Elbow pain can be caused by many disorders: Tennis Elbow, Golfers Elbow, Plicas, Osteochondritis Dissecans (OCD), fractures, ligament injuries, arthritis, and nerve entrapments. As many of these conditions have been well-covered in other sections of this website, this section will focus on Triceps Tendinosis (Posterior Tennis Elbow) and Posterior Impingement.
Triceps Tendinosis is degeneration of the triceps tendon, which causes pain on the back of the elbow. Triceps Tendinosis is also known as Posterior Tennis Elbow (‘posterior’ means ‘the back of’). Posterior Tennis Elbow is most often caused by repetitive sudden elbow extension, such as occurs during pitching, football line play, throwing the shot put or javelin, bowling and heavy weight lifting. Triceps Tendinosis is often associated with other problems, such as ‘Posterior Impingement’.
Posterior Impingement occurs when full elbow extension becomes blocked inside the elbow. In order for the elbow to fully extend, the convexity of the olecranon process (the bony process on the back of the elbow that the triceps inserts into) has to fit into its concave fossa. If the olecranon’s fossa becomes filled up with inflammation or bone spurs, or if bone spurs form on the tip of the olecranon, then the elbow cannot fully extend because of the impingement produced by these abnormal structures. Trying to fully extend the elbow leads to pain in the back of the elbow. The inflammation and bone spurs can occur from arthritis or from overuse caused by repetitive forceful elbow extension. This commonly occurs in throwers and boxers.
Both Triceps Tendinosis and Posterior Impingement are best diagnosed on a physical examination performed by a sub-specialist, i.e. an Orthopedic Upper Extremity or Elbow Surgeon. MRI is not overly accurate in detecting either of these conditions, although a CT scan is useful because it can show any bone spurs that have formed.
The initial treatment of Triceps Tendinosis and Posterior Impingement is a steroid injection. The injection is placed into the triceps tendon for Triceps Tendinosis and into the joint for Posterior Impingement. If the pain decreases, the diagnosis is confirmed. The steroid can decrease joint inflammation, possibly curing Posterior Impingement if it is caught early enough. Avoiding forceful elbow extension for a few months is also very helpful.
As for Tennis Elbow and Golfers Elbow, therapeutic strengthening exercises can be effective in treating Triceps Tendinosis. The Tennis Elbow exercises are well covered in the ‘Tennis Elbow’ and ‘Therapy Protocol’ sections of this website. In addition to these exercises, low-level elbow flexion and extension strengthening exercises are also performed with an elastic resistance.
If non-operative treatment does not provide significant relief, then outpatient surgery may be considered. The surgery for Triceps Tendinosis involves making an incision over the painful triceps tendon, splitting its fibers to expose the tendinosis, excising the tendinosis and then repairing the triceps tendon.
The elbow is splinting for 3 days, and then showering and range of motion exercises are allowed. Strengthening exercises are usually restarted after two weeks.
The surgery for Posterior Impingement involves removing the impinging inflammation and bone spurs. These can be removed arthroscopically if they are small. If the bone spurs are large, an open incision may be required. If Triceps Tendinosis is also being excised, then the Posterior Impingement can be treated through the same incision. The post-operative protocol is the same as for Triceps Tendinosis: the elbow is splinting for 3 days, and then showering and range of motion exercises are allowed. Forceful elbow extension should be avoided for a 2 months.
Bone Spurs in the Front of the Elbow and in the Back of the Elbow. The Bone Spurs in the Back of the Elbow Cause Posterior Impingement
The take home message: two of the most common causes of pain on the back of the elbow are Triceps Tendinosis and Posterior Impingement. Both of these problems can be well treated with excellent results.