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DOI: 10.1148/radiol.2243020034
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(Radiology 2002;224:933-934.)
© RSNA, 2002

Letters to the Editor

Diagnosis of Snapping Triceps with US

Robert J. Spinner, MD,*, Richard D. Goldner, MD,{dagger} and Robert A. Lee, MD{ddagger}

Departments of Neurologic Surgery and Orthopedics* and Radiology,{ddagger}
Mayo Clinic, 200 First Street SW, E-6B, Rochester, MN 55905* e-mail: spinner.robert@mayo.edu
Division of Orthopedics, Duke University Medical Center, Durham, NC{dagger}

Editor:

We read with interest the article by Jacobson et al (1) about diagnosing snapping triceps with ultrasonography (US). We agree that the value of this imaging modality has been underappreciated in this condition (2,3). US serves as a dynamic and interactive technique in the evaluation of snapping of the medial head of the triceps in real time.

We wish to emphasize that active contraction and loading of the triceps (active contraction against the examiner’s resistance) accentuate both symptoms (medial elbow pain, snapping, ulnar neuropathy) and physical findings (dislocating or snapping of the triceps and/or ulnar nerve). We have observed that these provocative testing maneuvers produce snapping that is more pronounced and occurs at lower degrees of elbow flexion; in addition, a larger amount of triceps is displaced anteriorly and is thicker when tested actively and when resistance is applied.

Passive testing alone or even active testing without resistance may not reproduce snapping (dislocating) in some cases. A small change in anteromedial displacement of the medial triceps produced by active testing against resistance may produce symptomatic snapping over the medial epicondyle rather than asymptomatic subluxation to the medial epicondyle (but not over it) that is produced with passive testing (4). Therefore, to assess episodic intermittent snapping, we recommend that physical examination and dynamic sonography, when performed, should include examination with the elbow flexed and extended passively, actively, and actively against resistance.

REFERENCES

  1. Jacobson JA, Jebson PJL, Jeffers AW, Fessell DP, Hayes CW. Ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography—report of three cases. Radiology 2001; 220:601-605.[Abstract/Free Full Text]
  2. Yiannakopoulos CK, Babalis G, Chatzimichail A. Snapping of the medial head of triceps brachii: diagnostic evaluation using dynamic real time ultrasonography. Acta Orthop Traumatol Hellenica [serial online] 2001; 52:1Available at: www.acta-ortho.gr/v52t1_8.html.
  3. Spinner RJ, Goldner RD. Snapping of the medial head of the triceps (letter). Acta Orthop Scand 2001; 72:320.[CrossRef][Medline]
  4. Spinner RJ, Wenger DE, Barry CT, Goldner RD. Episodic snapping of the medial head of the triceps due to weightlifting. J South Orthop Assoc 1999; 8:288-292.[Medline]

Dr Jacobson and colleagues respond:

Jon A. Jacobson, MD,*, Peter J. L. Jebson, MD,{dagger}, Andrew W. Jeffers, MD{dagger}, David P. Fessell, MD,* and Curtis W. Hayes, MD*

Departments of Radiology* and
Orthopedic Surgery,{dagger} University of Michigan Medical Center, 1500 East Medical Center Drive, TC-2910G, Ann Arbor, MI 48109-0326 e-mail: jjacobsn@umich.edu

My colleagues and I would like to thank Dr Spinner and colleagues for their comments. In the three subjects included in our research (1), abnormal displacement of the medial triceps over the apex of the medial epicondyle occurred with passive elbow flexion. After reading the recommendations of Dr Spinner and colleagues, in our routine assessment of snapping triceps syndrome and ulnar nerve dislocation, we now include active elbow flexion and extension, both with and without resistance, in addition to passive flexion and extension. The comments by Dr Spinner and colleagues further support the use of sonography in the diagnosis of snapping triceps syndrome rather than magnetic resonance imaging, as such provocative testing maneuvers would not easily be accomplished with the latter.

REFERENCES

  1. Jacobson JA, Jebson PJL, Jeffers AW, Fessell DP, Hayes CW. Ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography—report of three cases. Radiology 2001; 220:601-605.




This Article
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