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Snapping Triceps Syndrome: A Review of the Literature
Abstract
Snapping triceps syndrome is a rare and therefore often unknown cause of medial elbow pain. It is a condition in which the distal portion of the triceps dislocates over the medial epicondyle during flexion and extension of the elbow. It can occur, with or without ulnar neuropathy symptoms. The available literature on this subject is scarce and consists mainly of case reports. This report reviews the current literature and will provide guidance in diagnosis and treatment of this uncommon condition.
... En este reporte de caso, Rolfsen describe una resección de la parte medial del tendón y la corrección con suturas, obteniendo que el paciente estuviera libre de síntomas en menos de 1 año. (2). ...
... Un intervalo pequeño entre el borde medial del tríceps y el epicóndilo medial predispone al resalto del tríceps. (2). ...
... Si esto es posible, el codo se flexiona y por lo general el nervio se reubicará en la ranura con una mayor flexión, esta maniobra puede ser difícil de reproducir en pacientes obesos. (2) Estudios por imágenes La resonancia magnética, la ecografía dinámica y posiblemente la tomografía computarizada pueden ayudar en el diagnóstico del síndrome de tríceps instantáneo. ...
The dislocation of the medial belly of the triceps is a rare occurrence that occurs on the medial epicondyle during active flexion of this over the elbow and is often associated with an instability of the ulnar nerve, causing symptoms of compression of this nerve.
... Dislocation over lateral epicondyle has been described only once by Spinner and Goldner in 1999, and hence we focus only on medial snapping triceps. 1 The triceps muscle consists of three different parts: the medial, long, lateral heads and these heads combine to insert as a single tendon on the olecranon process of the ulna. 2 Patient usually complains of local tenderness and a snapping sensation aro medial side of elbow. This condition usually coexists with ulnar nerve dislocation. ...
... This condition usually coexists with ulnar nerve dislocation. 1 A rare case of snapping triceps syndrome caused by the snapping of the medial head of the triceps brachii muscle in a 27 old man was reported with complaint of medial elbow pain. It is a condition in which the distal portion of the triceps dislocates over the medial epicondyle during flexion and extension of the elbow. ...
... This can be combined with NSAID's, splinting of elbow and physical therapy. 1 Splinting the elbow with the kinesio tapes (KT) may be used for prevention and treatment of snapping triceps syndrome. KT are the colourful elastic cotton strips with the acrylic adhesive that may be stretched up to 140% of their original length. ...
A rare case of snapping triceps syndrome caused by the snapping of the medial head of the triceps brachii muscle in a 27- year-old man was reported with complaint of medial elbow pain. It is a condition in which the distal portion of the triceps dislocates over the medial epicondyle during flexion and extension of the elbow. The condition aggravates while doing calisthenics activities like push up and bodyweight triceps exercises. The available literature on this subject is scarce and consists mainly of case reports quoting the incidence of this syndrome and few literature reviews providing guidance for diagnosis and surgical treatment of this uncommon condition. This report tries to manage the snapping triceps syndrome with conservative therapeutic intervention like Kinesio-Taping.
... 1,2 There are also rare reports of unusual findings including ulnar nerve compression secondary to anatomic variations in the triceps musculature. [5][6][7][8][9][10] We present a case of ulnar nerve compression neuropathy at the elbow secondary to an abnormal snapping medial head of the triceps. ...
... A short interval between muscle and medial epicondyle predisposes the wider compressed triceps to subluxate anteriorly over the medial epicondyle. 10,11 The pull of an abnormal fourth head of the triceps has also been postulated to result in a snapping triceps. [12][13][14][15][16] Although this anatomical variation can present as medial elbow pain with repetitive flexion, it is not always associated with an ulnar neuropathy in the setting of a securely positioned ulnar nerve in the cubital tunnel. ...
... The ulnar nerve typically begins to dislocate at approximately 70 to 90 , quickly followed by medial head of triceps dislocation at approximately 115 . 10,17 There are very few case reports in the literature describing snapping triceps syndrome as a cause of ulnar nerve compression. Often, the dislocating triceps is initially unrecognized at the time of cubital tunnel release and results in recurrent ulnar neuropathy symptoms. ...
Cubital tunnel syndrome is the second most common compression neuropathy of the upper extremity and the most common point of compression for the ulnar nerve. We present a case of ulnar nerve compression neuropathy at the elbow secondary to an abnormal subluxating medial head of triceps. A 37-year-old right hand dominant male presented with a history of bilateral medial elbow pain and ulnar distribution hand numbness. During his left cubital tunnel release surgery, the abnormal anatomy was noted. Initial subfascial anterior transposition was insufficient and had to be revised to a subcutaneous transposition intraoperatively. Failure to recognize the contribution of triceps abnormalities can lead to incomplete resolution following surgery. Surgeons should be wary of uncommon findings and adjust their approach appropriately.
... Snapping elbow syndrome is divided into two groups, depending on the cause: intraarticular and extraarticular (Table 1). Skipping triceps syndrome is an example of the extraarticular syndrome and in a healthy population it is an uncommon condition [9]. It may sometimes be confused with other, better known ailments, like the golfer's elbow [10], present in this case. ...
... Following the classification of O'Driscoll [12], cubital tunnel anatomy depends on the type of the cubital tunnel retinaculum. In a normal joint (type Ia and Ib), the roof is [9,10,17]. ...
Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography.
A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3-0.6% in males and 0-3-1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head.
Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more "snapping reasons" is rare but should be always taken under consideration.
There are no sonoelastography studies describing golfers elbow syndrome, additional triceps band and ulnar neuritis. Our data suggest that the sonoelastography signs are similar to those seen in well described lateral epicondylitis syndrome, Achilles tendinitis and medial nerve neuralgia.
... 24 This can result in pain and tingling numbness in the ulnar nerve distribution. 25 The ulnar nerve at the elbow is located in the cubital tunnel, which is formed by the cubital retinaculum and medial epicondyle. The nerve runs between the medial edge of the triceps and the medial humeral epicondyle. ...
... A shallow groove or insufficiencies of the retinaculum are potential causes of a dislocating ulnar nerve. 25 The condition is also seen in bodybuilders, abnormal triceps tendons, and posttrauma. 26 Dislocation occurs if the nerve slides out of the cubital tunnel and over the medial epicondyle during elbow flexion. ...
There is an increasing trend in medicine to utilize ultrasound for diagnosis of musculoskeletal pathology. Although magnetic resonance imaging provides excellent spatial resolution of musculoskeletal structures in multiple imaging planes and is generally the cross-sectional modality of choice, it does not provide dynamic functional assessment of muscles, tendons, and ligaments. Dynamic maneuvers with ultrasound provide functional data and have been shown to be accurate for diagnosis. Ultrasound is also less expensive, portable, and more readily available. This article will review the common snapping, impingement, and friction syndromes imaged with dynamic ultrasound. It will also discuss future areas of research, including musculoskeletal sonoelastography. © 2014 Petscavage-Thomas. This work is published by Dove Medical Press Limited.
... Contraction of the additional slip might pull triceps medially resulting in snapping of triceps muscle over the medial epicondyle along with ulnar nerve, resulting in a condition called "snapping triceps syndrome". [7][8][9] It has been reported that the ulnar nerve can get dynamically compressed during its course through the passage in between the epitrochleoanconeus muscle and a prominent medial head of the triceps muscle. [10,11] There are also reports of abnormal insertion of medial head of triceps muscle leading to symptoms similar to cubital tunnel syndrome. ...
Rare additional slips of triceps brachii muscle was found bilaterally in a sixty two year old South Indian male cadaver during routine dissection of upper limb for undergraduate students at Melaka-Manipal Medical College, Manipal University, Manipal, India. On left side, the variant additional muscle slip took origin from the lower part of the medial intermuscular septum about 4 cm proximal to the medial humeral epicondyle. From its origin, the muscle fibres were passing over the ulnar nerve and were joining the triceps muscle to get inserted to the upper surface of olecranon process of ulna. On right side, the additional muscle slip was larger and bulkier and was arising from the lower part of the medial border of the humerus about 4 cm proximal to the medial epicondyle in addition to its attachment to the medial intermuscular septum. On both sides, the additional slips were supplied by twigs from the radial nerve. On both sides, the ulnar nerve was passing between variant additional slip and the lower part of the shaft of the humerus in an osseo-musculo-fibrous tunnel. Such variant additional muscle slips may affect the function of triceps muscle and can lead to snapping of medial head of triceps and ulnar nerve over medial epicondyle and also can dynamically compress the ulnar nerve during the contraction of triceps leading to ulnar neuropathy around the elbow.
The ulnar nerve is the second most commonly entrapped nerve after the median nerve. Although clinical evaluation and electrodiagnostic studies remain widely used for the evaluation of ulnar neuropathy, advancements in imaging have led to increased utilization of these newer / better imaging techniques in the overall management of ulnar neuropathy. Specifically, high-resolution ultrasonography of peripheral nerves as well as MRI has become quite useful in evaluating the ulnar nerve in order to better guide treatment. The caliber and fascicular pattern identified in the normal ulnar nerves are important distinguishing features from ulnar nerve pathology. The cubital tunnel within the elbow and Guyon's canal within the wrist are important sites to evaluate with respect to ulnar nerve compression. Both acute and chronic conditions resulting in deformity, trauma as well as inflammatory conditions may predispose certain patients to ulnar neuropathy. Granulomatous diseases as well as both neurogenic and non-neurogenic tumors can also potentially result in ulnar neuropathy. Tumors around the ulnar nerve can also lead to mass effect on the nerve, particularly in tight spaces like the aforementioned canals. Although high-resolution ultrasonography is a useful modality initially, particularly as it can be helpful for dynamic evaluation, MRI remains most reliable due to its higher resolution. Newer imaging techniques like sonoelastography and microneurography, as well as nerve-specific contrast agents, are currently being investigated for their usefulness and are not routinely being used currently.
Medial elbow pain is a common presentation that can be a challenge to appropriately treat for the orthopedic surgeon. Causes include medial epicondylitis, ulnar neuritis, ulnar collateral ligament injury, flexor pronator strain, or snapping medial triceps. A good outcome is typically achieved with adequate treatment of tendon degeneration at the common flexor tendon origin. Mainstay treatment is nonoperative modalities such as stretching, rest, activity modification, therapy, and injections. If nonoperative management fails, intermediate interventions such as extracorporeal shockwave therapy, platelet-rich plasma injections, prolotherapy, and ultrasound-guided percutaneous tenotomy can be attempted. Surgical treatments are dictated based on the severity of the pathology, involvement of soft tissues, and concomitant pathology. Medial elbow complaints can be multifactorial and require a broad differential diagnosis. [Orthopedics. 20XX;XX(X):xx-xx.].
Introduction
Ultrasound is useful in assessing patients with snapping syndromes around the elbow joint. The dynamic nature of the examination allows for direct visualisation of the underlying causative factor. Topic description: We discuss the role of dynamic ultrasound in assessing various snapping syndromes around the elbow, such as ulnar nerve instability, snapping triceps and less commonly, snapping brachialis. Ultrasound is also useful in evaluating the distal biceps tendon, particularly in differentiating partial from complete tendon injury.
Discussion
Ulnar nerve instability and snapping triceps can be assessed via a medial approach with the transducer placed transversely between the medial epicondyle and the olecranon. In ulnar nerve instability, the nerve can be seen crossing over the medial epicondyle on elbow flexion. In snapping triceps syndrome, both the ulnar nerve and the distal triceps can be seen dislocating over the medial epicondyle. Dynamic assessment of the distal biceps tendon using a lateral approach minimises anisotropy artefact often seen on the anterior approach. Passive pronation and supination of the forearm will reveal little or no movement in a completely torn tendon whereas moving tendon fibres will be appreciated in partial tears. In a snapping brachialis, the medial portion of brachialis will be seen abnormally translocating anterolateral to the medial border of the trochlea during elbow flexion and snapping back into its normal position on elbow extension.
Conclusion
Dynamic ultrasound of the elbow is valuable in diagnosing patients with snapping sensations around the joint and in evaluating the integrity of the distal biceps tendon.
Objective
Treatment of a persistently painful snapping triceps and possibly snapping ulnar nerve.
Indication
Snapping triceps.
Contraindications
General surgical risks.
Surgical technique
Following the anterior transposition of the ulnar nerve (subcutaneously or submuscular), the snapping portion of the triceps tendon is transsected and reinforced, and transposition of the medial triceps margin into the central triceps portion is carried out.
Postoperative management
Cast for 5–7 days; for a total of 6 weeks functional exercise without maximum flexion and resistance exercise of the triceps. Weight loading after 3 months.
Results
In the case presented, complaints were absent after 3 months. Full load exercise, e.g., push-ups, was achieved 4 months after surgery. There was no recurrent snapping within the first year. The results of this case are in agreement with the 25 patients previously reported in the PubMed literature. Recurrence, gross restrictions of movement, and complications were not observed in patients who underwent surgery.
Snapping and pain at the medial elbow can be caused by a snapping of the triceps tendon and muscle belly. It can be accompanied by a shooting pain in the distribution of the ulnar nerve. Eccentric loading of the triceps tendon is the most specific test to confirm a snapping triceps syndrome. Two snaps may be experienced during clinical exam. A first snap occurs at around 90°. This is the ulnar nerve subluxating out of its groove. A second snap usually occurs at around 115° when the triceps dislocates over the medial epicondyle. Surgical treatment consists of an anterior transposition of the ulnar nerve and removal of the medial part of the triceps.
Snapping of the medial head of the triceps, first described by Rolfsen back in 1970, has scarcely been described in the literature most likely because its clinical entity has long been unknown and underestimated. Recurrent snapping of the triceps is usually accompanied by ulnar nerve dislocation (Fig. 29.1). Patients affected by this condition may manifest a wide array of clinical features ranging from a complete absence of symptoms to pain and ulnar nerve neuropathy.
Lateral and medial elbow pain is frequently encountered in daily practice. Clinical assessment is essential to make the right diagnosis and formulate the appropriate treatment plan. Extra-articular causes for medial and lateral sided elbow pain often have overlapping symptoms with articular pathology, which can make discrimination between different causes difficult.
In this paper the possible causes of extra-articular medial and lateral sided elbow pain will be discussed and an overview is given to help make the right diagnosis and apply the right treatment.
In this study we describe a rare case of an aberrant fourth head of the triceps brachii muscle found
during a routine anatomical dissection of the left upper limb of an adult European cadaver from the autopsy
material, available in Department of Anatomy, Histology and Embryology, Medical University of
Sofia. The length of tendon and the fourth muscle belly was 7.5 cm and 3.5 cm, respectively. Like the other
three heads, it was also innervated by a branch from the radial nerve. We consider our finding to be of didactic
and clinical importance. Though the anatomical variations of the triceps brachii muscle are fairly
rare they can be of importance for clinicians who perform surgical intervention on the upper limb. Thus,
surgeons, traumatologists, anaesthetists and also anatomists should have knowledge about the incidence
of such variations.
Snapping elbow syndrome is an uncommon clinical entity with snapping occurring either at the medial or the lateral side of the elbow during certain motions of the elbow. Patients sometimes present with pain or local tenderness instead of snapping which may lead to the wrong diagnosis of the more common tennis or golfer's elbow syndrome. While making the clinical diagnosis of snapping elbow is obvious once the clinician is aware of the condition, to locate the cause of the snapping and arrive at an anatomical diagnosis can be difficult although it is crucial to successful treatment. In this article, we report two cases of snapping elbow syndrome, one at the lateral side and one at the medial side of the elbow, and share our experience with the use of musculoskeletal ultrasongraphy to arrive at an anatomical diagnosis of the condition.
We highlight a case of bilateral ulnar nerve instability in a young, competitive decathlete. The symptoms proved disabling to the athlete’s daily training routine and required operative measures in the form of an anterior submuscular transposition without epicondylectomy. The procedure proved effective with complete resolution of troublesome symptoms. Within 6 months post-operatively, the patient returned to train and perform at an elite national standard in his sport.
Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition.
Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms.
Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.
Distal triceps tendon ruptures occur rarely, and the diagnosis is often missed when the injury is acute. The literature provides little guidance regarding treatment or the outcome of treatment of these injuries. The goal of this report was to present our experience with the diagnosis, timing and technique of surgical treatment, and outcome of treatment of distal triceps tendon ruptures in twenty-two patients. None of the ruptures followed joint replacement.
Twenty-three procedures were performed in twenty-two patients with an average age of forty-seven years. The average duration of follow-up was ninety-three months (range, seven to 264 months). Data were obtained by a retrospective review of records and radiographs before and after surgery. Also, thirteen patients returned for follow-up and were examined clinically. Six additional patients responded to a telephone questionnaire. One patient was lost to follow-up, and two had died. Formal biomechanical evaluation of isokinetic strength and isokinetic work was performed in eight patients, at an average of eighty-eight months after surgery. Isokinetic strength data were available from the charts of two additional patients.
Ten of the triceps tendon ruptures were initially misdiagnosed. At the time of diagnosis, triceps weakness with a decreased active range of motion was found in most patients, and a palpable defect in the tendon was noted after sixteen ruptures. Operative findings revealed a complete tendon rupture in eight cases and partial injuries in fifteen. Fourteen primary repairs and nine reconstructions of various types were performed. Three of the primary repairs were followed by rerupture. At the time of follow-up, the range of elbow motion averaged 10 degrees to 136 degrees. All but two elbows had a functional range of motion; however, the lack of a functional range in the two elbows was probably due to posttraumatic arthritis and not to the triceps tendon rupture. Triceps strength was noted to be 4/5 or 5/5 on manual testing in all examined subjects. Isokinetic testing of ten patients showed that peak strength was, on the average, 82% of that of the untreated extremity. Testing showed the average endurance of the involved extremity to be 99% of that of the uninvolved arm. The results after repair and reconstruction were comparable, but the patients' recovery was slower after reconstruction.
The diagnosis of distal triceps tendon rupture is often missed when the injury is acute because of swelling and pain. Primary repair of the ruptured tendon is always possible when it is performed within three weeks after the injury. When the diagnosis is in doubt immediately after an injury, the patient should be followed closely and should be reexamined after the swelling and pain have diminished so that treatment can be instituted before the end of this three-week period. Reconstruction of the tendon is a much more complex, challenging procedure, and the postoperative recovery is slower. Thus, we believe that early surgical repair, within three weeks after the injury, is the treatment of choice for distal triceps tendon ruptures. of evidence.
The triceps tendon has been described as a single unit with contribution from each of the 3 heads of the muscle. An observation at the time of surgical repair of a triceps tendon injury led to an anatomical study to further define the anatomy of this tendon as it inserts on the olecranon.
The medial head of the triceps has a tendon that is distinct from, and deep to, the common tendon of the long and lateral heads.
Descriptive laboratory study and case report.
Eight cadaveric elbows were dissected to examine the triceps tendon. None of the specimens had any evidence of prior injury or surgery to the elbow. All specimens were fresh-frozen and stored at -4 degrees C until they were thawed for use. Skin and subcutaneous tissue were removed, and the tendon of each head of the triceps was explored from the muscle to its bony insertion.
In all 8 specimens, on gross inspection, the medial head had a separate insertion deep to the common insertion of the lateral and long heads. The muscle of the medial head extended further distally than did the long and lateral heads. The medial head was muscular to its deep insertion, with a small amount of tendon blended with the muscle distally. Histologic analysis demonstrated that the tendon of the medial head and that of the other 2 heads are confluent distally at their olecranon insertion.
The medial head of the triceps has a tendon that is distinct from, and deep to, the common tendon of the long and lateral heads on gross inspection. Histologic studies show the insertion of these 2 tendons is confluent.
This anatomy has important implications for surgical repair of these tendon injuries. Rupture of the deep triceps insertion alone can occur and lead to weakness of elbow extension with the elbow flexed beyond 90 degrees . Triceps strength should be tested with the elbow fully flexed when injury to the tendinous insertion is suspected.
Routine cadaver dissection has resulted in the identification of a fourth head of the triceps brachii muscle on the left side in one specimen. This novel arrangement demonstrated a single tendon arising from the proximal posteromedial aspect of the humeral shaft, distal to the shoulder capsule. The tendon of this fourth head passed along the medial aspect of the humerus and gave way to a muscle belly on the medial surface of the distal one-third of the humerus. The tendon of the fourth head passed directly over the neurovascular bundle containing the radial nerve and deep brachial artery at approximately the point where the neurovascular bundle entered the radial sulcus. This close positional relationship between the tendon of the fourth head, the radial nerve, and the deep brachial artery has prompted us to speculate on the possible clinical significance of this finding in relation to radial nerve palsy and arterial compression. Additionally, the position of the muscle belly, lying in close proximity to the ulnar groove, invites speculation on the role of the fourth head in cases of snapping elbow. To the authors' knowledge, a description of the muscular fourth head of the triceps as seen in the present work has not been noted in previous literature. Clin. Anat. 10:259–263, 1997. © 1997 Wiley-Liss Inc.
Two cases of unusual snapping at the elbow are described. In both, the medial head of the triceps was found to be separated from the main muscle belly. During flexion of the elbow, the medial head dislocated over the medial epicondyle, producing a characteristic snapping phenomenon. Both cases were of long standing and had been asymptomatic for years. The first clinical symptoms were those of an ulnar neuropathy. In order to restore the normal position of the medial head of the triceps, its tendon was detached from the olecranon, passed under the central tendon and interlaced to it. The ulnar nerve was left in the epicondylar groove in one case and transposed anteriorly in the other. At the end of the procedure flexion of the elbow was unobstructed and the snapping phenomenon had disappeared.
A rare case of cubital tunnel syndrome caused by the snapping of the medial head of the triceps brachii muscle in a 20-year-old man was reported. The ulnar nerve was compressed by the medial head of the triceps, which snapped from the back, and was constricted at the tendinous arch of origin of the flexor carpi ulnaris. Medial epicondylectomy with division of tendinous arch was carried out, and the postoperative course was satisfactory. Our case is compared with four cases reported previously.
An anomalous musculotendinous portion of the triceps muscle lying in the ulnar groove behind the medial humeral epicondyle is described. It was the cause of snapping elbow and ulnar neuritis and was mistaken for a snaping ulnar nerve.
Reports of subluxation of the medial head of the triceps tendon over the medial epicondyle are rare. This may be associated with symptomatic ulnar nerve compression at the elbow. We report a case of bilateral snapping triceps tendon after bilateral ulnar nerve release at the elbow with anterior submuscular transposition. Careful inspection of the triceps tendon in flexion and extension at the time of the ulnar nerve submuscular transposition may prevent this potential complication.
Some cases of cubital tunnel syndrome are caused by anatomical abnormalities such as the epitrochleo-anconeus muscle or snapping and bulkiness of the medial head of the triceps brachii muscle. We report a rare cause of cubital tunnel syndrome that has not been reported previously. It was caused by an abnormal insertion of the medial head of the triceps muscle into the medial epicondyle. The clinical course and operative findings are described.
A number of musculo-tendinous variations around the medial epicondyle have been alleged to cause ulnar nerve compression. Subluxation of the ulnar nerve, a "snapping" separate medial head of triceps, a prominent medial head of triceps covering the ulnar nerve, anconeus epitrochlearis, Osborne's band, and the ligament of Struthers have been implicated. We present a case of clearcut compression of the ulnar nerve at two levels just at and posterior to the epicondyle by a tightly applied prominent head of the triceps, and at a more distal level beneath an anconeus epitrochlearis muscle.
Variations in the medial triceps in conjunction with bilateral ulnar neuropathy have been identified in three generations of one family also possessing the phenotype of Waardenburg syndrome (a rare autosomal-dominant disorder with clinical features including cochlear deafness, dystopia canthorum, and pigmentation problems). To our knowledge, no other inherited condition with triceps anomalies has been reported. Study of this family provided insight into the relationship between dislocating medial triceps and ulnar neuropathy and demonstrated that a broad spectrum of clinical presentations exists-from being completely asymptomatic to producing symptomatic snapping and ulnar neuropathy.
We describe seventeen patients (twenty-two limbs) who had snapping (dislocation) of both the ulnar nerve and the medial head of the triceps over the medial epicondyle. Two patients (two limbs) were seen because of painless snapping, four patients (five limbs) had snapping and pain in the medial aspect of the elbow, three patients (three limbs) had symptoms related to the ulnar nerve only, and six patients (seven limbs) had snapping and symptoms related to the ulnar nerve. In addition, snapping was identified incidentally on routine screening in five asymptomatic limbs in four patients, one of whom was seen because of snapping and symptoms related to the ulnar nerve on the contralateral side. The diagnosis was confirmed with magnetic resonance imaging or computerized tomography, or both, in all but the first three patients, in whom the operative findings were confirmatory. Only six patients (seven limbs) were sufficiently symptomatic to be managed operatively. Of these six patients, five (six limbs) who had symptoms related to the ulnar nerve had lateral transposition or excision of the dislocating medial head of the triceps in addition to decompression and transposition of the ulnar nerve. Two of these patients had had persistent symptoms immediately after a previous transfer of the ulnar nerve performed at another institution for symptoms related to, and well documented dislocation of, the ulnar nerve; we performed the index procedure to correct the postoperative snapping, which was the result of an unrecognized dislocation of the medial head of the triceps in one patient and the result of an accessory triceps tendon in the other. One patient who had pain in the medial part of the elbow, snapping (without symptoms related to the ulnar nerve), and cubitus varus had a valgus osteotomy of the distal aspect of the humerus that corrected the line of pull of the triceps and relieved the snapping. All of the patients who were managed operatively had an excellent result (no snapping, no symptoms related to the ulnar nerve, and a full range of motion), at an average of 4.5 years postoperatively. Non-operative treatment provided control of symptoms related to the ulnar nerve in four limbs and control of pain from the snapping in four limbs. Snapping on the medial side of the elbow, even if it is associated with symptoms related to the ulnar nerve, is not necessarily caused by dislocation of the ulnar nerve alone. Patients who have a transposition of the ulnar nerve, especially those who have dislocation of the ulnar nerve, should be examined intraoperatively with the elbow in flexion and extension so that the surgeon can be certain that the medial head of the triceps does not snap over the medial epicondyle. Failure to recognize concurrent dislocation of the ulnar nerve and the medial head of the triceps can result in persistent, symptomatic snapping after an otherwise successful transposition of the ulnar nerve.
We present a patient with translocation (snapping) of a portion of the triceps over the lateral epicondyle with elbow flexion. This condition is in many ways analogous to its counterpart at the medial aspect of the elbow, snapping of the medial head of the triceps, a clinical entity that is being increasingly recognized.
Five patients with cubitus varus deformities from malunited childhood fractures had dislocation (snapping) of both the medial portion of the triceps and the ulnar nerve over the medial epicondyle. In addition to snapping, these patients had medial elbow pain or ulnar nerve symptoms. Cubitus varus shifts the line of pull of the triceps more medial, which can cause anteromedial displacement of the medial portion of the triceps during elbow flexion. The ulnar nerve is concomitantly pushed or pulled anteromedially by the triceps, and ulnar neuropathy may result from friction neuritis or from dynamic compression by the triceps against the epicondyle. Recognition of both the dislocating ulnar nerve and the snapping medial triceps is crucial in the successful treatment of this pathologic finding. In symptomatic individuals, we recommend either corrective valgus osteotomy of the distal humerus or partial excision or lateral transposition of the snapping medial triceps, or a combination of both. Alternatively, medial epicondylectomy can also eliminate the snapping. Transposition of the ulnar nerve can be performed for ulnar nerve symptoms and/or ulnar nerve instability. Using this approach, correction of the snapping and/or ulnar nerve symptoms was achieved in all cases.
Initial experience with the use of dynamic sonography of the elbow for diagnosing ulnar nerve dislocation and snapping triceps syndrome is reported. Cases of three consecutive patients who underwent sonographic evaluation of the elbow and subsequent open elbow surgery for symptomatic ulnar nerve dislocation were reviewed. Dynamic sonography of the elbow was used to aid in the accurate diagnosis of and differentiation between ulnar nerve dislocation and snapping of the medial triceps muscle.
Medial and lateral snapping (dislocation) of the distal triceps over the epicondyle during elbow flexion has been reported but is frequently misdiagnosed and is not well understood. In this study a mathematical model was designed to simulate the effect that bony abnormalities at the distal humerus and soft tissue variations of the distal triceps have on the line of pull of the triceps. The predictions were then tested on prefabricated and fabricated plastic elbow models, as well as 8 cadaveric elbows. When the bony alignment was altered, varus angulation had the greatest effect: 30 degrees varus malalignment of the distal humerus displaced the centroid of the triceps vector medially by approximately 2.0 cm. Valgus malalignment had a lesser effect: 30 degrees valgus displaced it laterally by 1.5 cm. Negligible effects on the triceps line of pull were seen with internal or external malrotation and with flexion or extension malalignment. Of the soft tissue alterations, displacement of the triceps insertion had a greater effect than movement of the triceps origin. The triceps vector was displaced by approximately 70% of the amount of translation of the triceps insertion. The relationship between the triceps line of pull and the bony alignment is represented by the triceps (T) angle. Our use of the T angle to understand snapping triceps is analogous to the use of the quadriceps (Q) angle for patellar subluxation/dislocation. Treatment should aim to restore normal triceps biomechanics with soft tissue or bony procedures.
We postulate an iatrogenic cause for snapping of the medial head of the triceps. A patient whose ulnar nerve and triceps did not dislocate over the medial epicondyle preoperatively had snapping of a portion of the medial triceps after submuscular transposition of the ulnar nerve. We believe that release of the brachial fascia and excision of the medial intermuscular septum removed the restraint to anterior translation of the medial aspect of the triceps, permitting dislocation of a portion of the medial head of the triceps with elbow flexion in this case. Previous reports of snapping of the triceps resulting after ulnar nerve transposition occurred in patients whose ulnar nerve dislocated preoperatively; in these cases, the triceps was thought to have dislocated preoperatively (along with the ulnar nerve) but was not recognized. Careful intraoperative assessment of the triceps after ulnar nerve transposition should prevent medial triceps instability as a postoperative concern.
We describe two patients who had episodic elbow snapping and ulnar nerve dysesthesias only after weightlifting. These symptoms would disappear soon afterward. The episodic nature of their complaints and findings led to misdiagnosis. We documented by repeated clinical examinations and magnetic resonance imaging that the presence of these symptoms correlated directly with the finding of intermittent, activity-related snapping of the medial triceps. In both patients, the symptoms disappeared when the medial portion of the triceps migrated medially but did not dislocate over the medial epicondyle with elbow flexion. Thus, a minor change in the configuration of the medial portion of the triceps (fluid accumulation) in the same individual at different times can cause intermittent dislocation of the medial triceps. Previous papers dealing with patients with snapping of the medial triceps describe symptoms exacerbated by athletic activities, but the constant finding of snapping on sequential examinations.
The authors describe rare phenomenon of the snapping of the medial head of the triceps muscle and recurrent dislocation of the ulnar nerve. The indications for operative treatment are established. The authors describe its own case making a conclusion that operative treatment is a good option in some cases.
To review the anatomy, etiology, and symptoms associated with compressive ulnar neuropathy at the elbow and to discuss the diagnosis and treatment of this condition.
The following were searched for information relevant to cubital tunnel syndrome: MEDLINE, WorldCat, and Index to Chiropractic Literature.
Cubital tunnel syndrome is the second most common nerve compression syndrome of the upper extremity. Clinical features of this syndrome are described along with electrodiagnostic techniques that can be used to provide evidence concerning the probable location, character, and severity of the lesion affecting the ulnar nerve. Conservative treatment of cubital tunnel syndrome is recommended for patients with intermittent symptoms and without changes in cutaneous sensation or muscle atrophy.
A definitive diagnosis can best be made using clinical tests along with nerve conduction studies and electromyography, conservative treatment can be effective in treating this neuropathy in mild cases; in moderate or severe cases, surgery may be necessary.
We treated a 64-year-old female with bilateral painful snapping elbows due to synovial folds. Resection of the bilateral synovial folds resulted in relief from pain and snapping, and resulted in patient satisfaction. Daily dumbbell exercises of the bilateral elbows starting at an elderly age may have led to the bilateral snapping. Painful snapping elbow is a relatively rare condition, which usually occurs in a unilateral elbow of a younger patient. To our knowledge, bilateral painful snapping elbows triggered by daily dumbbell exercises in older patients have not been previously reported.
Medial epicondylitis of the elbow involves pathologic alteration in the musculotendinous origins at the medial epicondyle. Although commonly referred to as "golfer's elbow", the condition may in fact be caused by a variety of sports and occupational activities. Accurate diagnosis requires a thorough understanding of the anatomic, epidemiologic, and pathophysiologic factors. Nonoperative treatment involves rest, ice, nonsteroidal anti-inflammatory agents, and possibly corticosteroid injection followed by guided rehabilitation and return to sport. Operative treatment is indicated for debilitating pain after exclusion of other pathologic causes that persists in spite of a well-managed nonoperative regimen spanning a minimum of 6 months. The surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin of the flexor pronator muscle group to the medial epicondyle. Surgical treatment results in a high degree of subjective relief, although objective strength deficits may persist.
To compare the muscle activation pattern in subjects with and without "snapping triceps syndrome" (dislocation of the medial head of the triceps and ulnar nerve over the medial epicondyle).
Controlled study.
Biomechanics laboratory.
Eight male subjects (9 elbows), with symptomatic snapping triceps and 9 male controls.
Not applicable.
Activation pattern of the 3 triceps heads during active elbow extension at 0 degrees , 45 degrees , 70 degrees , 90 degrees , and 115 degrees of flexion, recorded by fine-wire electromyography.
There were no significant differences between subjects and controls in the firing pattern of the triceps heads. The medial head fired first in 6 of 9 symptomatic elbows and in 7 of 9 controls at 90 degrees of flexion, and in 6 of 9 elbows of both subjects and controls at 115 degrees of flexion, positions where snapping typically occurs. There was no significant difference between the groups as to how often the medial head fired maximally.
This study suggests the firing pattern of the triceps heads may not contribute to the pathogenesis of this syndrome. Rather, the authors believe the anatomic position of the medial head causes it to dislocate over the medial epicondyle, often resulting in ulnar neuritis.
The Author(s) Journal Compilation ©
© 2009 The Author(s)
Journal Compilation © 2009 British Elbow and Shoulder Society. Shoulder & Elbow 2010 2, pp 30–33
Diagnosis of snapping triceps with US
- Rj Spinner
- Rd Goldner
- Ra Lee
Spinner RJ, Goldner RD, Lee RA. Diagnosis of snapping triceps with
US. Radiology 2002; 224:933-4; author reply 934.