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Distal Triceps Repair
CLINICAL CARE GUIDELINE
Background
Indications for distal triceps repair include partial or complete tendon ruptures. Repair is preferably performed
within the first three weeks for the best outcomes. Rehabilitation following distal triceps repair will progress more
slowly over the first 6 weeks to protect the healing triceps tendon. Consultation with the surgeon as well as a
review of the operative report should be completed prior to initiation of rehabilitation.
*Find surgeon preference of brace settings and ROM limitations in op note. If it is not in the op note,
contact surgeon.
Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.
Summary of Recommendations
Risk Factors
• Subsequent surgeries
• Lack of adherence to surgical precautions
• Secondary comorbidities
Precautions
• No aggressive stretching of the triceps
• Splint for first 2 weeks
• Light soft tissue mobilization, not directly on the scar, to improve blood flow and reduce
edema
• Limit passive shoulder flexion to <90 degrees for 6 weeks
• No isolated triceps contraction with elbow extension or shoulder extension for 6 weeks
• No resisted elbow extension or shoulder extensions/rows for 12 weeks
• No weight bearing through the surgical extremity (pushing open a door, pushing up from a
chair) for 12 weeks
Manual
Therapy
• PROM exercises and GH joint mobilizations (phase I & II)
• Scar massage is appropriate in phase III
Corrective
Interventions
• Cryotherapy for pain and inflammation
•
Manual Therapy
Functional
Outcome
Measures
• Disability of Arm Shoulder and Hand (DASH) Questionnaire
• Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire
Criteria for
discharge
• >90% with patient-reported outcome
• Full AROM, strength, and able to demonstrate pain-free, sports specific movements without
compensatory movements
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Phase I: Protection to PROM (0-2 weeks)
Pain and
Edema
Management
• Education: No elbow AROM, incisions clean and dry, hinged brace per physician instructions
• Vaso and E-stim for pain and edema control
• No soft tissue mobilization or cross friction massage directly on the scar
• No weight bearing through surgical extremity for 12 weeks
Restore
Passive
Shoulder and
Elbow ROM
• Limit shoulder flexion to 90° for 4 weeks
• Elbow flexion limited to 20 degrees in brace
• Gentle shoulder PROM (pulleys, self-passive ranging with uninvolved extremity, table slides)
• Gentle elbow PROM (therapist guided ranging, self-passive ranging with uninvolved extremity)
Home Exercise
Program
• Posture education
• Arm immobilized per physician instructions
• Scapular control exercises (sidelying clocks, seated retractions, scapular PNF)
• PROM elbow flexion locked at 20 degrees in hinged brace
• Able to progress elbow flexion 15 degrees every 5 days (3 sets of 30 minutes per day)
• No active elbow extension
• AROM wrist/ hand (gripping, wrist curl, pronation/supination)
Criterion to
Progress to
Phase II
• Protect the repair
• Minimal to no edema
Phase II: PROM progression to AROM (2-6 weeks)
Pain and
Edema
Management
• No soft tissue mobilization or cross friction massage directly on the scar for 6 weeks
• No active elbow extension for 6 weeks
•
Vaso and E-stim for pain and edema control
Post-op Weeks
2-4
• No shoulder flexion >90 degrees for 4 weeks
• Do not PUSH elbow flexion ROM until 6 weeks
• PROM-AAROM within limits at shoulder and elbow (therapist guided ranging, self-passive
ranging with uninvolved extremity)
• Gentle soft tissue mobilization, not on the surgical scar, for improved blood flow and reduced
edema
Post-op Weeks
4-6
• Do not PUSH elbow flexion ROM until 6 weeks
• Initiation of shoulder submaximal-isometrics (initiate at 25%-50% effort, pain-free): except
shoulder extension
• Progress shoulder AAROM-AROM (Pulleys, wand, self-passive ranging with uninvolved
extremity)
Criterion to
Progress to
Phase III
• Pain-free, full shoulder AROM with good scapular control
• Pain-free, full PROM elbow flexion (do not push ROM)
• Minimal to no edema
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Phase III: Initiation of Elbow AROM and Strength (6-12 weeks)
Introduction to
AROM
• No pain or reactive edema with initiation of active elbow extension
• Avoid resisted elbow extension and shoulder extensions/rows for 12 weeks
Post-op Weeks
6-8
• Continue progressing AROM of shoulder, gaining muscle endurance with high reps, low
resistance
• Initiate active, concentric elbow extension (no resistance) in pain-free range
• NO eccentric triceps activity (use uninvolved extremity to aid in eccentric phase of triceps
activity)
• Isotonic IR and ER light resistance resisted movement (at neutral)
• Supine ABC & SA punches with high reps, low resistance
• Gentle soft tissue mobilization (light scar massage of hypomobile)
Post-op Weeks
8-12
• Initiate prone scapular series at week 8
• Initiate light, sub-maximal triceps isometrics (25%-50% effort, pain-free) at week 8
• Allow for eccentric triceps activity, pain-free (no resistance)
• Gradual progression of biceps strengthening
• Resisted IR and ER at 30° ABD progressing to 90° abduction
• Resisted SA punch & bear hugs, standing
• Rhythmic stabilization for shoulder (supine progressing to various positions)
• No pressing activity or resisted triceps isotonics (tricep kickbacks, bench press, overhead
press) for 12 weeks
Return to
Activity After
Week 10
Stationary bike and light jogging
Criterion to
Progress to
Phase IV
• Pain-free, full AROM of shoulder and elbow
• 5/5 MMT for shoulder /rotator cuff strength
• 5/5 MMT for scapulothoracic musculature
Phase IV: Return to Sport/Recreational Activity (weeks 12-16)
•
Goal: Return to sport at 5-6 months at earliest
Goals
• Maintain full, non-painful AROM
• Progress isotonic strength of the triceps (including eccentrics) and surrounding musculature
• Introduce light pressing activity (pushups progression, bench press, overhead press)
• Return to sports progression: throwing/ swimming/lifting
• Analysis of sports specific movements
Exercises 12+
• Progress triceps strengthening (concentric) with light resistance
• CKC UE weight bearing (start with 25% weight bearing, wide hand position, 0-10 degrees of
elbow flexion to limit stress on triceps): wall weight shifts, quadruped rocking at week 12
• Gentle, short duration UBE (2-3 minutes initially, progressing as pain allows)
• Introduce pushup progression (limiting amount of elbow flexion to 45 degrees initially) at week
14
• Initiate plyometric training below shoulder height with progressing to overhead: begin with both
arms and progress to a single arm (16 weeks)
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• PNF/Diagonal pattern strengthening
Criterion to
Return to
Sport Activity,
Weeks 12+
• 5/5 MMT for triceps strength
• Pain-free, stability & control with higher velocity movements including sports specific patterns
and change of direction movements
• Proper kinematic control transfer from the hip & core to the shoulder with dynamic movement
Authors: Greg Hock, PT, DPT, OCS
Reviewers: Mitch Salsbery, PT, DPT, SCS
Completion date: Dec 2021
References
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10.1197/j.jht.2006.02.001
Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev. 2016;(1):255-259. DOI:10.1302/2058-
5241.1.000038.
Dunn JC, Kusnezov N, Fares A, Rubin S, Orr J, Friedman D, Kilcoyne K. Triceps tendon ruptures: a systematic
review. Hand. 2017;12(5): 431-438. Doi:10.1177?1558944716677338
Giannicola G., Bullitta G., Sacchetti F.M., Scacchi M., Merolla G., Porcellini G. (2016) Triceps Repair. In:
Pederzini L., Eygendaal D., Denti M. (eds) Elbow and Sport. Springer, Berlin, Heidelberg
Keener JD, Sethi PM. Distal Triceps Tendon Injuries. Hand Clin. 2015; (31): 641-650.
Doi:10.1177/155894471667733810.1016/j.hcl.2015.06.010
Kocialkowski C, Carter R, Peach C.Shoulder & Elbow. 2018;10(1): 62-65. Doi:10.1177/1758573217706358
Marinello PG, Peers S, Sraj S, Evans PJ. A Treatment Algorithm for the Management of Distal Triceps Ruptures.
Techniques in Hand & Upper Extremity Surgery. 2015; (19): 73-80. Doi: 10.1097/BTH.0000000000000082
Redler LH, Dines JS. Elbow Trauma in the Athlete. Hand Clin. 2015;31(4): 663-681.
Doi:10.1016/j.hcl.2015.07.002
