow in a position
of 30 degrees short of full extension. Potential compensatory action of
the flexor pronator group can be eliminated by placing the pronated
forearm in a position of wrist flexion and 30 degrees of elbow exten-
sion before stress is applied. The milking maneuver, in which the exam-
iner pulls on the patient’s thumb, generating a valgus stress when the
forearm is supinated in a position of elbow flexion, also tests for MCL
insufficiency. In both tests, pain and instability are typically absent
in pure medial epicondylitis, and their presence may represent MCL
injury.40,48
TREATMENT OF MEDIAL AND LATERAL
EPICONDYLITIS
Treatment considerations for medial and lateral epicondylitis are sim-
ilar and are considered together. The treatment of epicondylitis is con-
troversial. There are multiple reports advocating different techniques
for treatment, but many are flawed studies, burdened by small study
sizes, absent or inappropriate controls, and other such factors.56 It is
a difficult condition to study when the vast majority of cases are self-
limiting. Furthermore, review of the literature can be confusing, as
studies show conflicting evidence. It has been stated that “the onus is
upon us to show that any treatment we offer is significantly better, both
clinically and statistically, than the natural history of the condition
itself.”2
Nonoperative Treatment
Nonoperative therapy is the mainstay of treatment for medial and
lateral epicondylitis.24 It has been suggested that more than 85% to
90% of patients respond to nonoperative treatment,26,45,57 but some
series suggest more modest results, with 40% of patients with lateral
epicondylitis having some residual discomfort.58 Furthermore, it has
also been suggested that no treatment at all, other than symptom-
atic care, is appropriate, as this is a benign and self-limited condition
that frequently accompanies middle age. A recent metaanalysis using
pooled data from randomized controlled trials failed to demonstrate
any advantage of any nonsurgical treatment options over placebo. The
pooled studies included interventions such as injections of corticoste-
roid, platelet-rich plasma, autologous blood, hyaluronic acid, or gly-
cosaminoglycan and therapy (shock wave therapy, laser, ultrasound,
iontophoresis, topical agents, or oral naproxen).59
In terms of symptomatic care, activity modification is one of the
mainstays of treatment, with avoidance of precipitating activities.
Several studies have noted that tennis players who use a two-handed
backstroke are less likely to develop tennis elbow, perhaps because of
altered biomechanics and dissipation of the forces experienced at ball
contact.28,41,60 Likewise, other modifications of equipment and action
can help symptoms resolve.
Three phases of treatment have been proposed for epicondylitis.
Phase one involves activity modification to avoid precipitating activi-
ties and use of icing several times daily. Nonsteroidal antiinflammatory
drugs may be used to diminish any accompanying elbow synovitis.
Night splinting and corticosteroid injections may be considered,40,45
and counterforce bracing may be considered during phase one to limit
contraction of the muscles, although use of these treatment options has
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been questioned and efficacy of injections, bracing, therapy, and oral or
topical medications remains uncertain.40,61
Phase two involves starting a rehabilitation program after the acute
symptoms are diminished with restoration of full painless wrist and
elbow motion. A program of isometric exercises and stretching is ini-
tiated, followed by resistive exercises and sports or work hardening.40
The third phase is a maintenance phase involving equipment and
technique modification for sports or work and continued conditioning
to prevent recurrence.40
Injection of a variety of substances has been suggested as a treat-
ment for lateral and medial epicondylitis. Nevertheless, review of the
literature demonstrates often conflicting and inconclusive evidence
upon which to base recommendations for injections as treatment of
lateral epicondylitis.59,62
Botulinum toxin injection has been suggested for lateral epicon-
dylitis, with some benefit shown in some but not all series, although
muscle weakness may be seen as an expected side effect.63-65 Injection
of autologous blood has been suggested to be beneficial for epicondyli-
tis.66-68 One series showed a beneficial effect of dry needling and injec-
tion of autologous blood in medial epicondylitis,69 and another showed
a beneficial effect in lateral epicondylitis.67 Platelet-rich plasma (PRP)
injections have also been reported, with mixed results. Some results are
highly encouraging, although others are not.70-76
A metaanalysis of PRP versus autologous blood versus cortico-
steroid injection, based upon 10 studies, suggested autologous blood
injections were associated with improved outcomes relative to cortico-
steroid injections, although they were associated with a higher risk of
complications than PRP injections. PRP injections were associated with
significantly better visual analog scores than corticosteroid injections
but were inferior to autologous blood injection in terms of improve-
ment of Disabilities of Arm, Shoulder, and Hand (DASH) score.74
Most recently, a randomized controlled study investigated use
of PRP injection versus autologous blood versus saline injection for
lateral epicondylitis. At 1-year follow-up, no statistically significant
improvement over saline was noted with either autologous blood or
PRP injection.77
Corticosteroid injection has historically been suggested to decrease
pain and early inflammation or joint synovitis and in some series has
been found to be beneficial, particularly in the short term.78,79 Despite
short-term improvement, corticosteroid injection does not seem to
influence the outcome at 3 or 12 months.80-84 Another study found no
difference between injection with corticosteroid and local anesthetic
versus local anesthetic alone at 1 or 6 months; the presence of concom-
itant depression or poor coping skills was a better predictor of outcome
than treatment modality.85
In fact, there is one study and a subsequent metaanalysis that should
provoke caution in the use of corticosteroid injections. Coombes and
colleagues found that injection of corticosteroid resulted in poorer
outcomes relative to placebo at 1 year.86 A metaanalysis suggests that
despite short-term beneficial effects of corticosteroid injection, the
intermediate-term results show a negative effect and the long-term
effects are uncertain, with conflicting data.87
Other studies have suggested that the act or technique of injection
plays a larger role than the substance injected. These theories center
on the ability to induce a vascular healing response by a “peppering”
technique in which the needle is redirected multiple times to punc-
ture the epicondylar region at multiple sites. This idea is supported by
studies in which lateral epicondylitis was injected with either cortico-
steroid, autologous blood, or lidocaine, with equivalent good results
at follow-up and by a metaanalysis of 10 studies noting that saline
injection seems to have a clinically relevant and a statistically signifi-
cant effect in improvement of pain.71,88-90 Additionally, a recent study
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1028 PART IV Elbow and Forearm
compared PRP injection with percutaneous fenestration versus PRP
injection with percutaneous tenotomy. At mean 40-month follow-up,
there were no statistically significant outcomes differences, although
more aggressive injection (tenotomy) was associated with less conver-
sion to additional surgical treatment in the short term to midterm than
was fenestration.91
Physiotherapy has equivocal long-term results.82,92 Modalities
such as ultrasound or iontophoresis have been suggested to provide
benefit, but their efficacy and role in treatment remain controversial.
One study showed that ultrasound therapy for lateral epicondylitis has
no benefit.93 It has been suggested that therapy, specifically eccentric
strengthening, may be useful.94 Corticosteroid injection is better than
physiotherapy and modalities in most,58,80,83,84 but not all, series.82,92,95
Pulsed electromagnetic field therapy is suggested to be more benefi-
cial than placebo for treatment of lateral epicondylitis; however, results
across series are conflicting.96 In addition, extracorporeal shock-wave
therapy has shown some benefit in medial and lateral epicondyli-
tis,97-101 but most studies have failed to find any advantage for it over
control groups, and it is not routinely recommended.99,102-110
Surgical Treatment
Surgical indications for medial or lateral epicondylitis include failure
of a nonoperative treatment course of 6 to 9 or more months and, in
medial epicondylitis, tendon disruption in a throwing athlete or con-
comitant significant ulnar nerve symptoms.23,40,45,48
Surgical treatment typically involves excision of the area of tendi-
nosis and debridement of the local tissue bed, and it may include reat-
tachment of the tendon origin as indicated. Reported success rates are
97% in primary lateral epicondylitis, 83% in revision cases, and 87%
to 100% in primary medial epicondylitis.23,45,46,111-113 However, even
despite successful surgical treatment, many patients have low-grade
residual symptoms.
The area of pathologic change may extend beyond the visibly abnor-
mal area, and concern exists regarding the need to debride all affected
tissue while preserving normal structures. This concern is particularly
relevant because gross appearance of the tendon and patients’ symp-
toms do not always correlate with the degree of histopathology, with
grossly degenerative tissue having minimal histologic findings in some
cases.10 Some authors have proposed the “scratch test” to differentiate
between normal and abnormal tissue, suggesting that normal tendon
would not be removed by scraping with a No. 10 knife blade.10
In the setting of medial epicondylitis, it is important to query the
patient about symptoms and examine the patient specifically for ulnar
nerve findings, as failure to address this at the time of surgery may lead
to persistent discomfort.
Lateral Epicondylitis Surgery
Choices in lateral epicondylitis surgery include open or percutaneous
procedures that release the extensor origin from the lateral epicondyle,
procedures in which tendinosis is removed from the lateral epicondyle
and the ECRB origin is released or repaired, denervation of the lateral
epicondyle, intraarticular procedures, and arthroscopic debridement
or release of the ECRB origin. These may be done with an open pro-
cedure, using arthroscopy, or under ultrasound guidance. Outcomes
after open release or debridement are generally good to excellent in
70% to 97% of patients; however, a prolonged recovery and unsatis-
factory results can be seen in 15% to 20% of cases.111,114 Percutaneous
release of the common extensor origin from the lateral epicondyle has
been described using a small incision. Reported success rates are 70%
to 91%.57,115-117
Several cadaver and clinical studies have evaluated the safety
and efficacy of arthroscopic lateral epicondylitis surgery and have
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suggested it is a safe and reliably reproducible procedure.118-122 A clas-
sification system based on arthroscopic findings has described three
types, although outcomes do not correlate with classification type.119
Arthroscopic treatment has been suggested to have benefits over open
treatments, including easier and faster recovery, earlier return to work,
and provision of a surgical means for evaluating and treating intraar-
ticular pathologic conditions, which in some series are present in 69%
of cases.118,119,121,123-125 Likewise, selective release of the involved ECRB
with preservation of the uninvolved common extensor origin can be
achieved.119 However, a recent randomized controlled study between
open and arthroscopic treatment of lateral epicondylitis demonstrated
no differences in outcomes or complications at 12 months postopera-
tively; although there was a statistically significant difference in setup
and operative time, in favor of open surgery.126
Cohen and colleagues114 described the anatomic relationships of
the extensor tendon origins and made specific recommendations from
their cadaveric study for arthroscopic ECRB release. The bony origin
of the ECRB was reliably found just anterior to the distalmost tip of
the lateral supracondylar ridge, with a diamond-shaped footprint.
Proximally, the ECRB arose from a longitudinal line paralleling the
long axis of the humerus, and the superior margin was at the supe-
rior capitellum, whereas the inferior margin was at the midpoint of the
radiocapitellar joint or capitellum. The ECRB was intimate but easily
distinguishable from the joint capsule deep to it. Based on these dis-
sections, the authors performed arthroscopic release of the ECRB. A
standard anteromedial portal was established first, and a modified lat-
eral portal was made from an inside-out technique 2 to 3 cm proximal
and anterior to the lateral epicondyle. A monopolar thermal device was
used to expose the ECRB by ablation of the capsule, and then release of
the ECRB was performed.
Cohen and colleagues114 noted that the capsule must be resected
to gain access to the ECRB, which can be identified and released from
the top of the capitellum to the midportion of the radiocapitellar joint;
care is taken not to release it posterior to the midline of the joint so as
to protect the collateral ligament, and care is also taken to preserve the
extensor aponeurosis lying superficial to the ECRB tendon.
Smith and coworkers122 noted that inadvertent injury to the lateral
ulnar collateral ligament could be avoided by using the anterior half of
the radial head as a landmark for the safe region for debridement of the
extensor tendon origin.
With regard to outcomes, results comparable to those of open pro-
cedures have been seen with maintained success at a mean follow-up
of 130 months.118 Superiority over open procedures has not been
shown,125 however, and some authors have suggested that arthroscopic
procedures can be associated with residual tendinopathy and symp-
toms because of the inability to visualize and treat the area of patho-
logic change fully.2,127 In contrast, those who believe that the primary
pathology in lateral epicondylitis is associated with intraarticular
pathology, such as of the capsulosynovial region, espouse advantages
of arthroscopic techniques to address these findings.30
When considering elbow arthroscopy, the surgeon should be
reminded that elbow arthroscopy generally has a steep learning curve
and has been associated with neurovascular injuries, with the poten-
tial to destabilize the lateral ligamentous structures even in the most
experienced of hands; moreover, use of arthroscopy generally means
the patient will be under general or regional anesthesia, the procedure
will take place in an operating room, and the procedure will involve
substantial time and equipment outlay, as opposed to a small open pro-
cedure that may be done under local anesthesia, potentially in a proce-
dure room or office, without costly equipment.119,128-130
Comparative studies and metaanalyses suggest that open,
arthroscopic, and percutaneous treatment all demonstrate satisfactory
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures
results. All seem to demonstrate a high rate of patient satisfaction
and pain relief, with similar complication risks. Pain may be less with
arthroscopic or percutaneous treatment compared with open proce-
dures. One metaanalysis noted that percutaneous needle tenotomy
“presents an alternative” to surgical treatment, but the evidence sup-
porting it is of “low quality.” Thus, it is often recommended to consider
surgeon experience and preference in deciding which procedure, open
versus arthroscopic versus percutaneous, to perform.126,131-134
More recently, ultrasound-guided techniques have been proposed
for the treatment of medial and lateral epicondylitis. A variety of tech-
niques are available, including ultrasound-guided percutaneous tenot-
omy, ultrasound-guided ablation, or ultrasonic tenotomy of the tendon
origin. Many of these are proprietary techniques or use proprietary
instrumentation; many of the studies regarding this are small, with-
out controls, of short follow-up duration, and frequently authored by
the inventor of the commercially available instrumentation. The series
that are available demonstrate favorable results, but in aggregate may
be difficult to interpret due to the mixed nature (often concomitant
injections, variable treatment regimens) and the publication by pro-
ponents and small study sizes frequently with no controls. Neverthe-
less, the early favorable results, the perceived advantages of “minimally
invasive” and newer technology, and the advantages of office-based
procedures make these techniques of interest to patients and surgeons.
It is likely that these may receive increased attention in the future.135-140
Surgery for Recurrent Lateral Epicondylitis
Revision surgery for failed tennis elbow surgery has been reported
to have a greater than 80% success rate.113,141-143 Common findings
include inadequate or incomplete resection of tendinosis in 97% of
cases.113 Risk factors for undergoing revision surgery include younger
age, male sex, obesity, tobacco use, inflammatory arthritis, and having
had three or more previous corticosteroid injections for the condition;
this later was the most significant risk factor for having revision surgery
(odds ratio of 3.55).144 In terms of treatment, more thorough resection
of tissue and/or repair of the extensor aponeurosis resulted in an 83%
success rate.113 In addition, for recurrent or primary lateral epicondyli-
tis in which a wide degenerative tendon has been seen intraoperatively,
anconeus muscle flap transposition has been used with good results,
with a patient satisfaction rate of 94% in one series.141-143 In cases of
failed lateral epicondylitis surgery, one must evaluate the patient for
occult lateral ligament insufficiency. This can occur secondary to the
original pathology or iatrogenic from an overzealous resection of tissue
at the lateral epicondyle.
Surgical Treatment for Medial Epicondylitis
Surgical treatment of medial epicondylitis is performed in a manner
similar to that for surgery on the lateral side. The interval between the
PT and FCR is developed, revealing the deep tissues that are diseased,
and they are sharply excised.45,48,53 Repair techniques have been pro-
posed with good results.145
Caution is needed to avoid injury to the ulnar nerve and the
anterior bundle of the MCL. Injury to the medial antebrachial cuta-
neous nerve may result in a bothersome numb patch or a painful neu-
roma.45 Arthroscopic techniques have been proposed, but the surgeon
should be wary of potential for injury to the ulnar nerve.146 Likewise,
ultrasound-guided techniques similar to the lateral side of the elbow
have been described, although limited data regarding outcomes are
available.
Expected Outcomes
Good to excellent results have been achieved in 83% to 96% of patients
using variations in technique,45,51,53,115 with poorer outcomes reported
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1029
in patients with ulnar nerve symptoms.53,145 Little information is avail-
able in the literature regarding optimal treatment for recurrent medial
epicondylitis or failed prior surgery.
AUTHORS’ PREFERRED METHOD OF
TREATMENT: ELBOW EPICONDYLITIS
Variable opinions exist regarding the cause and natural history of epi-
condylitis. Even more controversial is the subject of the optimal treat-
ment of this condition, including the role of benign neglect, therapy,
injections, modalities, and surgery.56
When patients present for evaluation and treatment of epicondyli-
tis, they often expect some active intervention. Based on the available
evidence, most cases resolve with patience and minimal intervention
within 18 months; the probable best recommendation for treatment is
oral analgesics for symptom relief, activity modification (at work and at
play), and an overall plan of “waiting things out” for up to 18 months.
It may be unrealistic, however, to expect most patients to accept the
intellectual explanation that “lateral elbow pain is a harmless rite of
passage into middle age”85 that often resolves on its own, and that
“leaving things be” and allowing significant time for symptom resolu-
tion is sufficient treatment.
Based on available evidence in the literature, corticosteroid
injection, although commonly used by physicians and frequently
requested by patients, has little, if any, benefit over placebo. Like-
wise, such injections usually do not change the natural history of the
disease, although recent data suggest that poorer results are seen in
the intermediate and long term following corticosteroid injections
relative to placebo, and worrisome is the evidence that patients who
undergo corticosteroid injection may actually be worse at the end
of a year. With respect to corticosteroid injection and short-term
relief of symptoms, there is some evidence to suggest improvement,
although injection with local anesthetic or saline may fulfill the
same role.80-85
In our practice, we attempt to have a frank, complete discussion
with the patient about the pathologic conditions and explain the
available evidence, suggesting that with a significant amount of time
(≤2 years), the process tends to be self-limiting and dissipates.147 Some
patients will find this reassuring, but many do not. There is evidence
in the literature to suggest that poorer outcomes are seen in patients
who complain of severe pain, have concomitant neck pain, are involved
in workers’ compensation claims, have concomitant depression, or
have poor coping skills.85,147 Patients who are inclined to reject the
notion that this is a benign, albeit frustrating, self-limited process
and want “something done” may request and be offered an injection
with local anesthetic with a peppering technique or, rarely, corticoste-
roid, although the recent data again suggest that long-term outcomes
are poorer with corticosteroid injection, and we use this with caution
and only after discussion and informed consent, for this reason. We
encourage patients to modify activity to avoid sports and work-related
heavy loading involving extension of the elbow with wrist extension
and flexion. A high-repetition, low-resistance home exercise program
may also be useful.
If a patient continues to have symptoms beyond 6 to 9 months
despite activity modification, surgical intervention is offered if the
patient desires further treatment. Specifically, we avoid this if at all
possible, offering surgical intervention for patients with concomi-
tant depression, catastrophic thinking, and poor coping skills. We
use surgery with extreme caution, understanding the poor outcomes
and disappointing results seen in the patient with unresolved workers’
compensation claims.
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1030 PART IV Elbow and Forearm
Lateral epicondyle
B
Fig. 25.1 Skin incision is based just distal to lateral epicondyle.
Surgical treatment of lateral epicondylitis can be performed either
by open procedures or arthroscopically. The literature confirms that
outcomes between the two procedures are comparable. We discuss
with the patient the minimally invasive nature of arthroscopic treat-
ment; however, we also explain that arthroscopy is accompanied by an
increased risk of neurovascular injury and instability compared with
open release of the elbow.119,128 Surgical treatment of medial epicondy-
litis in our hands is by open procedure only.
Open release of lateral epicondylitis is performed under tourniquet
control for visualization or “wide awake” anesthesia with local anes-
thesia combined with epinephrine. A lateral incision of approximately
4 cm is made overlying the epicondyle or just anterior to it (Fig. 25.1).
The ECRL-EDC interface is identified and incised, and the ECRL is
retracted anteriorly (Fig. 25.2). The degenerated tissue at the ECRB
origin is identified, usually appearing as a white-gray friable abnormal
tissue. This tissue is sharply excised (Fig. 25.3). Typically, the joint is
not opened. It is also important to protect the lateral ulnar collateral
ligament by restricting the excision of the degenerated tissue to the
anterolateral epicondyle. As discussed in Chapter 23, some surgeons
have inadvertently excised the ligament, leading to chronic instabil-
ity and requiring repair or reconstruction. The epicondyle itself may
be rongeured to remove the diseased and degenerative tendon, and a
small bur may be used to decorticate the epicondyle; alternatively, a
Kirschner wire or drill may be used to drill into the bone (Fig. 25.4).
The ECRL origin is repaired as needed, hemostasis is obtained after
the tourniquet is released, and the wound is closed. A sterile soft dress-
ing is applied. The patient is asked to use a sling for 2 to 3 days and then
is allowed normal use of the elbow as tolerated. A cock-up removable
wrist splint may be placed at the time of surgery to take pressure off the
common extensor origins and can be worn for 1 to 2 weeks until the
wound is healed and elbow motion has returned to normal.
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Extensor carpi
radialis longus
Lateral epicondyle
Extensor aponeurosis
interface
Extensor aponeurosis
B
Fig. 25.2 Extensor carpi radialis longus–extensor digitorum communis
interval is identified.
Arthroscopic Technique
The patient is positioned in the lateral position, and the arm is secured
in a dedicated arm holder. Regional anesthesia is generally avoided, so
that an accurate neurovascular examination can be performed after
completion of the procedure. The elbow is examined to rule out a
subluxating ulnar nerve, and all portal sites and bony landmarks are
marked before joint insufflation. The joint is distended with up to 30 mL
of saline introduced via an 18-gauge needle into the anterolateral por-
tal. Arthroscopic treatment of lateral epicondylitis is achieved through
two portals, with viewing from the anteromedial portal and working
through the anterolateral portal. We prefer to start the arthroscopy from
the anterolateral portal, with a subsequent anteromedial portal made
under direct visualization and using a switching stick to swap viewing
portals; however, establishing the anteromedial portal first is acceptable
as well. The anterolateral portal should be placed slightly more proxi-
mally and anteriorly than the standard anterolateral portal, just proxi-
mal to the radiocapitellar joint. If the portal is placed directly over the
radiocapitellar joint, it can be difficult to address the area of the ECRB.
Diagnostic arthroscopy is performed to rule out any other articular
pathologic findings, such as loose bodies, plicae, or thickening of the
annular ligament. A shaver or radiofrequency probe is used to debride
the capsule through the anterolateral portal.119 This debridement
exposes the undersurface of the white tendinous ECRB-EDC con-
joined tendon origins, which have a clearly visible demarcation from
the muscular, more anterior ECRL. The ECRB (and part of the EDC)
is released from its origin with a shaver or a radiofrequency probe. A
radiofrequency probe is useful to elevate the ECRB, which may then be
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures 1031

Extensor carpi
radialis longus ECRB

Lateral epicondyle
Lateral epicondyle

A B

C
Fig. 25.3 A to C, Degenerated tissue at extensor carpi radialis brevis (ECRB) is identified and incised.

Surgical Technique for Treatment of Medial

Fig. 25.4 A bur is used to decorticate bone.
released from the lateral epicondyle. Release posterior to the midline
of the radiocapitellar joint should be avoided to prevent instability. A
shaver or bur may be used to decorticate the lateral epicondyle, espe-
cially in chronic cases, to promote vascularity and healing.119
The instruments are withdrawn, and no suturing or closure, other
than of the skin portals, is required. A sterile dressing is applied, and
the arm is placed into a sling. Within 24 to 48 hours, the patient is
allowed to use the arm for gentle activities. A removable cock-up wrist
splint, as used with the open procedure, is helpful.
Epicondylitis
Surgical treatment for medial epicondylitis is rarely required; most
patients respond to nonoperative treatment. Failure to respond to
activity modifications and other nonoperative means for more than
6 to 9 months may represent an indication for surgical manage-
ment, however. A procedure similar to what is done on the lateral
side is performed. There is no current arthroscopic treatment for this
condition.
A tourniquet is used on the upper arm to facilitate visualization.
The incision is made from 2 cm proximal to the medial epicondyle and
extends distally parallel to the epicondyle for 4 to 5 cm (Fig. 25.5). The
medial antebrachial cutaneous nerve and its branches are preserved;
inadvertent injury may lead to a bothersome numbness or a painful
neuroma. The interval between the PT and FCR is developed (Fig.
25.6).45,53 The PT is retracted anteriorly and the FCR is retracted poste-
riorly to reveal the deep tissues that are diseased in this condition; these
are sharply excised (Fig. 25.7).48 Care is taken to preserve the ante-
rior bundle of the MCL; otherwise, iatrogenic instability may ensue.
Abnormal tissue is removed, and the medial epicondyle is prepared by
cutting away fibrous tissue with a rongeur and placing small drill holes
through the cortex to improve vascularity (Fig. 25.8).
The PT-FCR interval is closed with running 2-0 braided suture
(Fig. 25.9); this is adequate in simple cases of medial epicondylitis
without concomitant MCL injury. For the latter condition, the PT-FCR
interval is developed further, and the common flexor origin is split
along its fibers. The MCL is exposed, the anterior bundle of the MCL is

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1032 PART IV Elbow and Forearm

Medial epicondyle

Medial epicondyle
A

B
Fig. 25.5 Medial incision posterior to medial epicondyle is made.

B
Fig. 25.7 A and B, Area of tendinosis is identified and excised.

Medial epicondyle

Fig. 25.6 Interval between pronator teres and flexor carpi radialis is
identified and developed.

reconstructed as indicated, and drilling and reattachment of the origin

are performed, as described earlier. If ulnar nerve symptoms are pres-
ent preoperatively, the ulnar nerve should be decompressed in situ or
transposed.
Postoperatively, the arm is placed in a sling for comfort for 1 to 2
weeks until sutures are removed. Range of motion and gentle use of the
arm are allowed. Resisted wrist flexion or pronation is avoided for 4 to
6 weeks for simple medial epicondylitis; more restrictions are required
if reconstruction of the MCL has been performed.
Avulsion of the flexor pronator origin is important to rule out in the
evaluation of medial elbow pain. This condition can commonly occur
in golfers who hit the ground instead of the ball or in individuals after a
Fig. 25.8 Medial epicondyle is prepared by removing fibrous tissue
with rongeur.
fall, conferring a sudden injury to the medial elbow. In this instance, this
is not medial epicondylitis but rather true avulsion of the flexor prona-
tor origin. This avulsion can often be mistaken for medial epicondylitis;
however, flexor pronator avulsion does not tend to improve with con-
servative treatment. It is surprising how trivial injuries, such as hitting
the ground with a golf club or falling while playing sports, can avulse
the flexor pronator group; however, MRI shows avulsion of a significant
portion of the flexor pronator group with interposed scar tissue.

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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures
Repaired
flexor pronator
group
Fig. 25.9 Pronator teres–flexor carpi radialis interval is closed with 2-0
suture.
If the patient is seen acutely, operative fixation of the flexor prona-
tor group may be indicated. Patients with late presentations should be
given the option of conservative treatment for 3 to 6 months, however.
Although most patients do not improve with conservative manage-
ment, they should be given a chance.
Operative treatment of a flexor pronator avulsion involves a
posterior incision with full-thickness flaps developed to expose the
medial side or a direct medial approach. Often chronic cases have
interposed scar at the edge of the flexor pronator group; this must
be debrided to a healthy muscular origin. The origin is repaired
with No. 0 braided nonabsorbable suture to the medial epicondyle
through drill holes (or, alternatively, suture anchors may be used).
The wound is closed in the usual fashion. The patient is placed in a
long-arm splint in neutral rotation and neutral wrist position until
he or she returns for suture removal at 7 to 14 days. Subsequently,
the patient is protected from forced extension of the wrist or pow-
erful active flexion of the wrist for 4 to 6 weeks with a removable
splint.
CRITICAL POINTS
Lateral and Medial Epicondylitis
In lateral and medial epicondylitis, most patients respond to nonoperative
therapy (activity modifications with or without adjunctive measures and
symptomatic care) within 18 months.
Little evidence exists regarding the efficacy of adjunctive nonoperative
therapies over placebo; however, they are widely used and may give the
patient satisfaction and some subjective benefit in pursuing an “active”
treatment.
Operative treatment may be considered after more than 6 to 9 months of
recalcitrant symptoms; in medial epicondylitis, the presence of acute avul-
sion of the flexor pronator origin, worsening ulnar neuritis, or MCL insuffi-
ciency in a throwing athlete are also indications for surgery.
In open lateral epicondylitis surgery and medial epicondylitis surgery, the
abnormal tissue is identified as a gray, friable, edematous tendon and is
excised.
The origins are repaired as indicated, and resisted wrist motion is avoided
postoperatively.
Arthroscopic lateral epicondylitis surgery requires familiarity and compe-
tency with arthroscopic elbow procedures and anatomy.
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DISTAL BICEPS RUPTURE
Ruptures of the distal biceps tendon are readily diagnosed by the his-
tory in most cases. The patient is typically a middle-aged man (fifth
or sixth decade) who relates a history of lifting an object or a forced
extension of a flexed and loaded forearm.148 It is exceedingly unusual
for distal biceps pathologic conditions to occur in women. There
have been anecdotal reports of distal biceps rupture in women149,150;
however, our personal experience involves only two female patients
who had partial tearing and tendinopathy involving the distal biceps
that did not improve and responded well to operative treatment of
debridement and reinsertion of the biceps tendon. Commonly, a
middle-aged man experiences a sudden “pop” or giving way in the
antecubital fossa after flexing and supinating the elbow against a form
of resistance. If the patient is seen a few days after this episode, there
is commonly ecchymosis present over the elbow and proximal fore-
arm, and the patient often points out the asymmetry and the “Pop-
eye” deformity in the biceps muscle belly. This makes the diagnosis
quite easy to make, and with this classic history, the diagnosis can also
be made over the telephone. Partial biceps tendon tears may result
from an acute event or tearing in conjunction with chronic degen-
eration.151,152 Clinical complaints and findings are similar to those
of complete rupture, with pain in the antecubital fossa and weakness
of supination. In contrast, the biceps may still be palpable, and MRI
findings suggest a partial tear.151
In some patients, the diagnosis is less clear. These patients fre-
quently have a partial tear of a chronic and slowly degenerative nature
and complain of nonspecific elbow pain that is worsened with daily
activities. They may not complain specifically of pain while supinating
the forearm. On physical examination, patients often point to the ante-
rior middle aspect of the antecubital fossa but do not specifically point
to the posterolateral aspect of the elbow or the area of the radial tuber-
osity. This presentation can make the diagnosis less obvious, and other
pathologic changes around the elbow, such as lateral epicondylitis,
plica, or elbow arthritis, may be considered. On examination, full range
of motion is present, but frequently there is exacerbation of symptoms
with resisted elbow flexion and supination and with deep palpation
of the biceps and antecubital fossa. In addition, deep palpation of the
radial tuberosity from the posterolateral aspect while passively pronat-
ing the forearm sometimes elicits pain. This finding of pain noted with
palpation over the radial tuberosity is a very good indication of tendi-
nopathy involving the insertion of the distal biceps.
The pathologic changes that occur with distal biceps tendinopathy
may be similar to those of tendinopathies elsewhere in the body, such
as in the shoulder or wrist. The insertion site of the tendon on the radial
tuberosity undergoes degenerative changes that are visible and begin
with partial tearing of the tendon. This process can be painful, but it
also clearly can be asymptomatic. We have treated many patients with
distal biceps ruptures that showed, in addition to the acute rupture
for which they were undergoing surgical treatment, signs of signifi-
cant chronic degeneration with partial tearing before rupture. Many
of these patients deny having any symptoms referable to their distal
biceps insertion before the acute event (rupture) that caused them to
present for treatment.
Diagnosis
On clinical examination, a patient with biceps pathologic conditions
exhibits pain and weakness in flexion and supination and sometimes
ecchymoses in the antecubital fossa or an abnormal muscle contour of
the biceps. Also, with the elbow at 90 degrees of flexion, one may ask
the patient to rotate the pronated forearm into supination; normally,
the examiner can hook the tip of his or her thumb around the biceps
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1034 PART IV Elbow and Forearm
tendon in the cubital fossa (Fig. 25.10).153 With distal avulsion of the
tendon, this may be impossible.
Occasionally, some fibers or a fascial sleeve may remain intact, giv-
ing an appearance of an intact tendon. The examiner must discriminate
between the normal lacertus fibrosus, which often remains intact even
with biceps rupture, and the biceps tendon.
Imaging studies are of mixed benefit in the workup of a patient with
suspected distal biceps pathologic findings. Plain film radiographs
should be obtained but are most commonly normal and do not show
pathologic changes. Biceps ruptures typically do not involve bony rup-
tures, and minimal changes are seen on standard radiographs of the
elbow.
MRI may show rupture, but it is unnecessary in most cases and
occasionally may be read as falsely negative, although some authors
suggest a 100% correlation with intraoperative findings.154 If obtained,
the surgeon should view the images themselves, as the radiologic inter-
pretation is just that: an interpretation. Additionally, arguing against
routine MRI scanning is the finding that even in the setting of rerup-
ture of a previously repaired ruptured distal biceps tendon, the MRI
did not affect the operative plan.155 MRI may, however, be useful to
exclude alternative diagnoses and to evaluate the extent of suspected
partial rupture; it also may be useful in cases in which the history sug-
gests a biceps rupture but the clinical examination is unclear.154,156,157
MRI also tells the surgeon the expected location of the distal tendon
end and whether it has retracted proximally. MRI findings suggestive
of complete rupture include absence of the tendon insertion or a fluid-
filled sheath, whereas partial ruptures are typically seen as high signal
Fig. 25.10 A and B, Hook test described by O’Driscoll and colleagues involves assessment for intact biceps
tendon by “hooking” examiner’s finger around biceps with elbow at 90 degrees and in supination. (From
O’Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med.
2007;35[11]:1865–1869. Redrawn by Elizabeth Martin.)
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intensity, fluid within the tendon sheath, or thinning or thickening
of the tendon distally.156,158 Positioning of the prone patient with the
shoulder abducted over the head and the elbow in 90 degrees of flexion
and the forearm in supination (the so-called FABS view) (Fig. 25.11)159
has been suggested to improve visualization of the distal biceps inser-
tion into the radial tuberosity.158 Ultrasound is a lower-cost diagnostic
tool that is also usually unnecessary but has been shown to be accurate
in the diagnosis of complete or partial tears.157,160 Findings suggestive
of complete rupture include tendon absence, fluid, and mass in the
antecubital fossa; incomplete rupture may be represented by a focal
hypoechogenic area or thinning of the tendon.157,160,161
Treatment
Treatment of partial or complete biceps ruptures may be nonoperative;
however, an estimated loss of 40% to 60% of supination power and 30%
of flexion power can be anticipated in the setting of untreated complete
distal biceps ruptures. Despite this, some patients may compensate
well and even regain substantial supination strength over time.162-167
Although functional difficulties may persist and one series has sug-
gested that a high rate of residual pain and weakness may persist at 4.5
years of follow-up after nonoperative treatment,163,168,169 other series
have suggested that many patients compensate well, with a high rate
of satisfactory outcomes scores and only a modest loss of supination
strength at a median follow-up of 38 months.164 If operative treatment
is elected, it should ideally proceed within 7 to 10 days of injury, before
tissue can become retracted and scarred. In addition, it has been sug-
gested that complications of early repairs are less likely, although a
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures
recent series challenges this thought, with no higher complication rate
seen in patients up to 4 weeks following rupture.170-173
Primary repair is almost certainly possible 4 weeks after injury and
as late as 9 months in our experience. Commonly, the lacertus fibrosus
is partially intact, which serves to anchor the biceps distally and pre-
vent proximal retraction to some extent. The biceps can be mobilized
and repaired to the tuberosity even with the elbow in some flexion,
which universally stretches out over time, yielding nearly full exten-
sion at final follow-up. Rarely, augmentation, as with Achilles tendon
or hamstring allograft, is required.174 Using a graft extension does not
restore the proper muscle tendon length, just as adding a tendon graft
to a profundus tendon rupture does not restore finger flexion. Although
it is tempting to add a graft to restore continuity of the muscle-tendon
Fig. 25.11 Forearm in supination view by magnetic resonance imag-
ing shows insertion of biceps tendon into radial tuberosity (arrows,
biceps tendon; arrowhead, biceps insertion into radial tuberosity).
(From Giuffrè BM, Moss MJ. Optimal positioning for MRI of the dis-
tal biceps brachii tendon: flexed abducted supinated view. AJR Am J
Roentgenol. 2004;182[4]:944–946.)
Anterior
Fig. 25.12 Biceps insertion occurs in long, ribbon-like fashion onto ulnar aspect of radial tuberosity. (From
Mazzocca AD, Cohen M, Berkson E, et al. The anatomy of the bicipital tuberosity and distal biceps tendon. J
Shoulder Elbow Surg. 2007;16[1]:122–127.)
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1035
unit, it does little to restore elbow active function. An alternative to
repair with graft in chronic cases is tenodesis of the distal biceps to the
brachialis, although results in postoperative strength may be less satis-
factory.162 Good results can be seen with operative treatment of partial
tears.152,173 In surgical treatment, issues that remain unclear include
optimal fixation technique of the tendon to bone and whether a two-
incision versus one-incision surgical approach has fewer complications
or a better outcome.175,176
PERTINENT ANATOMY
Anatomic studies have shown that the insertion site of the tendon onto
the radial tuberosity occurs through a long, thin, ribbon-like insertion.
The advantage of this long, thin insertion, primarily on the medial
aspect of the tuberosity, is that the tendon can wrap around the tuber-
osity, which acts as a cam, giving mechanical advantage to rotation of
the radius (Fig. 25.12). In addition, it has become apparent that the dis-
tal biceps tendon represents continuations of the short and long heads
of the muscle distally. The short head, which is more significant, inserts
distal to the radial tuberosity and functions as a flexor of the elbow,
whereas the long head inserts away from the axis of rotation, to func-
tion in supination (Fig. 25.13).177-180 Restoring the correct anatomic
alignment is important for optimal function of the biceps.177-183
The anatomy of the radial tuberosity varies widely; it is similar to
retroversion of the humeral head. This can range from 30 degrees off
of the radial tuberosity to almost 90 degrees. Repair techniques using a
single anterior incision may be unable to accurately restore the correct
insertion point of the tendon if the medially oriented angle of insertion
is closer to 90 degrees. Detailed anatomic studies of the footprint of
the biceps insertion have revealed that the biceps inserts on the poste-
rior ulnar portion of the radial tuberosity, suggesting that an anatomic
repair through a single anterior approach may be difficult, particularly
if forearm supination is limited preoperatively.177,179
Two-incision techniques offer the ability to limit the size of the
anterior exposure and decrease the risk of neurovascular injury, and
if a muscle-splitting approach is used, there is no higher risk of radi-
oulnar synostosis (Fig. 25.14). El-Hawary and associates184 compared
complications after a single-incision technique and after a modified
Ulnar
Radial
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1036 PART IV Elbow and Forearm
Long head
tendon insertion
Short head
tendon insertion
A B
Fig. 25.13 A and B, Long and short heads of biceps have distinct anatomic insertions at radial tuberosity.
(From Athwal GS, Steinmann SP, Rispoli DM. The distal biceps tendon: footprint and relevant clinical anatomy.
J Hand Surg Am. 2007;32[8]:1225–1229.)
Boyd-Anderson two-incision technique. Complication rates were 44%
versus 10% in the single-incision and two-incision techniques, respec-
tively; patients undergoing the two-incision technique had a slightly
more rapid recovery of flexion strength. At final follow-up, differences
between the two groups were minimal. Other series have suggested a
7% synostosis rate with a two-incision technique.171 Although a two-
incision technique is said to be associated with heterotopic ossification,
a single-incision technique may also be complicated by this problem.185
Grewal and colleagues186 evaluated patients who were prospectively
randomized to either a single-incision repair with suture anchors or
a two-incision technique with bony tunnels. Outcomes were similar,
with two exceptions: There was a significantly increased risk of compli-
cations (mostly related to neurapraxia of the lateral antebrachial cuta-
neous nerve) associated with the single-incision technique, and there
was a significant increase of 10% in flexion strength in the two-incision
group over the single-incision group. Additionally, one recent study
found improved supination torque at 12 months following surgery
with the two-incision technique.182
The technique of tendon repair to bone is also variable. Options
include direct repair to bone through bony tunnels and use of inter-
ference screws, suture anchors, or other devices. Although fixation
with a button device is strongest in biomechanical testing in  vitro,
it seems from clinical series and biomechanical testing that fixation
with transosseous sutures and suture anchors is sufficient to withstand
forces in vivo exerted during rehabilitation.171,176,187-189 Transosseous
sutures are also less costly and biologically provide a bone-to-tendon
interface for robust healing. Comparisons of transosseous fixation
two-incision techniques with suture anchor techniques or tie-on but-
ton techniques show satisfactory outcomes in all groups. Practically
speaking, all techniques in common practice today have an accept-
able complication risk and nearly comparable results. A recent trend
is modification of button repair of distal biceps tendons. Historically,
placement of the button might span the entire width of the radius,
which often involves, with single incision approaches, passing a
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Beath needle through the forearm and exiting the skin dorsally. More
recently, modifications have been made, including docking the distal
biceps into the radius intramedullary canal. This may also decrease
the risk of proximal radius fracture due to a bicortical hole (stress
riser), as well as obviate concerns about encountering or entrapment
of the posterior interosseous nerve (PIN). Likewise, recent attention
has focused on the site of repair at the footprint with an attempt to
more anatomically replicate the insertion site, which may reproduce
more normal kinematics and restore supination strength. Practically
speaking, this can be done easily from a two-incision approach, but
it may also be approximated through a single-incision approach; in
such cases, avoiding placement of the repaired biceps in an ante-
rior or central site is appropriate. Rather, the biceps may be inserted
more over the tuberosity in its anatomic position. Typically, this will
require forearm hypersupination to gain access. The drill holes are
started more on the ulnar side then angled slightly distally and radi-
ally toward the center of the radius bone entering into the medullary
canal, which allows placement of the button to allow the distal biceps
to exert its full rotational force.181-183,190-193
Complications
Risks of surgery include recurrence of rupture; heterotopic ossification;
injury to neurovascular structures, especially the lateral antebrachial
cutaneous nerve and the posterior interosseous nerve; and persistent
anterior elbow pain. Recurrence of rupture is exceedingly rare, with
most series reporting a rate of 0% to 4%.
Heterotopic ossification is uncommon and likely depends on
patient-related and injury-related factors rather than surgical technique.
Heterotopic ossification around the elbow remains poorly understood,
and the role of possible prophylaxis with nonsteroidal antiinflamma-
tory drugs remains unclear. It has been suggested that heterotopic ossi-
fication is more common with a two-incision technique; however, this
finding seems variable across series.176,184 Nonetheless, biceps repair
surgery seems particularly prone to this complication.
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures
A lose motion with a partial biceps tendon rupture, and strengthening
B injury. Long-term studies of nonoperative treatment of biceps tendon
Fig. 25.14 A, Large incision is required to perform repair safely via sin-
gle anterior approach. B, Two-incision approach allows use of smaller
cosmetic anterior incision. (From Hartman MW, Merten SM, Steinmann
SP. Mini-open 2-incision technique for repair of distal biceps tendon rup-
tures. J Shoulder Elbow Surg. 2007;16[5]:616–620.)
Injury to vascular structures around the elbow, including the lat-
eral antebrachial cutaneous nerve and the posterior interosseous
nerve, have been described. A single anterior exposure may be associ-
ated with a higher risk of neurovascular injury compared with a two-
incision approach; however, injury to the posterior interosseous nerve
can occur in a two-incision approach if excessive traction is placed
for a prolonged period, as with a self-retaining retractor or Hohmann
retractor placed over the neck of the radius. When the radial tuberos-
ity is exposed through the posterolateral approach of the two-incision
technique, the forearm should be placed in a position of pronation to
allow the posterior interosseous nerve to fall farther away from the sur-
gical field.128
Expected Outcomes
Postoperatively, most patients are satisfied and experience a full return
to flexion-extension motion. Rotation motion may be limited in
some, but not all, cases, and strength and endurance in flexion can be
expected to return to nearly normal over time. Supination strength and
endurance in most series return to normal or nearly normal, although
they may be less than normal in some cases, particularly in the non-
dominant arm.168,194-197
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1037
AUTHORS’ PREFERRED METHOD OF
TREATMENT: PARTIAL BICEPS TEARS
Patients who present with a classic history of a “pop” in the arm with
resisted motion and sudden onset of pain should be treated as having
complete biceps tears regardless of MRI findings suggestive of “partial
tear.” In these cases, some strands of the distal biceps may be intact;
however, they are not functional, and this lesion should be regarded as
and treated as an acute complete distal biceps rupture.
Partial biceps tears are described as a chronic tendinopathy in
which the patient complains of a chronic aching in the antecubital
fossa, rather than a sudden onset of pain. When the diagnosis of a par-
tial distal biceps tear is made through clinical examination and imag-
ing modalities, treatment should be nonoperative for the first 3 to 6
months. Patients are encouraged to avoid heavy lifting and to use the
arm primarily for activities of daily living only. Patients typically do not
exercises and physical therapy are unnecessary for these individuals.
In some instances, several months of conservative management may
result in symptom abatement.
In our experience, significant partial distal biceps tears commonly
do not improve after even 6 months of nonoperative treatment. In this
situation, operative treatment, which involves taking down the remain-
ing fibers of the distal biceps and repair to the insertion site, has been
found to be satisfactory with restoration of function and resolution of
symptoms through a single posterior incision.
Treatment of Acute Complete Biceps Ruptures
Acute distal biceps ruptures are commonly seen in middle-aged men,
and operative and nonoperative treatments have been advocated for
these individuals. Proponents of nonoperative treatment point out
the fact that patients have full flexion and extension of the elbow and
are able to pronate and supinate even when seen shortly after an acute
ruptures show that with time, patients experience resolution of pain
and continue to have full flexion and extension and good pronation
and supination but may continue to have functional deficits. Studies
performed at the Mayo Clinic on chronic tears showed a loss of supina-
tion strength of 40% and loss of flexion strength of 30%.162,163,165
In our experience, many patients are told that they should be treated
nonoperatively, often by a primary care provider or family member.
Quite often, these patients come to orthopedic attention because they
find nonoperative care to be unsatisfactory, with functional difficul-
ties, cosmetic complaints owing to the “Popeye muscle,” and a sense
of achiness and cramping in the biceps muscle itself. Although studies
after nonoperative treatment show a small loss of flexion and supina-
tion strength, they cannot put a “number” on the achiness and cramp-
ing that patients often experience because the muscle-tendon unit (the
biceps) has been detached and is nonfunctional. It is common to have
a patient complain of a cramping and aching in the biceps that takes
several hours to resolve after a vigorous day of work or play. Loss of
endurance is also common.
Operative treatment of acute distal biceps ruptures is preferred in
most cases. Operative treatment tends to involve either a single ante-
rior incision or dual incisions, one in an anterior location and one in a
posterolateral location. Essentially, the literature supports use of either
approach, and the individual surgeon should use the one that he or she
is most comfortable with and yields the best results in his or her hands.
Single-Incision Technique
The single-incision approach typically involves either a large longi-
tudinal (see Fig. 25.14) or a boat-race type of incision that mirrors
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1038 PART IV Elbow and Forearm
the River Thames from Putney to Mortlake as it makes an “S” shape
up the arm. Our preference is a longitudinal incision distal to the
antecubital flexion crease. If the distal biceps is retracted, a sepa-
rate incision may be made proximal to the crease to “fish out” the
retracted tendon, although this is rarely necessary. It is important
when doing a single anterior approach to have good visualization of
the radial tuberosity, which is deep in the forearm, and this involves
a significant operative exposure to visualize the radial tuberosity
safely. The surgery is performed under tourniquet control for this
purpose.
During the exposure, the lateral antebrachial cutaneous nerve is at
risk as it enters the antecubital area between the biceps and the brachi-
alis laterally. There are multiple veins in this area that must be ligated
as needed, and the radial nerve, although not directly in the area of
dissection, is within a few centimeters. The significant neurovascular
structures on the medial aspect of the elbow, the median nerve, and the
brachial artery can be palpated and are located more medially than the
biceps itself. The stump of the tendon is identified in the antecubital
fossa wound or retrieved proximally if it has retracted. Dissection pro-
ceeds distally to identify the bicipital tuberosity on the radius, which
can be palpated by pronating and supinating the forearm. It is cleared
of tendon debris and fibrous tissue and prepared for reinsertion of the
biceps tendon.
Multiple techniques have been proposed for securing the tendon
to bone; essentially all have been shown to provide sufficient in vivo
strength of repair. Through an anterior incision, suture anchors or
endobutton devices typically are used according to the manufactur-
er’s instructions (Video 25.1). Our preference with this approach is to
identify the tendon, prepare it, and place running, locking Krackow
stitches from the distal end, working proximal and then back down,
exiting the tendon for placement of the buttons, one set of stitches
on either side of the tendon such that four limbs of suture exit the
tendon. The double button technique is used, and buttons are applied
to the end, with sutures running through the button holes in opposite
directions, such that when one pulls on the sutures, the construct
tightens. Slack is left between the end of the biceps and the button
to allow working room. The insertion site is prepared, and typically
we hypersupinate the forearm and plan two unicortical drill holes,
initiating slightly ulnarly and aiming distally and radially. The near
cortex is drilled, without drilling into the second cortex. Sufficient
space is allowed between the two holes to allow the buttons to “flip.”
The suture buttons are passed into the holes, and the ends of the
sutures are pulled, alternately, to flip the buttons and to tighten the
distal biceps down to the insertion. A free needle may be used to
pass suture limbs through the biceps tendon and tie to secure the
tightened and repaired distal biceps. Minifluoroscopy at time of sur-
gery is helpful to ensure that the buttons have “flipped” and do not
escape through the drill holes, although generally it is not necessary.
The tourniquet is released and meticulous hemostasis obtained. The
wound is irrigated to remove any bony fragments or dust, and the
wound is closed.
The postoperative regimen is described subsequently in the two-
incision technique.
Two-Incision Repair
In our hands, advantages of a two-incision technique include a more
cosmetic and smaller (<2 cm) scar anteriorly (Fig. 25.15; see also Fig.
25.14) and the ability to restore the biceps insertion site more ana-
tomically through the second posterolateral incision. The surgery is
performed with the patient in the supine position, with an arm board.
A sterile tourniquet is applied, and just distal to the cubital crease, a
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transverse incision of 2 to 3 cm is made centered over the cubital fossa
(Fig. 25.16; see also Fig. 25.15B and D). Dissection proceeds, with care
taken to identify and preserve the lateral antebrachial cutaneous nerve,
which lies lateral to the biceps tendon (Fig. 25.17). The unwary surgeon
may mistake the brachialis for an untorn biceps tendon.
The biceps tendon often retracts proximally, and blunt explora-
tion with the surgeon’s finger can retrieve the stump into the surgical
wound. The end of the tendon is typically bulbous and thickened. This
is debrided, and the end is freshened up to healthy tissue and trimmed
so that it fits into the tuberosity. A Krackow stitch is used with No. 2
nonabsorbable braided suture, with the tails exiting through the center
of the tendon distally (Fig. 25.18).
After the tendon is prepared, attention is turned to the insertion
site. Multiple techniques have been proposed for securing the tendon
to bone; essentially, all have been shown to provide sufficient strength
of repair. We prefer a bony tunnel technique. By pronating and supi-
nating the forearm, the biceps tuberosity can be palpated in all but the
most muscular or obese patients. Intraoperative fluoroscopy can be
useful in larger individuals for this purpose. An incision is made over
this region (see Fig. 25.15D), with dissection proceeding down to the
tuberosity, splitting the common extensors and supinator (Fig. 25.19).
The forearm is placed in a position of full pronation, and the tuberosity
is prepared. Usually, there is retained soft tissue and tendon debris on
the tuberosity; this is excised, and a bur is used to create a cancellous
trough for the tendon (Fig. 25.20). The forearm is supinated slightly,
bringing the radial edge of the trough into view, and two small drill
holes are placed exiting into the trough. Care should be taken to allow
for a sufficient bony bridge.
The suture tails of the prepared biceps stump are passed distally
into the posterolateral wound (Fig. 25.21). Care should be taken to exit
through the muscle-splitting approach rather than exposing the ulna.
The sutures are passed through the bony tunnels such that the biceps
tendon is delivered into the tuberosity trough; this is facilitated by supi-
nating the forearm slightly and may be done with the Hewson suture
passer, 26-gauge wire, or a free needle. The sutures are drawn taut, and
the forearm is gently supinated and pronated to seat the tendon into
the tuberosity trough (Fig. 25.22). Finally, the sutures are tied over the
bony bridge with the forearm slightly supinated (Fig. 25.23). The elbow
is gently ranged in pronation-supination and flexion-extension. One
can fully pronate to document seating of the tendon end into the bony
cavity. The wounds are closed in layers, with a running subcuticular
stitch for the skin.
Postoperative Treatment Protocol
Historically, patients have been immobilized in a cast or splint for 2 to
4 weeks before initiation of motion. More recently, early mobilization
has become more widespread, and in our experience, after a standard
repair, patients can be allowed full active motion of the elbow with
no resistance at 2 days postoperatively with no splinting.187 Patients
are allowed to use the arm for activities of daily living with no “lift-
ing heavier than a telephone receiver.” Passive supination and prona-
tion with the elbow at 90 degrees of flexion are initiated within days
of surgery.
With this motion protocol, at 2 to 3 weeks patients typically have
a full range of motion in flexion-extension and by the end of 1 month
have full pronation and supination of the elbow. Although good results
in general and a high percentage of intact repairs have been reported
in series where patients have been immobilized for 4 weeks or more, it
has been shown that earlier mobilization of the elbow allows for high
patient satisfaction and, most importantly, continuity of the repaired
tendon.187
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures 1039

A
B

C
Fig. 25.15 A to D, Two-incision approach involves short anterior transverse incision and posterolateral inci-
sion. (C, Copyright © Elizabeth Martin.)

CRITICAL POINTS
Distal Biceps Rupture
Patients with the classic history of a “pop” while lifting objects and pain
in the antecubital fossa almost inevitably have an acute complete distal
biceps rupture.
In most cases, acute complete distal biceps ruptures are treated operatively
in younger, more active individuals.
Chronic tendinopathy may ultimately require surgical management.
The available literature supports either a single anterior incision or a two-
incision technique.
Most techniques have sufficient strength at the time of repair to permit
early, gentle active motion during the initial postoperative period.
Fig. 25.16 A 2-cm incision is made in antecubital fossa.

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1040 PART IV Elbow and Forearm
Fig. 25.17 Lateral antebrachial cutaneous nerve (short arrow) lies in
close proximity to biceps tendon (long arrow).
Fig. 25.18 Krackow stitch is placed in preparation for fixation to bone.
(From Hartman MW, Merten SM, Steinmann SP. Mini-open 2-incision
technique for repair of distal biceps tendon ruptures. J Shoulder Elbow
Surg. 2007;16[5]:616–620.)
TRICEPS AVULSIONS AND RUPTURE
Injury to the triceps may occur at the osseous insertion, at the mus-
culotendinous junction, or as an intrasubstance muscle rupture. Avul-
sion from the osseous insertion is the most common pattern of injury,
whereas intrasubstance rupture is the least common.198-200
Although the terms rupture and avulsion are often used inter-
changeably, Tarsney200 suggested that avulsion be used for disruption
at the osseous insertion and rupture be used for intrasubstance or
musculotendinous disruption. It must be noted that “complete” rup-
ture typically involves both the long and lateral tendinous heads of the
triceps, with some of the deeper muscular insertion of the medial head
remaining intact. Thus persistent active elbow extension does not rule
out disruption of the triceps tendon insertion.
Spontaneous injury of the triceps tendon other than that associated
with prior total elbow arthroplasty is rare.198-201,203,208,210,213,214 At the
Mayo Clinic, over a 25-year period, only 14 patients were seen with 16
triceps avulsions.198 Of 1014 tendon injuries in one review, less than 0.8%
were triceps injuries, and half of those represented open lacerations.201
The pathogenesis usually involves direct or indirect trauma in asso-
ciation with forced eccentric contraction.198,199,201-203 Typically, the
defect occurs at the osseous insertion. Diagnosis is usually clinical,
with a palpable defect and lack of forceful active extension function.
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Extensor
digitorum
communis
Radial tuberosity
A Supinator
B
Fig. 25.19 A and B, Incision is made over tuberosity, and muscle-
splitting approach is made to expose tuberosity.
Partial ruptures may occur and are marked by decreased extension
strength or pain against resistance. Radiographs are indicated and
are useful to rule out olecranon fracture or bony avulsion.198,202,203 In
addition, a radial head fracture has been reported in association with
this lesion.204 MRI or ultrasound may be useful to show the pathologic
changes and help differentiate between partial and complete lesions
(Fig. 25.24).198,205-207
Much has been speculated about predisposing factors, including
enthesopathies, medication associations, renal failure with or with-
out hyperparathyroidism, and anabolic steroid usage.198,202,208-210 It
seems that intrasubstance rupture is not associated with steroid use or
chronic medical conditions, in contrast to avulsion or musculotendi-
nous rupture.199,207,211,212
Early surgical repair is indicated for acute complete avulsions. This
involves repair with locking nonabsorbable sutures attaching the ten-
don to the olecranon through drill holes, suture bridge techniques,
or suture anchors. Repair techniques have differing biomechanical
strength in the laboratory or at time zero, but functional results and
clinical outcomes appear satisfactory regardless of technique. If a large
bony fragment is present, use of hardware to fix bone to bone may facil-
itate earlier rehabilitation, but prominent hardware sometimes man-
dates later reoperation for hardware removal.198,202,203,205,207,213-219 The
arm is immobilized for approximately 3 to 4 weeks in 30 to 45 degrees
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 CHAPTER 25 Elbow Tendinopathies and Tendon Ruptures 1041

A
Fig. 25.22 Sutures are drawn taut, and forearm is gently supinated and
pronated to seat tendon into tuberosity.

B
Fig. 25.20 A and B, Tuberosity is exposed, and bur is used to create
trough.

Fig. 25.23 Sutures are tied over bony bridge.

which local tissue is inadequate or in which retraction of the muscle

Fig. 25.21 Tails of sutures are passed into posterolateral wound.
of flexion, followed by gentle mobilization and, finally, active extension
beginning at 6 weeks. Weight bearing or lifting should be avoided for
4 to 6 months.198,202,213
The treating physician should differentiate between complete avul-
sions and partial avulsions by assessing active elbow extension. It has
been suggested that incomplete avulsions may be treated nonopera-
tively with close follow-up to ensure that they do not become com-
plete.202 In addition, some patients with partial triceps avulsions treated
nonoperatively have residual weakness, pain or functional defects, or
both and come to surgical management.206,220,221 Chronic lesions in
tendon makes primary repair difficult may require augmentation using
allograft or reconstruction with triceps aponeurosis or fascia or a local
rotational anconeus flap.143,222,223
Intramuscular ruptures of the triceps or ruptures at the muscu-
lotendinous junction are even more rare, and the literature is mixed
regarding the need for operative therapy. It has been suggested that
nonoperative treatment is effective, particularly in patients who
have only partial rupture and do not require full elbow extension
strength.199,212 This lesion is more likely to be seen in young patients
without significant comorbidities and may be associated with sports
injury.199,211,212
AUTHORS’ PREFERRED METHOD OF
TREATMENT: REPAIR OF COMPLETE
AVULSION INJURIES
The surgery is performed with the patient in the supine position with
the arm across the chest. A midline posterior incision is used to expose
the triceps tendon (Fig. 25.25). Commonly, there is a portion of the
deep muscular fibers of the triceps still attached to the olecranon.
Sometimes this is a delaminating tear in which the triceps splits along
superficial and deep planes; similar to the situation in rotator cuff tears,
the dorsal portion may have a superficially benign appearance. MRI

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1042 PART IV Elbow and Forearm

A B
Fig. 25.24 A and B, Magnetic resonance images showing avulsion of triceps with proximal retraction of mus-
culotendinous units. (From Sierra RJ, Weiss NG, Shrader MW, Steinmann SP. Acute triceps ruptures: case
report and retrospective chart review. J Shoulder Elbow Surg. 2006;15[1]:130–134.)

Fig. 25.26 Triceps is exposed and prepared for reattachment to bone.

Arrows indicate the triceps tendon.

Fig. 25.25 Posterior midline incision is used to expose triceps.
and surgical exposure show a deeper injury to the tendon, however,
than had been initially apparent.
After the tear has been exposed (Fig. 25.26), any fibrous tissue or
scar tissue is excised to “freshen up” the tendon edges. A heavy nonab-
sorbable braided No. 5 suture is placed with a Krackow stitch through
the triceps to prepare for reattachment to bone (Fig. 25.27). The tip
of the olecranon is decorticated to bleeding bone, and a 2-mm drill
or Keith needle is used to create bony tunnels to pass the sutures. The
sutures are passed and tied over a bony bridge (Fig. 25.28). The patient
is placed in a sling, and gentle motion is initiated in 1 to 2 weeks. If
the repair occurs late or if myotendinous contracture has occurred, the
arm should be splinted in extension for the initial 2 weeks after sur-
gery and then slowly allowed to regain motion over the ensuing 4 to
6 weeks.
Partial tears of the triceps may sometimes present a diagnostic and
therapeutic dilemma. The typical history is one in which the patient
sustains an eccentric load to the elbow and presents with point tender-
ness over the posterior humerus and elbow. There is often tenderness at
the triceps insertion. Active elbow extension is intact; however, it may
be painful, and MRI reveals a partial triceps tear. In our experience,
many patients do poorly with nonoperative therapy; however, some
respond. Patients should be given a trial of conservative treatment and
followed for 3 to 6 months; they may be offered surgical intervention if
improvement is not seen. Of note, it is important to differentiate what
can be read as a “partial triceps rupture.” As discussed, in a partial

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 A

B
Fig. 25.27 A and B, Krackow stitches are placed to secure triceps to bone.

A B

C D
Fig. 25.28 A to D, Sutures are passed through bony tunnels and tied. (C and D, From Sierra RJ, Weiss NG,
Shrader MW, Steinmann SP. Acute triceps ruptures: case report and retrospective chart review. J Shoulder
Elbow Surg. 2006;15[1]:130–134.)
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1044 PART IV Elbow and Forearm
rupture, no tendon has been torn and retracted proximally. A complete
rupture of the long and lateral heads with some deep triceps muscle
remaining intact is not a “partial” injury.
CRITICAL POINTS
Triceps Avulsions and Ruptures
Triceps injuries are rare.
Injuries may occur at the tendinous insertion (avulsion), as a rupture at the
musculotendinous junction, or as an intramuscular rupture.
Early repair of avulsions is generally preferred.
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