Elbow

Biceps and Triceps Tendinitis at the Elbow

A sudden pop in the front of the elbow with a bulging arm muscle usually means a distal biceps rupture that needs prompt attention. Dr. Peter FitzGibbons evaluates and treats biceps and triceps tendon injuries at the elbow for patients across Montgomery County in Bethesda and Germantown.

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What is biceps and triceps tendinitis at the elbow?

Biceps and triceps tendinitis are overuse or degenerative injuries to the tendons crossing the elbow, ranging from mild inflammation to partial tearing to complete rupture. Distal biceps injuries usually follow a sudden eccentric load and cause a Popeye-shaped bulge; triceps injuries are rarer. Complete ruptures generally need surgical repair; tendinitis and partial tears often respond to therapy.

The biceps muscle has two heads that join into one muscle belly and taper into the distal biceps tendon, which attaches to the radial tuberosity, a bony prominence on the forearm bone (radius) just below the elbow. The long head of the biceps mainly rotates the forearm to turn the palm up, while the short head mainly bends the elbow (PMC). A fibrous band called the lacertus fibrosus connects the tendon to the forearm's flexor muscles; when it stays intact after a tendon tear, it limits how far the torn tendon can retract up the arm, but when it also tears, the tendon can pull back significantly, which changes the surgical approach needed to retrieve and reattach it.

Distal biceps tendon problems tend to arise at a specific spot near the tendon's attachment, a relatively poorly supplied area sometimes called a watershed zone, combined with mechanical pinching between the radius and ulna during forearm rotation (PMC). Cadaver testing shows the tendon fails at an average load of about 204 newtons, which helps explain why a single forceful, unexpected load, rather than gradual wear, is the usual trigger for a complete tear (PMC).

The triceps tendon attaches to the olecranon, the bony tip of the elbow, and is the main muscle straightening the elbow. Triceps tendon injuries follow the same general spectrum as biceps injuries but are much less common; triceps tendon ruptures are described as among the rarest tendon ruptures anywhere in the body (Current Sports Medicine Reports).

The Spectrum: Tendinitis, Partial Tear, Complete Rupture

Rather than a numbered staging system like those used for some finger deformities, biceps and triceps tendon injuries are described along a spectrum. Tendinosis or tendinopathy is degenerative change and irritation within the tendon without any actual tear. A partial tear involves some torn fibers while the tendon remains attached to bone. A complete rupture is total detachment of the tendon from its bony attachment (PMC). Distinguishing complete from partial tears matters clinically, because complete ruptures usually need prompt surgical repair to restore strength, while most partial tears are managed without surgery first (PMC).

Why These Injuries Happen

Distal biceps rupture occurs at a rate of roughly 5.4 cases per 100,000 people annually, with the American Academy of Orthopaedic Surgeons citing a similar figure of 3 to 5 per 100,000, and it happens rarely in women (PMC; AAOS OrthoInfo). It tends to affect two different groups: young, active athletes, and men in their 40s through 60s, in whom underlying tendon degeneration may play a role (PMC). Recognized risk factors include contact sports, anabolic steroid use, heavy pushing or lifting, smoking, higher body weight, and corticosteroid use, and men over 30 are most commonly affected (PMC; AAOS OrthoInfo). The typical mechanism is a bent elbow forced suddenly into straightening against resistance, an eccentric load, such as trying to catch a heavier-than-expected object; injury during forceful bending against a load happens less often (AAOS OrthoInfo; PMC).

Triceps injuries typically follow a fall onto an outstretched hand, a direct blow to the elbow, or forceful lifting or pushing (PubMed). Triceps tendinopathy specifically causes stress-related pain at the back of the elbow and is linked to repetitive activities that load the elbow into extension (Springer).

Symptoms — do you recognize these?

A sudden, painful pop at the front of the elbow, sometimes preceded by an aching sensation in the days before rupture
Swelling and bruising in the front of the elbow and forearm
Weakness bending the elbow and, especially, turning the forearm to palm-up, making tasks like using a screwdriver or opening a jar difficult
A bulging muscle in the upper arm from a retracted biceps, the classic "Popeye" appearance, with a palpable gap where the tendon used to be
For triceps injuries: pain, swelling, and bruising at the back of the elbow, with weakness straightening the arm and, in complete rupture, a palpable gap over the olecranon
Gradual, activity-related aching at the front or back of the elbow without a specific pop, more typical of tendinitis than rupture

A sudden pop with a new bulge in the upper arm, or an inability to fully straighten the elbow after a fall, should be seen promptly. Complete tendon ruptures are repaired most easily and successfully within the first few weeks after injury, so delay works against a good outcome.

How we diagnose it

The hook test. This is the primary exam maneuver for a suspected distal biceps injury. With the elbow bent 90 degrees, the patient actively turns the forearm palm-up while the examiner tries to hook a finger underneath the tendon from the side. An intact tendon feels like a firm cord that can be hooked; a complete tear leaves nothing to catch. In the study that established this test, it was abnormal in all 33 complete tears and normal in all 12 partial tears, though painful in most of those, giving it 100 percent sensitivity and specificity for complete rupture in that cohort, outperforming MRI, which had 92 percent sensitivity and 85 percent specificity in the same patients (O'Driscoll et al., PubMed). Because the standard hook test can be less clear-cut for partial tears specifically, a modified version adding resisted forearm rotation has been described to improve accuracy in that setting (ORS).

Imaging. X-rays do not show the tendon itself and are mainly used to rule out a bone injury (AAOS OrthoInfo). MRI is the preferred imaging test for confirming and grading a partial versus complete distal biceps tear, and images taken across the arm (axial views) are more useful than side views for this grading (PMC; PubMed). In one study comparing MRI findings against what surgeons actually found in the operating room, MRI had 92.4 percent sensitivity and 100 percent specificity for detecting a distal biceps rupture (PubMed). Ultrasound can also show a retracted, coiled tendon end and offers an accessible, real-time alternative to MRI (AAOS OrthoInfo).

Triceps evaluation. Examination looks for reduced strength straightening the elbow and increasing pain with resisted extension. X-rays occasionally show a "flake sign," a small bone fragment avulsed from the olecranon, which indicates a bony avulsion of the tendon (PubMed). Ultrasound and MRI are both used to characterize partial versus complete triceps injuries (Springer).

Treatment options

Treatment is guided mainly by whether the tendon is intact, partially torn, or completely ruptured, and by how much strength and function the injury has cost you.

Activity modification, ice, and NSAIDs

Reducing the specific activities that provoke pain, along with ice and anti-inflammatory medication, calms an irritated tendon before starting a structured strengthening program.

When used: Early management of biceps or triceps tendinitis and most partial tears without a significant strength deficit.

Eccentric loading physical therapy

A structured strengthening program that loads the tendon while it lengthens under control, which stimulates the tendon's collagen fibers to remodel and strengthen. This approach is best studied for tendinitis at other sites around the elbow and is applied clinically to biceps and triceps tendinopathy using the same underlying principle (PMC). Progression is guided by how the tendon responds to load rather than a fixed schedule (Strength & Conditioning Journal). We should note that evidence specific to eccentric loading of the biceps tendon itself is currently limited to a single published case report, so we present it to patients as a reasonable adjunct rather than a fully proven biceps-specific protocol (PMC).

When used: Tendinitis and most partial tears once acute pain has settled, typically supervised through our physical therapy team in Rockville.

Brief immobilization (triceps partial tears)

The elbow is splinted at about 30 degrees of bend for four to six weeks to protect a partial triceps tear while it heals.

When used: Acute partial triceps tendon injuries with intact strength on examination (PubMed).

Continued nonoperative care for partial tears with preserved strength

Ongoing activity modification and therapy for a partial tear that is not causing a significant strength deficit, reassessed periodically for progression.

When used: Distal biceps partial tears in patients with lower functional demands, and triceps partial tears without demonstrated weakness. For triceps specifically, surgery is generally considered if conservative care fails after six months or if a strength deficit is found on exam (Current Sports Medicine Reports).

Recovery & rehabilitation

Recovery timelines and expectations differ meaningfully depending on which tendon is involved and whether the injury needed surgery. For biceps or triceps tendinitis and most partial tears treated without surgery, symptoms typically improve over six to twelve weeks of structured therapy, though a full return to heavy lifting or throwing sports may take longer and should be guided by strength testing rather than the calendar.

After surgical repair of a complete distal biceps rupture, most patients regain good functional strength and are satisfied with the outcome, although full return of forearm rotation strength does not always exactly match the uninjured arm, depending on the technique used and how promptly the repair was performed (PMC). Early repair, generally within two to four weeks, is favored specifically to avoid the technical difficulty and higher complication risk that come with a retracted, scarred tendon in delayed repairs (PMC). Following triceps repair, most surgical series report favorable strength recovery when repair is performed early, with re-tearing as the main long-term concern at a rate of roughly 4.6 percent (Current Sports Medicine Reports). Postoperative therapy generally progresses from a protective splint through gentle motion and then resisted strengthening over two to four months; patients in Bethesda, Germantown, and elsewhere in Montgomery County typically complete this rehabilitation at our physical therapy location in Rockville.

Frequently Asked Questions

How do I know if I tore my biceps tendon or just strained it?

A true tendon rupture usually announces itself with a sudden, sharp pop, followed quickly by a bulge in the upper arm as the muscle retracts, weakness turning your palm upward, and often visible bruising. A strain tends to cause gradual soreness without that sudden pop or the characteristic bulge. The hook test, where we try to feel a cord-like tendon just above the elbow crease during active forearm rotation, distinguishes the two reliably in most patients and can be confirmed with MRI if there's any uncertainty.

Do all distal biceps tears need surgery?

No, but most complete ruptures benefit from it. A completely torn distal biceps tendon cannot heal back to bone on its own, and leaving it unrepaired typically costs 30 to 40 percent of normal supination and flexion strength. Partial tears are a different story: many respond well to activity modification and structured physical therapy, particularly in patients without high physical demands. We base the decision on the degree of tearing seen on MRI combined with your strength on examination and your functional goals.

Why is the timing of biceps or triceps repair surgery important?

Both tendons begin to retract and scar into a shortened position once torn, and the longer that process continues, the harder it becomes to pull the tendon back down to its original attachment point without added surgical steps like a graft. Repair within roughly two to four weeks for the biceps, or three to four weeks for the triceps, generally allows a more straightforward primary repair with a lower complication rate. Beyond that window, reconstruction with a tendon graft may be necessary instead of a simple repair.

Is triceps tendon injury as common as biceps injury at the elbow?

No, it is considerably rarer. Triceps tendon ruptures are described as among the least common tendon ruptures anywhere in the body, while distal biceps rupture, though still uncommon overall, occurs at an estimated rate of roughly 3 to 5 cases per 100,000 people each year. Because triceps ruptures are so infrequent, there is less consensus in the surgical literature about the single best repair technique, though the overall principles of early repair and structured rehabilitation still apply.

What happens if I ignore ongoing elbow tendinitis?

Ongoing tendinitis that is never addressed can progress along the same spectrum from tendinosis to a partial tear and, less commonly, to a complete rupture, particularly if the same aggravating activity continues without any change in load or technique. It also tends to become more resistant to conservative treatment the longer it persists untreated. We recommend evaluation for elbow pain that has lasted more than a few weeks despite rest, since starting a structured eccentric loading program earlier generally produces a faster, more complete recovery than waiting.

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Peter G. Fitzgibbons, MD

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Medically reviewed by Peter G. Fitzgibbons, MD, MD

Last reviewed August 5, 2026