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Pectoralis Major Injuries
From WikiSM
Contents
Other Names
- Pectoralis tendon tear
- Pectoralis rupture
- Pectoralis tendinitis
- Pec tendinitis
Background
- This page refers to all injuries to the Pectoralis Major, most commonly as a tear of the lateral insertion
- Generally, this refers to partial and complete tears of the lateral insertion, although tendinopathies can develop
History
- First described by Patissier in 1822 in Paris involving a butcher boy[1]
Epidemiology
- Men ages 20 - 39[2]
Pathophysiology
Etiology
- High risk when arm is externally rotated and extended with eccentric pectoralis activation[3]
- Occur primarily during bench press or other weight lifting activities[4]
- Rupture is often followed by an audible "pop"
- No preference for dominant or non dominant arm
- Bilateral injuries have been reported
Pathoanatomy
- See: Pectoralis Major
Associated Injuries
- One case report of Shoulder Dislocation in ipsilateral shoulder[5]
Risk Factors
- Sports
- Weightlifting by far, especially bench press (need citation)
- Less commonly
- Work related
- Trauma
- Anabolic steroid use[10]
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Clinical Features
- General: Physical Exam Shoulder
- History
- Most commonly, patients endorse an audible pop while bench pressing
- This is followed by pain, weakness, bruising, swelling
- Patients will complain of swelling and bruising
- Ecchymosis may last up to 6 weeks and can be significant[11]
- Physical
- Important to compare to unaffected shoulder
- In the setting of rupture, there will likely be a loss of the anterior axillary fold
- This can be accentuated with abduction
- Adduction may demonstrate a bulge near the sternocostal region
- The patient will have pain or weakness with abduction, internal rotation and to a lesser extent, flexion and extension
- "Dropped nipple" sign: Ipsilateral nipple appears lower due to medial retraction of muscle belly
Evaluation
- Radiographs
- Standard Radiographs Shoulder
- Useful to exclude other pathology
- Limited in terms of evaluating pectoralis injuries
- May demonstrate bony avulsion, seen in 5% of cases
- Loss of pectoralis shadow is not sensitive
- Ultrasound
- Effective and inexpensive way to evaluate for pectoralis tendon rupture[12]
- May help expedite surgery
- Normal:
- hypoechoic region, representing the muscle surrounded by parallel echogenic lines (perimysium)
- Rupture:
- Disruption of above pattern, hematoma, hypoechoic structure
- Disruption or absence of tendon distally, retraction of tendon and muscle fibers
- MRI
- Modality of choice in evaluating pectoralis major rupture
- Controversial how well it can distinguish between partial and complete tears
- T2 sequence better for acute injuries
- T1 for evaluating chronic injuries
- Acute injuries demonstrate[13]
- Increased signal intensity at the musculotendinous junction
- Tendon-bone discontinuity and/or tendon-muscle retraction at the rupture site
- Examination in the operating room
- Most rupture patterns documented in the literature are identified peri-operatively
Classification
Modified Tietjen Classification
- Type
- I: Muscle contusion or sprain
- II: Partial tear
- III: Complete tear (further subclassified by location)
- Location[14]
- A: Muscle origin (1%)
- B: Muscle belly (1%)
- C: Myotendinous junction (27%)
- D: Tendon avulsion off humerus (no bone) (65%)
- E: Bony tendon avulsion off humerus (5%)
- F: Tendinous rupture (1%)
Management
Nonoperative
- Indications
- Elderly patients or those with low demand ADLs[15]
- Suspected partial ruptures
- Muscle belly tears
- Treatment
- Relative rest
- Shoulder Sling immobilization in adducted, internally rotated position
- Cold compress
- Analgesia including NSAIDS, Acetaminophen
- Physical Therapy
- Outcomes
- Only 27% of patients report excellent results with nonoperative treatment[16]
Operative
- Indications
- Gold standard for most active individuals
- Technique
- Open primary repair for acute injuries
- Reconstruction for chronic injuries
- Outcomes
- Bak et al: 88% of surgically treated patients experienced excellent outcomes
- General consensus is outcomes are better if treated within 8 weeks although this is controversial
Rehab and Return to Play
Rehabilitation
Nonoperative
- General
- Weeks 1-2: Begin passive and active range of motion and continue through week 6
- Week 6: Begin resistance training
- Week 8-12: Can begin to return to activity if motion, pain and function are improving
- Komurcu et al developed a 3 phased approach[9]
- Ultrasound, electrotherapy, and range of motion exercises for the first 10 days
- Stretching, light resistance, and ultrasound for days 11 to 30
- Guided resistance program and limited athletic activity from 30 days to 6 months
Operative
- Postoperatively in sling or Velpeau dressing
- Immobilized for 3-6 weeks in internally and adducted position
- Week 1-2: Start pendulum exercises
- Weeks 3-8: active range of motion and light resistance training
- Month 4: No heavy weight lifting before this period
Return to Play
- Nonoperative: variable but not until at least 8 weeks
- Operative: can begin weight lifting at 4 months, unrestricted activity at about 6 months
Complications
- Chronic or persistent pain pain
- Loss of ADLs
- Inability to return to sport
- Cosmetic deformity
- Residual weakness
- Postoperative
- Infection
- Re-rupture, rates 0-7.7%[17]
- Heterotopic Ossification
See Also
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ Hayes, WM . Rupture of the pectoralis major muscle: review of the literature and report of two cases. J Int Coll Surg. 1950;14(1):82-88.
- ↑ ElMaraghy AW, Devereaux MW. A systematic review and comprehensive classification of pectoralis major tears. (2012) Journal of shoulder and elbow surgery. 21 (3): 412-22.
- ↑ Potter, BK, Lehman, RA, Doukas, WC. Pectoralis major ruptures. Am J Orthop. 2006;35(4):189-195.
- ↑ Provencher, CDR Matthew T., et al. "Injuries to the pectoralis major muscle: diagnosis and management." The American Journal of Sports Medicine 38.8 (2010): 1693-1705.
- ↑ Arciero RA, Cruser DL. Pectoralis major rupture with simultaneous anterior dislocation of the shoulder. J Shoulder Elbow Surg. 1997; 6(3):318-320.
- ↑ Kersch, TCR, Fay, M. Pectoralis tendon rupture in a water skiier: case report. Contemp Orthop. 1992;24:437-441.
- ↑ Miller, MD, Johnson, DL, Fu, FH, Thaete, FL, Blanc, RO. Rupture of the pectoralis major muscle in a collegiate football player: use of magnetic resonance imaging in early diagnosis. Am J Sports Med. 1993;21(3):475-477.
- ↑ Carek, PJ, Hawkins, A. Rupture of pectoralis major during parallel bar dips: case report and review. Med Sci Sports Exerc. 1998;30(3):335-338.
- ↑ 9.0 9.1 Komurcu, M, Yildiz, Y, Ozdemir, MT, Erler, K. Rupture of the pectoralis major muscle in a paratrooper. Aviat Space Environ Med. 2004;75(1):81-84.
- ↑ Inhofe PD, Grana WA, Egle D, Min KW, Tomasek J. The effects of anabolic steroids on rat tendon: an ultrastructural, biomechanical, and biochemical analysis. Am J Sports Med. 1995;23(2):227-232.
- ↑ Beloosesky Y, Grinblat J, Weiss A, Rosenberg PH, Weisbort M, Hendel D. Pectoralis major rupture in elderly patients: a clinical study of 13 patients. Clin Orthop Relat Res. 2003;413:164-169.
- ↑ Beloosesky Y, Grinblat J, Katz M, Hendel D, Sommer R. Pectoralis major rupture in the elderly: clinical and sonographic findings. Clin Imaging. 2003;27(4):261-264.
- ↑ . Connell DA, Potter HG, Sherman MF, Wickiewicz TL. Injuries of the pectoralis major muscle: evaluation with MR imaging. Radiology. 1999;210(3):785-791.
- ↑ Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc. 2000;8(2):113-119.
- ↑ Beloosesky Y, Grinblat J, Weiss A, Rosenberg PH, Weisbort M, Hendel D. Pectoralis major rupture in elderly patients: a clinical study of 13 patients. Clin Orthop Relat Res. 2003;413:164-169.
- ↑ Hanna CM, Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med. 2001;35(3):202-206.
- ↑ Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle: an anatomic and clinical analysis. Am J Sports Med. 1992;20(5):587-593.
Created by:
John Kiel on 17 June 2019 19:17:37
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Last edited:
1 October 2022 19:07:43
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