Elbow pain when doing tricep extensions: the back of the elbow, the nerve and what helps

What no study has counted, and what an extension asks of the elbowEmerging evidence

No study counts what causes elbow pain in tricep extensions, and none has tested the grip, the bar, the depth or the arm position against pain. So the map on this page comes from what each condition is known to do, cadaver and lab studies, a gym survey, case reports and health-service pages.

Every triceps extension straightens the elbow against a weight while the upper arm stays still. The three heads of the triceps share one tendon that attaches to the point of the elbow (the olecranon). Overhead extensions (dumbbell, cable rope or French press) and lying extensions (skull crushers) start from a deep bend with the upper arm raised; pushdowns and kickbacks work with the arm at your side and the elbow bending less.

In an online survey of 1,387 recreational gym users, 732 reported pain with training. Among those who did dumbbell triceps extensions, 17.7% linked them to pain (85 of 481), against 7.7% for cable extensions and 6.6% for machine extensions; the elbow was the fourth commonest painful area, though the survey didn't record where each exercise hurt. These figures are of people who reported training pain, not of everyone who trains, so they can't give a risk per session. Across the weight-training sports, the elbow is among the five commonest injured areas, though injury rates are low against team sports; in surveys of competitive lifters it is among the commonest painful areas, more so after 40, and many train on with the pain.

Sources 1, 2, 3, 4, 5, 6, 7, 8

Where it hurts sorts the causesEmerging evidence

NHS referral guidance describes triceps tendon pain as "well localised pain at the triceps insertion on resisted elbow extension", usually after a change in load, stiff in the morning and painful as you start; it is less common than biceps tendon pain but "occurs occasionally in weightlifters". Its list of other causes at the back of the elbow includes bursitis, arthritis, gout, a loose body, a stress fracture and the back of the joint pinching.

A bursitis is a soft swelling at the tip from pressure or knocks; the American Academy of Orthopaedic Surgeons (AAOS) names long holds of the plank position among the causes. Cubital tunnel syndrome starts with numbness or tingling in the little and ring fingers, at first on and off, brought on by leaning on the elbow or holding it bent. A snap over the inner bump is often the nerve slipping out of its groove, sometimes with part of the triceps; in 2 lifters it appeared only after weightlifting. A snapping triceps is rare: in 64 reported cases, 9 in 10 also had an unstable ulnar nerve. A jamming pain at the back as the elbow snaps straight is the back of the joint pinching, mostly described in throwers. The bony bump on the outside, worse gripping, lifting and moving the wrist, is usually tennis elbow, which the NHS says usually goes away with rest; golfer's elbow on the inside is up to 6 times less common.

Rarer causes are on record too: a stress fracture of the point of the elbow in a young weightlifter (most are in throwers and gymnasts, and an early X-ray can be normal), and a complete teres major tear, felt below the shoulder blade, during an overhead triceps extension in a 40-year-old gym user. These show what can happen, not how often.

Sources 1, 9, 10, 11, 12, 13, 14, 15, 16, 17, 2, 18, 19, 20

The inner elbow and the nerve: why deep bending mattersEmerging evidence

The ulnar nerve runs in a tunnel behind the inner bump, the funny bone. The AAOS says bending the elbow slightly compresses and stretches the nerve and lowers its blood supply, which is why symptoms get worse with the elbow bent. The bottom of an overhead or lying extension is that position, under load.

In 20 cadaver arms, bending the elbow from straight to 135 degrees shrank the tunnel by 30% to 41% and the nerve by up to 50%, and from 90 degrees the pressure inside the nerve was higher than around it. In another cadaver study, the nerve stretched most at full bend, directly behind the inner bump. In 20 people with cubital tunnel syndrome measured during surgery, a changed shoulder position (the shoulder turned in, with the elbow bent) added more stretch to the nerve in every case. In healthy people the nerve slipped out of its groove more often at full bend than at a right angle, and more than half of 42 volunteers without symptoms had a nerve that moved out of place.

That overhead extensions strain the nerve more than other versions is our inference from these studies: none of them tested the overhead position, a weight or lifters. What they do support is that less bend means less squeeze and stretch, which is why stopping the lowering at about a right angle, or swapping to pushdowns, is the first change for tingling.

Sources 21, 22, 23, 24, 11, 12, 10

A torn triceps tendon: rare, and sometimes mistaken for bursitisEmerging evidence

Triceps tears are rare: about 0.5% of the tendon tears seen in US emergency departments over 20 years, in men about 12 times as often as women, at an average age of about 44. The AAOS says most come from pushing a heavy load, lifting weights or a fall onto an outstretched hand, with a pop, swelling, bruising, a gap above the point of the elbow and weakness straightening the arm. The mechanism most often described is a heavy load forcing a contracting triceps to lengthen, and anabolic steroids, a steroid injection near the tendon, kidney disease and an existing bursitis make a tear more likely.

One report describes a 53-year-old recreational bodybuilder who felt a tearing sensation during triceps extension training, then swelling and weakness straightening the arm. It was diagnosed as bursitis, and the repair of a full tear was delayed by 5 weeks. In a surgical series of 22 people, 10 tears were missed at first, and repair was always possible within 3 weeks of the injury. That is why a swelling that began with a tearing feeling needs checking for a tear, not just bursitis.

Sources 25, 3, 26, 27, 28, 29, 30

What a scan shows, and when it mattersEmerging evidence

Not for ordinary overuse pain: the NHS doesn't suggest a scan for it, and in 205 elbow magnetic resonance imaging (MRI) scans every triceps tendon showed a bright line that the authors think is normal.

A scan matters for a suspected tear, after an examination: an X-ray shows a fleck of bone pulled off with the tendon in 61% to 88% of operated tears, and ultrasound or MRI confirms it and shows how much is torn, though in one small series MRI called 2 of 6 partial tears complete. Tingling that lasts more than about 6 weeks, or any weakness in the hand, may need nerve conduction tests; the AAOS says most causes of a squeezed ulnar nerve can't be seen on an X-ray. After a fall or a knock, an elbow you can't fully straighten needs an X-ray: in a study of 2,127 people, nearly half of those who couldn't had a fracture. A hot, swollen bursa may need fluid drawn off to test for infection.

Sources 31, 32, 3, 30, 33, 34, 21, 35, 36

How it usually goesEmerging evidence

NHS referral guidance says most people with triceps tendon pain improve without surgery, "within weeks to months depending on contributing factors", though it "may persist for several years" in some. NHS inform expects new elbow pain to begin to settle within 6 weeks in many cases.

Most people with mild or moderate cubital tunnel syndrome improve with night splints and position changes, though it is unclear whether that is the treatment or time. Most tennis elbow had recovered at a year whatever the treatment, 83% with waiting alone in one trial, and an NHS trust leaflet expects improvement after 8 to 12 weeks of the right exercises. Bursitis that isn't infected often settles by itself. After a triceps repair, 89% of 262 people returned to their previous activity. No one can promise a date.

Sources 1, 37, 38, 39, 40, 41, 30

Overhead, lying or at your side: what the training studies showEmerging evidence

Over 12 weeks in 21 adults, overhead cable extensions grew the triceps more than the same exercise with the arm at the side (19.9% against 13.9%), with 34% to 39% lighter weights, through an elbow bend of only 90 degrees to straight. Over 6 weeks in 9 women, pushdowns and overhead extensions built strength and size about equally. With the arm overhead the inner head of the triceps does more of the work, and lying extensions added growth to the long head beyond bench pressing in 43 men.

In a muscle activity study of 15 women funded by the American Council on Exercise (ACE), diamond push-ups drew the most triceps activity, with kickbacks and dips close behind, overhead extensions and rope pushdowns a little less, and lying barbell extensions and close-grip bench presses less again; it was not peer reviewed. None of these studies measured elbow pain, so swapping overhead and lying versions for pushdowns while the elbow is sore costs little in the short term (our reading).

Sources 42, 43, 44, 45, 46

Loading helps other tendons; the triceps hasn't been testedEmerging evidence

No trial has tested any treatment for triceps tendon pain; a review calls it very rare with limited evidence. So the plan on this page borrows from tendons that have been studied, and says so. In patellar tendon pain, heavy, slow resistance kept its benefit at 6 months while a steroid injection's faded (39 men), and still holds gave immediate pain relief in a small crossover study; in Achilles tendon pain, heavy, slow resistance did as well as heel-drop training (58 people), and carrying on with sport under a pain-monitoring rule did no harm (38 people).

For tennis elbow, still holds below a person's pain threshold didn't raise pain 30 minutes later, while holds above it did (24 people). One rock climber's back-of-elbow pain settled over 10 weeks of shoulder blade and triceps exercise. These are other tendons and single cases, not the triceps in lifters.

Sources 1, 2, 47, 48, 49, 50, 51, 52

For the nerve: change the positions firstEmerging evidence

A Cochrane review of 15 trials (970 people) found that in mild cases, information about which positions to avoid may reduce discomfort, from one small trial; the evidence for night splints is of very low certainty. NHS trust leaflets start with avoiding repeated or long bending, a night splint for 6 to 8 weeks (up to 12), and nerve glides that "should not be painful or make your symptoms worse". The AAOS says steroid injections are generally not used for it.

Surgery is for severe or lasting cases, and freeing the nerve where it lies does about as well as moving it (low to moderate certainty evidence). Numbness that doesn't go, a weak or clumsy hand or wasting of the hand muscles needs a general practitioner (GP), as the warning signs say.

Sources 53, 38, 54, 55, 21, 10

For tennis elbow, time and exercise beat injectionsStrong evidence

This is outer elbow pain, not the triceps, but it comes up with straight-bar work. In 185 people, 83% were better at a year with waiting alone and 91% with physiotherapy, against 69% after steroid injections. In 165 people, a steroid injection left fewer recovered at a year than a placebo injection (83% against 96%), with more recurrence (54% against 12%).

A UK consensus physiotherapy protocol uses holds and slow strengthening within acceptable pain, and an NHS trust leaflet says avoid complete rest.

Sources 39, 56, 57, 40

Injections, surgery and a torn tendonEmerging evidence

A steroid injection near the triceps tendon is a recognised risk factor for a tear: 5 of 19 professional American football players with triceps tears had had one. This guide doesn't suggest one.

A complete tear in an active person is usually repaired, best within about 3 weeks; partial tears that keep strength straightening the arm are usually managed without surgery, and 6 of 10 partial tears in professional players healed without it. Bursitis that isn't infected usually settles without an injection or surgery, which bring more complications, including infection. About a third of inflamed elbow and knee bursae are infected; an infected bursa needs antibiotics and sometimes draining, and most settle with treatment.

Sources 26, 27, 29, 3, 30, 41, 58, 59, 60, 61

Your extensions for now (written steps)

Our 3D figure can't show all of these. They come from ACE, AAOS and British Society for Surgery of the Hand pages, cadaver and lab studies and our triceps guides; where a step is our suggestion, it says so. No trial has tested a change to tricep extensions for elbow pain.

• 1. Arm at your side for now: pushdowns (rope, V-bar or bar) and kickbacks instead of overhead and lying extensions. Pushdowns built strength and size about as well as overhead work over 6 weeks in one small study.
• 2. When lying or overhead versions come back, lower to about a right angle at the elbow first, as an ACE article teaches for skull crushers, then to just above the forehead, stopping as the upper arms start to drift back. Deep bending is what squeezes and stretches the nerve.
• 3. Bar and grip: dumbbells, an EZ bar or a rope rather than a straight bar, wrists straight, elbows about shoulder width apart. A review of gym injuries suggests triceps presses with an angled grip or a rope and no maximum stretch; no study has compared bars for pain.
• 4. Load and speed: lighter (overhead versions need 34% to 39% less weight anyway), about 3 seconds down, stopping 2 or 3 reps short of failure, with no heavy negatives or cheat reps (our suggestion). Tears are described when a heavy load forces a contracting triceps to lengthen.
• 5. Lockout: straighten under control rather than snapping into a hard lockout if the very back of the elbow jams (our suggestion).
• 6. Pressure on the point: don't lean on the point of the elbow, and pad it for forearm planks.
• 7. Tingling: stop any position that brings it on, don't hold the elbow fully bent between reps, and keep it straighter at night, for example with a towel wrapped loosely round it. In mild cases, advice on positions to avoid helped in one small trial.
• 8. At least a day between hard arm sessions, and build into a new programme over 1 to 3 weeks (our suggestion).

Sources 43, 63, 64, 22, 23, 65, 27, 26, 9, 21, 10, 53

Keep the arm moving, and the rest of you training

NHS inform says that after the first 48 hours, "exercise really helps your elbow and can relieve pain", and to avoid sports or heavy lifting only until you have less discomfort and good movement. For the first couple of days the NHS suggests a heat pack or a bag of frozen peas wrapped in a towel for 10 to 15 minutes every few hours, painkillers such as paracetamol or ibuprofen if you need them, and raising a swollen arm. An NHS trust leaflet says avoid complete rest.

Everyday life comes back alongside the plan: carry and lift with the elbow close to straight and the load close to you, don't lean on the point of the elbow at a desk, and sleep with the elbow straighter if your fingers tingle at night (editorial, from the nerve leaflets). Push-ups, dips and presses follow our push-up and dips guides.

Some arm pain isn't the elbow. Pain in the arms that comes on with exercise and eases after a few minutes' rest can be angina, a sign of a heart problem; a hot, swollen joint with a high temperature (although not everyone has one) can be a joint infection; and pain, swelling and stiffness in several joints, often worse in the mornings, can be rheumatoid arthritis. See the warning signs.

Sources 37, 31, 40, 66, 67, 68

Back to your usual training (written steps)

No study has tested how extensions come back after elbow pain, so these steps are our suggestion unless a source is named.

• 1. One change at a time: reps, then load, then lying extensions to a right angle, then the full lying range, then overhead work, then a straight bar or close-grip presses if your programme uses them.
• 2. Add load in small steps, about 2% to 10%, only after a session that passed the pain rule.
• 3. With inner-elbow tingling, overhead extensions come back last and stay short at the bottom if the tingling returns: deep bending squeezes the nerve, and in one study shoulder position added to the stretch.
• 4. Keep one slow triceps exercise twice a week for a few months.

Sources 22, 24