Tricep tear Injury is also known as tricep strain, torn tricep, tricep tear, strained tricep muscle or pulled tricep. A tricep strain is a relatively uncommon condition that usually causes pain in the back of the upper arm (Chomiak, Junge, Peterson & Dvorak, 2010) . This injury typically occurs when there is a partial or complete tearing of the triceps brachii muscle. The triceps muscle is found at the back of the upper arm and is comprised of three (“tri”) muscle bellies (“ceps”) that’s how it got its name (Daglar et al., 2012) . The three muscle bellies are the long, medial and lateral head. The triceps muscle originates from the shoulder blade (scapula) and upper aspect of the back of the humerus (upper arm bone). It attaches to the back of the elbow (the olecranon process of the ulnar) via the tendon at the triceps.
The triceps muscle is mainly responsible for straightening the elbow joint thus allowing elbow extension. At the shoulder, the long head of triceps also assists adduction and extension movements of the upper arm (moving the upper arm toward the body and backward respectively). In everyday life, the tricep muscle usually helps in pushing movements like performing push-ups and also plays a significant role in stabilizing the elbow when doing activities that require excellent motor control such as writing (Chomiak, Junge, Peterson & Dvorak, 2010) . When a stretch or contraction of the triceps takes place, tension is placed through the triceps muscle and its associated tendons. It is when this extension is excessive due to too much repetition or prolonged intense force that is greater than the muscle can withstand that one or more of the triceps muscle bellies tear and therefore resulting in tricep strain.
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Tricep strains can range from a minor partial tear that causes minimal pain and loss of function, to a complete rupture. The severity can be classified into three grades starting from a grade 1 tear to a grade 3 tear (Chomiak, Junge, Peterson & Dvorak, 2010) . In a grade 1 tear, there is a small percentage of fibers that are torn resulting in minimal pain but still supporting full function. In a grade 2 tear, a significant portion of fibers are torn with moderate loss of function, and finally, in grade 3 tear, all muscle fibers are ruptured resulting in a lot of pain and significant loss of function. Most tricep tears are classified as grade 2 tears.
A tricep tear usually occurs due to a sudden, forceful contraction or stretch of the triceps muscle (mostly contraction). A tricep tear typically happens during a heavy pushing or straightening of the elbow against resistance such as performing exercises like explosive dips, push-ups, bench presses, and cable triceps exercises amongst others. The likelihood of the condition occurring is mostly at the gym due to the use of heavyweights (such that the muscles cannot support comfortably), quick movements and eccentric training. A tricep strain may also occur in sports characterized by throwing such as cricket or baseball or sports involving heavy falls or blocking such as football or lacrosse (Cheatham, Kolber, Salamh & Hanney, 2013) . Occasionally a tricep tear may develop slowly over time because of repetitive or prolonged activities that place stress on the triceps muscle. It may lead to microscopic tearing, degeneration, and weakening of the triceps making the tissue susceptible to further injury. Tricep strains or tears occur more commonly following an inadequate warm-up or in older athletes who are deconditioned.
Patients with a torn tricep usually experience sudden pain or tearing sensation in the back of the upper arm at the time the injury occurs. In less severe cases the pain may be minimal, and patients may be able to continue the provocative activity only to make it worse and thus experiencing an increase in pain, ache and stiffness after resting, typically at night or upon waking the following morning (Cheatham, Kolber, Salamh & Hanney, 2013) . In more severe cases the pain may be disabling, preventing further activity. The pain often associated with this condition is often experienced as an ache that develops to a sharper pain during actions involving prolonged, repetitive or forceful contractions or stretches of the tricep muscle. Some of these activities include pushing yourself up from a chair, or performing exercises such as push-ups and bench press, this is because these activities involve straightening of the elbow against resistance or pushing. Occasionally pain may radiate into the shoulder, forearm or elbow however the symptoms are usually located in the back of the upper arm (Cheatham, Kolber, Salamh & Hanney, 2013) . It can also be characterized by additional symptoms like tricep muscle tightness, tenderness, and spasm on firmly touching the injured region. Some patients have also complained of swelling, bruising, and weakness of different severity. However, in some cases, patients with a minor tricep tear may experience little or no symptoms (Daglar et al., 2012) . These patients usually complain of minor discomfort or tightness. In severe or chronic instances, noticeable deformity and muscle wasting are detected at the location of the tear.
A tricep tear investigation is usually done by a physiotherapist who performs a thorough subjective and objective examination to ensure that the severity of the tear is known. Further tests are typically carried out using an X-Ray, Ultrasound, CT scan or MRI scan machines to confirm the diagnosis, rule out the other conditions with similar symptoms and further asses the degree of the tear. With appropriate physiotherapy treatment, most of the patients with minor to moderate tricep strain that hasn’t lasted for long can usually recover within some weeks. In more severe or chronic cases, patients may take many weeks to months to fully recover. Those patients with a complete tricep rupture that need surgery, usually require a rehabilitation time lasting between 6-9 months or longer before returning to full activity or sport.
In cases of a complete rupture, surgical repair is recommended, but no guidelines are in place on the optimum reconstructive rehabilitation. There are various surgical techniques and rehabilitation programs for the management of different tricep tears. A posterior midline incision is performed, the ruptured triceps tendon is identified and mobilized, and the tendon footprint is prepared (Ribot- Ciscar, Butler & Thomas, 2013) . Bone suture anchors are used to repair the tendon using a parachuting technique and are held at 40 ° of flexion. Immediately after surgical repair, the arm is immobilized in a brace for about two weeks after which physical therapy begins to help slowly regain elbow motion.
The rehabilitation program constitutes five phases, over a period of 12 weeks. The range of tricep muscles movement is gradually increased during the first 6 weeks. However, only gentle exercises are allowed, so that tendon healing does not slow down. The rehabilitation then goes ahead with activities that gradually increase in intensity, progressing from isometric extension exercises to weight-restricted exercises, plyometrics and finally throwing exercises. Once full range of motion is restored, strengthening exercises can begin typically at four to six months. The surgical technique provides a reliable tendon repair without the need for further metalwork removal enabling most patients to recover close to their full range of motion and strength one year after surgery. An active rehabilitation program should help protect the integrity of the repair and at the same time enable patients to slowly increase the strength of the triceps tendon and eventually return to sports activities.
Severe tricep tears are a significant injury for any athlete. These tears cause significant disability in normal day-to-day activities, for instance, pushing oneself up from a seated position and also place severe limitations on athletes’ goals (Ribot- Ciscar, Butler & Thomas, 2013) . Even when tears are diagnosed and treated shortly after an injury, rehabilitation can be lengthy and might result in long-term functional deficits. However much some weightlifters and professional football players get surgical repairs and get back to play it is best to avoid the injury altogether by avoiding activities like poor weight lifting, push up or dip techniques and inappropriate or excess training habits.
References
Chomiak, J., Junge, A., Peterson, L., & Dvorak, J. (2010). Severe injuries in football players. The American journal of sports medicine , 28 (5_suppl), 58-68.
Cheatham, S. W., Kolber, M. J., Salamh, P. A., & Hanney, W. J. (2013). Rehabilitation of a partially torn distal triceps tendon after platelet-rich plasma injection: a case report. International journal of sports physical therapy , 8 (3), 290.
Daglar, B., Delialioglu, O. M., Ceyhan, E., Altas, O., Bayrakci, K., & Gunel, U. (2012). Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass. Strategies in Trauma and Limb Reconstruction , 4 (1), 35-39.
Ribot-Ciscar, E., Butler, J. E., & Thomas, C. K. (2013). Facilitation of triceps brachii muscle contraction by tendon vibration after chronic cervical spinal cord injury. Journal of applied Physiology , 94 (6), 2358-2367.
