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Triceps tendinitis
TRICEPS TENDINITIS KOUROSH JAFARNIA, GERARD T. GABEL, AND BERNARD F. MORREY
Elbow extension is very critical for the throwing athlete. The extensor mechanism of the elbow is a relatively uncommon source of clinical dysfunction. However, two primary processes may affect the triceps tendon, triceps tendonitis, and triceps avulsion injuries. Triceps tendonitis, the more common of the two, is manifested by chronic posterior elbow pain with extension activities. It occurs almost exclusively in males, usually in the fourth decade of life, and especially in individuals who perform forceful repetitive extension activities, eg, throwing athletes. Two distinct subsets of patients exist: those with and those without an olecranon traction spur. Conservative management involves avoidance of repetitive forceful elbow extension, nonsteroidal anti-inflammatories, and time. Splinting in 45 ° of elbow flexion may be useful if tolerated. Counterforce bracing is typically unsuccessful because the cross-section of the arm changes with biceps contraction. Corticosteroid injection is contraindicated. Although conservative management is limited in scope, it is usually successful in triceps tendonitis in the absence of an olecranon traction spur. The presence of an olecranon traction spur is associated with a higher failure rate of conservative treatment necessitating surgical intervention. Surgical management, when required, involves subperiosteal exposure and excision of the spur and the olecranon tip and formal repair of the triceps tendon. KEY WORDS: triceps tendinitis, olecranon spur Copyright © 2001 by W.B. Saunders Company
Elbow extension is a critical component of the mechanics involved in throwing. Forceful triceps activity is required t h r o u g h o u t the acceleration phase to the release phase. Overload of the triceps insertion either acutely or chronically m a y result in triceps tendinitis. Triceps tendinitis is manifested by chronic posterior elbow pain with extension activities. 1 It occurs almost exclusively in men, usually in the fourth decade of life, and especially in individuals w h o perform forceful repetitive extension activities, eg, throwing athletes. The clinical presentation of triceps tendinitis consists of posterior elbow discomfort with active extension. It is distinguished from posterior impingement by pain with isometric active extension short of full extension. Unlike olecranon bursitis, which m a y occur concomitantly, triceps tendinitis exhibits both direct and indirect tenderness. Radiographic evaluation usually shows a triceps/olecranon traction spur emanating from the posterior olecranon (Fig 1). Conservative m a n a g e m e n t involves avoidance of repetitive forceful elbow extension, nonsteroidal anti-inflammatory drugs, and time. Splinting in 45 ° of elbow flexion m a y be useful if tolerated. Counterforce bracing is typically unsuccessful because the cross-section of the arm changes with biceps contraction. Corticosteroid injection into a discrete tendon insertion is contraindicated. 2 Alt h o u g h conservative m a n a g e m e n t is limited in scope, it is
From the Department of Orthopedic Surgery, Harvard Medical School, Boston, MA; Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX; and the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN. Address reprint requests to Kourosh Jafarnia, MD, Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114. Copyright © 2001 by W.B. Saunders Company 1060-1872/01/0904-0005535.00/0 do i: 10.1053/otsm.2001.26782
Fig 1. Lateral radiograph showing large olecranon spur in 42-year-old recreational pitcher with chronic posterior elbow pain and recent exacerbation. Note the fracture at the midpoint of the spur.
usually successful in triceps tendonitis in the absence of an olecranon traction spur. The presence of an olecranon traction spur is associated with a higher failure rate of conservative treatment and a subsequent need for surgical intervention. Surgical m a n a g e m e n t involves subperiosteal exposure and excision of the spur and the olecronan tip and formal repair of the triceps tendon.
ANATOMY Awareness and treatment of disorders of the elbow extensor mechanism have increased considerably over the past 2 decades, leading to a more thorough appreciation of the
Operative Techniques in Sports Medicine, Vol 9, No 4 (October), 2001: pp 217-221
21 7
Extent of triceps tendon
, yp~u~ extent of triceps extension on olecranon spur Fig 2, Proximal surface of the olecranon. The triceps tendon inserts on the posterior 50% of this surface with the traction spur typically involving 50% of this insertion,
anatomy of this region. 3-s The extensor mechanism of the elbow consists mainly of the triceps tendon. The triceps tendon originates within the triceps muscle at a point approximately 20 cm proximal to the tip of the olecranon. The triceps extensor mechanism, as it approaches its insertion, forms 2 components, the triceps proper (that portion inserting on the olecronan) and the triceps expansion, which inserts distally and laterally primarily through the anconeus. The triceps proper thickens rapidly as it approaches the olecranon, although the triceps expansion remains relatively thin.
.
Fig 4, A planned surgical incision for triceps tendinitis, There was a large olecranon bursa present in this patient.
The triceps proper inserts on the posterior 40% of the olecranon, with the anterior 60% of the olecranon covered only by capsule and fat. The tendinous insertion averages 20 to 24 m m by 8 to 12 m m and extends to the medial margin of the olecranon whereas 2 to 4 m m of the lateral olecranon is bare. The triceps expansion, the lateral continuation of the extensor mechanism, consists of the continuum of the lateral head of the triceps into the anconeus. In 50% of specimens, a well-defined interval is located between the triceps expansion and the triceps proper just proximal to the olecronano This interval is the anatomic triceps decussation. In triceps tendinitis, the traction spur involves the posterior 30% to 50% of the triceps proper insertion (Fig 2). The triceps tendon inserts on the proximal face of the spur and curves beneath it to insert on the olecranon immediately anterior to the spur (Fig 3). Indications
Athletes are initially treated conservatively with anti-inflammatory drugs, rest and avoidance of repetitive elbow
Spur Olecranon excision Fig 3, A lateral drawing of the triceps insertion on the spur and olecranon proper, Note that a portion of the tendon actually curves around the tip on its way to inserting. This portion of the normal insertion can be preserved if the exposure of the spur is subperiosteal.
218
Fig 5. Bursal debris of varying degree is typically seen overlying the olecranon tip. It should be removed to allow for exposure of the tip/spur.
JAFARNIA ET AL
Fig 6. The spur extends proximally intratendinously but may also have a 3 to 4 mm posterior extension, as seen in this patient, making discrete identification of the spur easier.
Fig 7. The tendon is sharply elevated with a longitudinal incision at the midpoint of the spur, which is usually the midpoint of the olecranon as the spur is centrally located on the tip of the olecranon.
Fig 8. In this patient, as implied in the radiographs (Figure 1), a fracture through the spur had occurred. The nonunion interface between the spur base and the fracture fragment has developed. Note the triceps tendon fibers coursing intimately deep around the spur. TRICEPS TENDINITIS
Fig 9. The spur is removed with a rongeur, and care is taken to minimize additional injury to the tendon.
Fig 10. The bony removal should include a portion of the normal olecranon tip to allow for a good bed for tendinous healing but more so to minimize posterior prominence postoperatively.
Fig 11. After the fragment is excised, the degree of take down of the triceps insertion can be assessed (outlined). Usually 50% of the insertion is involved and needs formal repair.
219
Fig 12. Suture anchor placement divides the olecranon into thirds, with the anchors being placed at the margins of the central third.
extension exercises, and splinting, best done in 45 ° of elbow flexion. Ultrasound and other physical therapy modalities may be attempted but usually provide only temporary relief. Indications for surgical intervention include pain and limitation of function refractory to conservative treatment.
OPERATIVE TECHNIQUE A general anesthetic is required for this procedure. The patient is positioned in either a lateral or semilateral position with a beanbag or a bump underneath the trunk, allowing the arm to rest across the chest for a posterior exposure to the elbow. A nonsterile tourniquet is applied with the tubing posterior. After standard preparation and draping, a 4- to 5-cm longitudinal incision is created 1.5 cm lateral to the tip of the olecranon. The incision begins 2 cm distal to the olecranon tip and extends proximally for 2 to 3 cm (Fig 4). Subcutaneous dissection frequently reveals an olecranon bursitis, which is excised (Fig 5). The exten-
Fig 13. A grasping suture method is used with one end of the suture, and the other end is the gliding suture. The repair is placed at the tendon-bone interface to minimize prominence.
220
Fig 14. The repair is completed with an epitendinous, running suture,
sot mechanism is exposed and the midaxis of the olecranon identified. The olecranon spur is usually easily palpable within the triceps tendon and can, at times, be directly visualized (Fig 6). Subperiosteal exposure of the triceps spur begins with a longitudinal incision over the midpoint of the olecranon spur (Fig 7). Using a No. 64 beaver blade, the exposure is carried medially and laterally with limited difficulty. In approximately 50% of patients, a fracture of the spur will be encountered (Fig 8). Once the posterior and proximal surface of the spur is exposed, elevation of the triceps insertion off the remaining portion of the spur requires dissection between the spur and the olecranon itself. The plane of dissection extends around the tip of the olecranon because some fibers tend to curve deep to the spur to their normal insertion site and if preserved, will limit the extent of take d o w n of the triceps insertion (Fig 3). Once the spur is fully exposed, the spur itself is removed with a rongeur (Fig 9), including a portion of the posterior olecranon tip (Fig 10). The normal cross-sectional area of the insertion is 200 m m 2, and in the majority of the triceps spur excisions, approximately 50% of the area, ie, 20 by 5 m m or more, is
Fig 15. The fracture fragment size (21 mm x 6 mm) approximates the portion of the triceps tendon inserting on the spur. JAFARNIA ET AL
c o m p r o m i s e d (Fig 11). If this is the case, r e p a i r of the triceps w i t h 1 or 2 s u t u r e a n c h o r s s h o u l d be p e r f o r m e d . One or 2 c o r k s c r e w s u t u r e a n c h o r s are p l a c e d in a s y m m e t r i c m a n n e r in the defect (Fig 12). A locking s u t u r e is p l a c e d t h r o u g h the i n v o l v e d triceps, p a s s i n g the s u t u r e back t h r o u g h to the defect site. Both s u t u r e s a r e p a s s e d in this m a n n e r . The k n o t is tied at the t e n d o n b o n e interface to m i n i m i z e p r o m i n e n c e (Fig 13). After b o t h knots h a v e b e e n tied, the triceps are u s u a l l y well a p p r o x i m a t e d , and an e p i t e n d i n o u s r e p a i r w i t h a buried, r u n n i n g 4-0 Mersilene s u t u r e is p e r f o r m e d to c o v e r the knots fully a n d c o m p l e t e the r e p a i r (Fig 14). The w o u n d is irrigated, a s u b c u t i c u l a r closure is p e r f o r m e d , and a splint w i t h the e l b o w in a p p r o x i m a t e l y 45 ° of flexion is applied.
Postoperative Care and Rehabilitation P o s t o p e r a t i v e l y the s p l i n t / c a s t is m a i n t a i n e d for 3 weeks. A n active f l e x i o n / p a s s i v e e x t e n s i o n r a n g e of m o t i o n p r o g r a m is p e r f o r m e d for an a d d i t i o n a l 3 weeks, w i t h active e x t e n s i o n b e g i n n i n g at 6 w e e k s and a s t r e n g t h e n i n g p r o g r a m at 3 m o n t h s . A g r a d u a l p i t c h i n g p r o g r a m can be initiated w h e n s t r e n g t h is restored. Full r e c o v e r y , as far as p i t c h i n g is c o n c e r n e d , takes 6 to 12 months. Results. The majority of triceps tendinitis requiring surgery occurs in the fourth or fifth decade of life. Most y o u n g e r pitchers will r e s p o n d to conservative measures. Competitive pitchers, w h o fail to r e s p o n d to n o n o p e r a t i v e
TRICEPS TENDINITIS
measures and w h o u n d e r g o surgery, as a rule do resume their p r e m o r b i d level of performance. Complications. Suture p r o m i n e n c e has been seen in 1 of 9 patients. Persistent pain w i t h o u t discrete clinical findings was encountered in 1 patient (nonsports, work-related injury).
CONCLUSION Triceps tendinitis, although a rare entity, must be considered in throwing athletes w h o complain of posterior elbow pain with active extension. Conservative m a n a g e m e n t is usually successful, especially in the absence of an olecronan spur. H o w e v e r , in the presence of a spur, there is frequently a n e e d for surgical intervention, including excision, debridement, and t e n d o n repair.
REFERENCES 1. Gabel GT, Morrey BF: Tennis elbow, in Cannon WD (ed): Instr Course Lect (vol 47). Rosemont, IL, 1998, pp 165-72 2. Smith AG, Kosygan K, Williams H, et al: Common extensor tendon rupture following corticosteroid injection for lateral tendinosis of the elbow. Br J Sports Med 33:423-424, 1999 3. Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1993, pp 16-52 4. Gabel GT, Zwahlen B, Morrey BF: Surgical Managemen.t of the elbow extensor mechanism of the elbow, in Cannon WD (ed): AAOS Instr Course Lect (vol 47). Rosemont, IL, 1998, pp 151-156 5. Salmons S: Muscle, in Williams PL, Bannisdexter LH, Berry MM, et al (eds): Gray's Anatomy (ed 38). New York, NY, Churchill Livingstone, 1995, pp 737-900
221
Elbow extension is very critical for the throwing athlete. The extensor mechanism of the elbow is a relatively uncommon source of clinical dysfunction. However, two primary processes may affect the triceps tendon, triceps tendonitis, and triceps avulsion injuries. Triceps tendonitis, the more common of the two, is manifested by chronic posterior elbow pain with extension activities. It occurs almost exclusively in males, usually in the fourth decade of life, and especially in individuals who perform forceful repetitive extension activities, eg, throwing athletes. Two distinct subsets of patients exist: those with and those without an olecranon traction spur. Conservative management involves avoidance of repetitive forceful elbow extension, nonsteroidal anti-inflammatories, and time. Splinting in 45 ° of elbow flexion may be useful if tolerated. Counterforce bracing is typically unsuccessful because the cross-section of the arm changes with biceps contraction. Corticosteroid injection is contraindicated. Although conservative management is limited in scope, it is usually successful in triceps tendonitis in the absence of an olecranon traction spur. The presence of an olecranon traction spur is associated with a higher failure rate of conservative treatment necessitating surgical intervention. Surgical management, when required, involves subperiosteal exposure and excision of the spur and the olecranon tip and formal repair of the triceps tendon. KEY WORDS: triceps tendinitis, olecranon spur Copyright © 2001 by W.B. Saunders Company
Elbow extension is a critical component of the mechanics involved in throwing. Forceful triceps activity is required t h r o u g h o u t the acceleration phase to the release phase. Overload of the triceps insertion either acutely or chronically m a y result in triceps tendinitis. Triceps tendinitis is manifested by chronic posterior elbow pain with extension activities. 1 It occurs almost exclusively in men, usually in the fourth decade of life, and especially in individuals w h o perform forceful repetitive extension activities, eg, throwing athletes. The clinical presentation of triceps tendinitis consists of posterior elbow discomfort with active extension. It is distinguished from posterior impingement by pain with isometric active extension short of full extension. Unlike olecranon bursitis, which m a y occur concomitantly, triceps tendinitis exhibits both direct and indirect tenderness. Radiographic evaluation usually shows a triceps/olecranon traction spur emanating from the posterior olecranon (Fig 1). Conservative m a n a g e m e n t involves avoidance of repetitive forceful elbow extension, nonsteroidal anti-inflammatory drugs, and time. Splinting in 45 ° of elbow flexion m a y be useful if tolerated. Counterforce bracing is typically unsuccessful because the cross-section of the arm changes with biceps contraction. Corticosteroid injection into a discrete tendon insertion is contraindicated. 2 Alt h o u g h conservative m a n a g e m e n t is limited in scope, it is
From the Department of Orthopedic Surgery, Harvard Medical School, Boston, MA; Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX; and the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN. Address reprint requests to Kourosh Jafarnia, MD, Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114. Copyright © 2001 by W.B. Saunders Company 1060-1872/01/0904-0005535.00/0 do i: 10.1053/otsm.2001.26782
Fig 1. Lateral radiograph showing large olecranon spur in 42-year-old recreational pitcher with chronic posterior elbow pain and recent exacerbation. Note the fracture at the midpoint of the spur.
usually successful in triceps tendonitis in the absence of an olecranon traction spur. The presence of an olecranon traction spur is associated with a higher failure rate of conservative treatment and a subsequent need for surgical intervention. Surgical m a n a g e m e n t involves subperiosteal exposure and excision of the spur and the olecronan tip and formal repair of the triceps tendon.
ANATOMY Awareness and treatment of disorders of the elbow extensor mechanism have increased considerably over the past 2 decades, leading to a more thorough appreciation of the
Operative Techniques in Sports Medicine, Vol 9, No 4 (October), 2001: pp 217-221
21 7
Extent of triceps tendon
, yp~u~ extent of triceps extension on olecranon spur Fig 2, Proximal surface of the olecranon. The triceps tendon inserts on the posterior 50% of this surface with the traction spur typically involving 50% of this insertion,
anatomy of this region. 3-s The extensor mechanism of the elbow consists mainly of the triceps tendon. The triceps tendon originates within the triceps muscle at a point approximately 20 cm proximal to the tip of the olecranon. The triceps extensor mechanism, as it approaches its insertion, forms 2 components, the triceps proper (that portion inserting on the olecronan) and the triceps expansion, which inserts distally and laterally primarily through the anconeus. The triceps proper thickens rapidly as it approaches the olecranon, although the triceps expansion remains relatively thin.
.
Fig 4, A planned surgical incision for triceps tendinitis, There was a large olecranon bursa present in this patient.
The triceps proper inserts on the posterior 40% of the olecranon, with the anterior 60% of the olecranon covered only by capsule and fat. The tendinous insertion averages 20 to 24 m m by 8 to 12 m m and extends to the medial margin of the olecranon whereas 2 to 4 m m of the lateral olecranon is bare. The triceps expansion, the lateral continuation of the extensor mechanism, consists of the continuum of the lateral head of the triceps into the anconeus. In 50% of specimens, a well-defined interval is located between the triceps expansion and the triceps proper just proximal to the olecronano This interval is the anatomic triceps decussation. In triceps tendinitis, the traction spur involves the posterior 30% to 50% of the triceps proper insertion (Fig 2). The triceps tendon inserts on the proximal face of the spur and curves beneath it to insert on the olecranon immediately anterior to the spur (Fig 3). Indications
Athletes are initially treated conservatively with anti-inflammatory drugs, rest and avoidance of repetitive elbow
Spur Olecranon excision Fig 3, A lateral drawing of the triceps insertion on the spur and olecranon proper, Note that a portion of the tendon actually curves around the tip on its way to inserting. This portion of the normal insertion can be preserved if the exposure of the spur is subperiosteal.
218
Fig 5. Bursal debris of varying degree is typically seen overlying the olecranon tip. It should be removed to allow for exposure of the tip/spur.
JAFARNIA ET AL
Fig 6. The spur extends proximally intratendinously but may also have a 3 to 4 mm posterior extension, as seen in this patient, making discrete identification of the spur easier.
Fig 7. The tendon is sharply elevated with a longitudinal incision at the midpoint of the spur, which is usually the midpoint of the olecranon as the spur is centrally located on the tip of the olecranon.
Fig 8. In this patient, as implied in the radiographs (Figure 1), a fracture through the spur had occurred. The nonunion interface between the spur base and the fracture fragment has developed. Note the triceps tendon fibers coursing intimately deep around the spur. TRICEPS TENDINITIS
Fig 9. The spur is removed with a rongeur, and care is taken to minimize additional injury to the tendon.
Fig 10. The bony removal should include a portion of the normal olecranon tip to allow for a good bed for tendinous healing but more so to minimize posterior prominence postoperatively.
Fig 11. After the fragment is excised, the degree of take down of the triceps insertion can be assessed (outlined). Usually 50% of the insertion is involved and needs formal repair.
219
Fig 12. Suture anchor placement divides the olecranon into thirds, with the anchors being placed at the margins of the central third.
extension exercises, and splinting, best done in 45 ° of elbow flexion. Ultrasound and other physical therapy modalities may be attempted but usually provide only temporary relief. Indications for surgical intervention include pain and limitation of function refractory to conservative treatment.
OPERATIVE TECHNIQUE A general anesthetic is required for this procedure. The patient is positioned in either a lateral or semilateral position with a beanbag or a bump underneath the trunk, allowing the arm to rest across the chest for a posterior exposure to the elbow. A nonsterile tourniquet is applied with the tubing posterior. After standard preparation and draping, a 4- to 5-cm longitudinal incision is created 1.5 cm lateral to the tip of the olecranon. The incision begins 2 cm distal to the olecranon tip and extends proximally for 2 to 3 cm (Fig 4). Subcutaneous dissection frequently reveals an olecranon bursitis, which is excised (Fig 5). The exten-
Fig 13. A grasping suture method is used with one end of the suture, and the other end is the gliding suture. The repair is placed at the tendon-bone interface to minimize prominence.
220
Fig 14. The repair is completed with an epitendinous, running suture,
sot mechanism is exposed and the midaxis of the olecranon identified. The olecranon spur is usually easily palpable within the triceps tendon and can, at times, be directly visualized (Fig 6). Subperiosteal exposure of the triceps spur begins with a longitudinal incision over the midpoint of the olecranon spur (Fig 7). Using a No. 64 beaver blade, the exposure is carried medially and laterally with limited difficulty. In approximately 50% of patients, a fracture of the spur will be encountered (Fig 8). Once the posterior and proximal surface of the spur is exposed, elevation of the triceps insertion off the remaining portion of the spur requires dissection between the spur and the olecranon itself. The plane of dissection extends around the tip of the olecranon because some fibers tend to curve deep to the spur to their normal insertion site and if preserved, will limit the extent of take d o w n of the triceps insertion (Fig 3). Once the spur is fully exposed, the spur itself is removed with a rongeur (Fig 9), including a portion of the posterior olecranon tip (Fig 10). The normal cross-sectional area of the insertion is 200 m m 2, and in the majority of the triceps spur excisions, approximately 50% of the area, ie, 20 by 5 m m or more, is
Fig 15. The fracture fragment size (21 mm x 6 mm) approximates the portion of the triceps tendon inserting on the spur. JAFARNIA ET AL
c o m p r o m i s e d (Fig 11). If this is the case, r e p a i r of the triceps w i t h 1 or 2 s u t u r e a n c h o r s s h o u l d be p e r f o r m e d . One or 2 c o r k s c r e w s u t u r e a n c h o r s are p l a c e d in a s y m m e t r i c m a n n e r in the defect (Fig 12). A locking s u t u r e is p l a c e d t h r o u g h the i n v o l v e d triceps, p a s s i n g the s u t u r e back t h r o u g h to the defect site. Both s u t u r e s a r e p a s s e d in this m a n n e r . The k n o t is tied at the t e n d o n b o n e interface to m i n i m i z e p r o m i n e n c e (Fig 13). After b o t h knots h a v e b e e n tied, the triceps are u s u a l l y well a p p r o x i m a t e d , and an e p i t e n d i n o u s r e p a i r w i t h a buried, r u n n i n g 4-0 Mersilene s u t u r e is p e r f o r m e d to c o v e r the knots fully a n d c o m p l e t e the r e p a i r (Fig 14). The w o u n d is irrigated, a s u b c u t i c u l a r closure is p e r f o r m e d , and a splint w i t h the e l b o w in a p p r o x i m a t e l y 45 ° of flexion is applied.
Postoperative Care and Rehabilitation P o s t o p e r a t i v e l y the s p l i n t / c a s t is m a i n t a i n e d for 3 weeks. A n active f l e x i o n / p a s s i v e e x t e n s i o n r a n g e of m o t i o n p r o g r a m is p e r f o r m e d for an a d d i t i o n a l 3 weeks, w i t h active e x t e n s i o n b e g i n n i n g at 6 w e e k s and a s t r e n g t h e n i n g p r o g r a m at 3 m o n t h s . A g r a d u a l p i t c h i n g p r o g r a m can be initiated w h e n s t r e n g t h is restored. Full r e c o v e r y , as far as p i t c h i n g is c o n c e r n e d , takes 6 to 12 months. Results. The majority of triceps tendinitis requiring surgery occurs in the fourth or fifth decade of life. Most y o u n g e r pitchers will r e s p o n d to conservative measures. Competitive pitchers, w h o fail to r e s p o n d to n o n o p e r a t i v e
TRICEPS TENDINITIS
measures and w h o u n d e r g o surgery, as a rule do resume their p r e m o r b i d level of performance. Complications. Suture p r o m i n e n c e has been seen in 1 of 9 patients. Persistent pain w i t h o u t discrete clinical findings was encountered in 1 patient (nonsports, work-related injury).
CONCLUSION Triceps tendinitis, although a rare entity, must be considered in throwing athletes w h o complain of posterior elbow pain with active extension. Conservative m a n a g e m e n t is usually successful, especially in the absence of an olecronan spur. H o w e v e r , in the presence of a spur, there is frequently a n e e d for surgical intervention, including excision, debridement, and t e n d o n repair.
REFERENCES 1. Gabel GT, Morrey BF: Tennis elbow, in Cannon WD (ed): Instr Course Lect (vol 47). Rosemont, IL, 1998, pp 165-72 2. Smith AG, Kosygan K, Williams H, et al: Common extensor tendon rupture following corticosteroid injection for lateral tendinosis of the elbow. Br J Sports Med 33:423-424, 1999 3. Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders (ed 2). Philadelphia, PA, Saunders, 1993, pp 16-52 4. Gabel GT, Zwahlen B, Morrey BF: Surgical Managemen.t of the elbow extensor mechanism of the elbow, in Cannon WD (ed): AAOS Instr Course Lect (vol 47). Rosemont, IL, 1998, pp 151-156 5. Salmons S: Muscle, in Williams PL, Bannisdexter LH, Berry MM, et al (eds): Gray's Anatomy (ed 38). New York, NY, Churchill Livingstone, 1995, pp 737-900
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