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Pectoralis Major Injuries

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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

Associated Injuries


Risk Factors

  • Sports
    • Weightlifting by far, especially bench press (need citation)
  • Less commonly
    • Rugby
    • Snow skiing
    • Water skiing[6]
    • Football[7]
    • Wrestling
    • Parallel bar dips[8]
    • Boxing
    • Sailboarding
    • Parachuting[9]
    • Hockey
  • Work related
  • Trauma
  • Anabolic steroid use[10]

Differential Diagnosis


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
  • 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

See Also


References


  1. 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.
  2. 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.
  3. Potter, BK, Lehman, RA, Doukas, WC. Pectoralis major ruptures. Am J Orthop. 2006;35(4):189-195.
  4. 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.
  5. Arciero RA, Cruser DL. Pectoralis major rupture with simultaneous anterior dislocation of the shoulder. J Shoulder Elbow Surg. 1997; 6(3):318-320.
  6. Kersch, TCR, Fay, M. Pectoralis tendon rupture in a water skiier: case report. Contemp Orthop. 1992;24:437-441.
  7. 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.
  8. 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. 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.
  10. 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.
  11. 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.
  12. 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.
  13. . Connell DA, Potter HG, Sherman MF, Wickiewicz TL. Injuries of the pectoralis major muscle: evaluation with MR imaging. Radiology. 1999;210(3):785-791.
  14. 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.
  15. 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.
  16. 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.
  17. 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:
13 November 2020 13:51:06
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