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REVIEW ARTICLE
Pectoralis major ruptures: a review of current
management
Usman Butt, FRCS (Tr & Orth)*, Saurabh Mehta, FRCS (Tr & Orth),
Lennard Funk, MSc FRCS(Tr & Orth) FFSEM(UK),
Puneet Monga, MSc, DipSportsMed FRCS (Tr & Orth), MD
Upper Limb Unit, Wrightington Hospital, Wigan, Lancashire, UK
Background: Rupture of the pectoralis major tendon is increasing in incidence, with a spike in the number
of reported cases in the last decade. This is commonly attributed to an increased interest in health, fitness,
and weight training combined occasionally with concomitant use of anabolic steroids. It is essential for the
diagnosis to be recognized and for the patient to be referred to a surgeon with expertise in dealing with
these injuries so that appropriate and informed care can be implemented.
Methods: Based on a comprehensive review of the literature and expert opinion, we present a review of
pectoralis major ruptures, including information pertaining to the anatomy and biomechanics of the mus-
culotendinous unit and how this relates to the injury pattern and management; the clinical diagnosis and
indications for additional imaging; and the indications for nonoperative and operative management
along with the authors’ preferred technique. A summary of outcomes is presented.
Conclusion: The combination of patient demographics and clinical features frequently yields an accurate
diagnosis, but further imaging is helpful. Magnetic resonance imaging with dedicated sequencing is the
investigation of choice and can aid in diagnosis, surgical planning, and providing important information
about prognosis and outcome. Early surgery is preferable, but good outcomes in the chronic setting are
achievable. With a detailed understanding of the anatomy, direct repair to bone is possible with either trans-
osseous or anchor repair techniques in acute and the majority of chronic cases. In chronic cases in which
direct repair is not achievable, autograft and allograft reconstruction should be considered.
Level of evidence: Narrative Review.
Ó2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Pectoralis major; tendon; repair; reconstruction
Rupture of the pectoralis major (PM) tendon is
increasing in incidence, with a spike in the number of re-
ported cases in the last decade. This is commonly attributed
to an increased interest in health, fitness, and weight
training combined occasionally with concomitant use of
anabolic steroids.
7,24
Delayed diagnosis can prejudice
subsequent management, requiring the need for allograft
reconstruction rather than direct repair, which in turn may
have less favorable outcomes.
29
We present a comprehen-
sive review of the current state of knowledge surrounding
these important injuries.
Institutional Review Board approval was not required (Review Article).
*Reprint requests: Usman Butt, FRCS (Tr & Orth), Wrightington
Upper Limb Unit, Hall Lane, Appley Bridge, Wigan, Lancashire WN6
9EP, UK.
E-mail address: usmanbutt02@yahoo.co.uk (U. Butt).
J Shoulder Elbow Surg (2014) -, 1-8
www.elsevier.com/locate/ymse
1058-2746/$ - see front matter Ó2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2014.10.024
Anatomy and biomechanics
The PM has a complex musculotendinous morphology, an
understanding of which is essential for any surgeon
considering surgery on this structure. Anatomic studies
have demonstrated the presence of 2 heads: the clavicular
head, arising from the medial half of the clavicle; and the
larger sternal head, arising from the second to sixth ribs, the
costal margin of the sternum, and the external oblique
aponeurosis. The sternal head is the much larger of the 2,
accounting for >80% of the total muscle volume, and can
be further subdivided into 7 overlapping segments.
10,21,26
The 2 muscle heads converge laterally into a rather broad
and flat bilaminate tendon consisting of an anterior layer,
formed from the clavicular head and the upper segments of
the sternal head coursing inferolaterally, and a posterior
layer, formed from the lower segments of the sternal head
coursing superolaterally (Fig. 1). Immediately before inser-
tion on the lateral edge of the intertubercular sulcus, the 2
laminae of the tendon fuse.
10
In the most recent cadaveric
study based on 6 specimens, both the anterior and posterior
layers had an average length of 5.4 cm, with respective
tendon widths about 1 cm less than their lengths without the
‘‘twist’’ noted in previous studies.
10,38
The investing layer of
fascia of the PM is continuous with the fascia of the arm and
medial intermuscular septum.
24
The PM is innervated by the medial and lateral pectoral
nerves. The medial pectoral nerve (C8-T1) arises from the
medial cord of the brachial plexus in the majority of cases.
It passes through the pectoralis minor, along the lower
border of which it then runs before supplying the inferior
portion of the PM.
24-26
The lateral pectoral nerve (C5-7),
the larger of the 2 nerves, commonly arises from the lateral
cord of the plexus before traversing along the upper border
of the pectoralis minor muscle. It then passes to the un-
dersurface of the PM muscle along with the pectoral branch
of the thoracoacromial artery, supplying the upper two
thirds of the PM.
24-26
In a recent cadaveric study, the lateral
and medial pectoral nerves were found to pierce the pec-
toral musculature at a mean of 10.1 cm and 8.6 cm,
respectively, from the lateral edge of the sternum.
25
The PM’s primary role is as an adductor and internal ro-
tator of the arm, although there is a contribution to forward
flexion by the clavicular head.
26
The muscle is somewhat
unusual in that it consists of myofibers of varying lengths.
38
This allows differential shortening velocities within the
muscle, resulting in the possibility of power production being
maximized over a broad range of motion.
9,38
In an assessment of individual fiber lengths, Wolfe
et al
38
found that through an arc of forward flexion,
excursion remained consistent, averaging about 19%.
However, when the same measurements were done through
an arc of 30extension from neutral, the inferior fibers had
an excursion of 40%, twice that of the more superior fibers.
Hence, one can see that in the extended bench press posi-
tion with an eccentrically loaded musculotendinous unit, a
biomechanical explanation for the incidence of PM tendon
ruptures exists. It is proposed that the tendon fails in a
predictable sequence, with the inferior segments of the
sternal head failing first, followed by the more superior
segments of the sternal head and subsequently the clavic-
ular head.
7,38
Etiopathogenesis
The overwhelming majority of cases occur in muscular
young adult men aged between 20 and 40 years during
bench press, although a number of other demanding ac-
tivities have been reported as causative, including rugby,
wrestling, and boxing, among others.
20,23,26,38,41
It is
postulated that the male predominance relates to the less
elastic nature of male tendons, lower tendon to muscle
diameter, and engagement in higher energy activities,
although there is no evidence to support this.
1
Another less
common subset of PM ruptures is in the elderly, thought to
be secondary to stiff, atrophic muscles contracting during
relatively strenuous activities, such as manual transfers.
5
Anabolic steroids are frequently associated with tendon
ruptures, including those of the PM. Although the reasons
are unclear, studies have suggested that anabolic steroids
result in stiffer tendons that absorb less energy and fail with
Figure 1 Schematic diagram of the pectoralis major’s
segmental anatomy. (Reprinted with permission from ElMaraghy
AW, Devereaux MW. A systematic review and comprehensive
classification of pectoralis major tears. J Shoulder Elbow Surg
2012;21:412-22.)
7
2 U. Butt et al.
less elongation
14
and with inferior stress values.
37
On a
histologic level, anabolic steroid use is associated with
collagen dysplasia, increased vascularization and cellu-
larity, and microdamage of collagen fibers.
37
Presentation and diagnosis
The diagnosis of a PM rupture is usually apparent from the
history and the clinical setting. Frequently, there is a sudden
pain at the medial aspect of the upper arm associated with a
‘‘pop’’ felt by the patient. This most commonly occurs with
eccentric contraction during bench press. In the acute setting,
physical examination may reveal ecchymosis over the ante-
rolateral chest wall and upper arm along with a variable de-
gree of swelling. Loss of the anterior axillary fold with an
asymmetric muscle outline that is retracted medially is a
useful diagnostic feature (Fig. 2), although these features
may be partially obscured acutely as a result of soft tissue
swelling. The absence of the anterior axillary fold can be
accentuated by abducting the affected arm or with resisted
adduction.
26,38
Testing the power of the muscle is helpful for
documentation purposes and as a baseline for comparison
after any intervention. This may be carried out clinically or
more formally with dynamometry.
8,24
The use of plain radiographs in the diagnosis and char-
acterization of PM ruptures is limited. Loss of the PM
shadow is a finding that is described but is inconsistent, and
its presence or absence should not influence decision-
making. In the rare case of a bone avulsion, plain radio-
graphs may be useful.
32
Ultrasound assessment can be a
useful adjunct to clinical examination when the diagnosis is
in doubt or when there is an unacceptable delay to magnetic
resonance imaging (MRI).
26
However, MRI is the investi-
gation of choice for its added value in the characterization
of tears and for surgical planning.
A standard shoulder MRI study will not be sufficient to
fully identify or to characterize a PM tear, as most
sequences will not extend caudally enough to include the
tendinous insertion.
18
A dedicated sequence is required
with axial slices extending superiorly from the quadrilateral
space and inferiorly to the deltoid tuberosity along with
coronal oblique cuts. For a thorough assessment, it is
suggested that T1, T2, and proton density images should be
obtained, although it is the T2-weighted axial images that
provide the most useful information, particularly in the
acute setting.
18,26
In the presence of a tear, the normally
low signal intensity tendon is absent from a point 1 to
1.5 cm inferior to the quadrilateral space and 1 cm superior
to the origin of the lateral head triceps.
18
The retracted
stump can be traced and visualized with abnormally high
signal intensity adjacent to it, which may be better high-
lighted with fat saturation sequences.
18,22
T1-weighted
images are more helpful in identification of chronic
tears.
18,23
Classification
The traditional descriptive classification system laid out by
Tietjen
36
divides PM injuries into 3 principal categories
ranging from a contusion through partial to complete tears.
Complete tears are further subdivided into the anatomic
location, whether that is the muscle origin, muscle belly,
musculotendinous junction, or tendinous insertion. A more
contemporaneous classification
7
has been proposed that
takes note of the importance of the chronicity of the tear,
the location, and the thickness and width of the tear.
Certainly, the chronicity and location of the injury are
crucial to operative planning and can drastically alter the
nature of planned intervention, particularly with regard to
whether an anatomic repair is feasible or whether graft
reconstruction may be required. With regard to the extent of
the tear, the authors of the classification suggest that normal
tendon thickness should be 4 mm thick (2 mm per layer)
and 4 cm wide so that intraoperative estimation of any
remaining tendon against these estimations will provide an
accurate classification of partial or incomplete tears.
7
There
are no data regarding intraobserver or interobserver reli-
ability to support this classification, and its applicability
and practicality are debatable. Nevertheless, it does draw
attention to the importance attached to understanding the
anatomy of the PM in approaching this type of surgery. In
the senior author’s experience, the key determinants to
surgical planning are the chronicity of the injury and its
location along the muscle-tendon unit.
Management and outcomes
Nonoperative management of PM ruptures tends to be
reserved for the lower demand and elderly subgroup of
patients or those not wishing to undergo surgery. It may
also be appropriate to treat certain partial tears and tears of
the muscle belly in this way.
24,26
Initially, the affected limb
Figure 2 Note the ecchymosis on the upper arm and loss of the
anterior axillary fold with asymmetry of the chest wall.
Pectoralis major ruptures 3
Table I Published series (>5 cases) of pectoralis major ruptures since 2000
First
author
Publication
date
Case
number
Mean
age
Mean
follow-up
Surgical
management
Outcome Conservative
management
Outcome Specific
complication
Comments
Schepsis
30
2000 17 29 28 13 (7 chronic) 16 (96%) satisfied
Peak torque
96%-110%
uninjured side
4 51% patients
satisfied
Peak torque
52%-78%
uninjured side
NR No significant
difference in
outcome of acute
and chronic repairs
Hanna
12
2001 22 30.9 21.6 12 6 group I)
3 group II)
Peak torque 99%
of uninjured side
10 1 group I)
7 group II)
4 group III)
Peak torque 56%
of uninjured side
NR
€
A€
arimaa
1
2004 33 28 52 33 (18 chronic
y
) 13 excellent
17 good
3 fair
NA NA NR d
Zvijac
42
2006 27 31.6 12.3 19 18 excellent
1 poor
8 1 poor NR d
Kakwani
16
2007 13 28.6 23.6 13 6 excellent
6 good
1 poor
NA NA 1 traumatic rerupture
1 postoperative hematoma
(surgery required)
11 returned to
preinjury sporting
level
Antosh
3
2009 14 31.4 NR 14 (6 chronic) 5 excellent
5 good
5 average
1 poor
NA NA NR Active-duty military
population
Better outcome with
acute repair
All returned to
active duty
He
13
2010 9 32 80.4 9 (2 chronic) 3 excellent
5 good
1 fair
NA NA None
Shah
31
2010 10 33.9 20.3 10 8 satisfied
1 moderately
satisfied
1 unsatisfied
NA NA 1 wound infection Elite athletes
No difference between
acute and delayed
repair
Garrigues
11
2012 34 24 33 24 (3 chronic, 2
allograft
reconstructions)
14 excellent
4 good
1 fair/poor
NA NA 1 keloid scar
1 infection (surgery not
required)
1 numbness in ulnar nerve
distribution resolved; 1
ulnar nerve numbness and
weakness resolved, 1
persistent radicular
pain nonresolving
4 U. Butt et al.
is rested in a sling (arm in adduction and internal rotation)
supplemented with cryotherapy for swelling control and
analgesia as required. Passive exercises can begin imme-
diately as tolerated, followed by active assisted and active
exercises during the course of the subsequent 6 weeks.
After this, resistance therapy can be implemented and un-
restricted activity allowed at 2 to 3 months.
24,26
Although there are infrequent reports of higher demand
patients being successfully managed nonoperatively,
17
the
literature overwhelmingly supports surgical treatment for
active individuals.
1,7,24,30
The literature, however, is based
largely on case reports, small series, and systematic reviews
of these small series. There is a lack of high-quality trials.
Outcomes in the literature are presented heterogeneously,
although the criteria developed by Bak et al,
4
grouping
outcomes as excellent, good, fair, and poor, are the most
frequently adopted. A summary of the more recent studies
is presented in Table I.
The chronicity of a tear may have an impact on the
repair strategy, but a good outcome is still achievable, and
chronicity should not be a barrier to surgical management,
even years from the original time of injury.
1,7,24,26,30
The
definition of a chronic tear varies between reports,
1,20,30
although it is possible that there may be a degree of mus-
cle belly retraction even by 3 weeks. Techniques of medial
fascial release performed through a separate incision have
been described in an effort to mobilize the myotendinous
unit sufficiently to allow primary repair,
2
although a
reconstruction rather than repair may be more appropriate if
sufficient mobilization of the tendon is not possible through
the primary incision. In performing any fascial release and
clearance of adhesions, care must be maintained to avoid
injury to the pectoral nerves.
Autograft and allograft reconstructions are described
alternative techniques in the chronic setting when primary
repair is not possible and should always be considered and
available before a chronic tear of the PM is explored.
Autograft options include hamstring, fascia lata, and bone
patellar tendon.
6,15,29,34,40
Allograft reconstruction with
Achilles tendon is the authors’ preferred option as it avoids
donor site morbidity, has excellent loading characteristics,
has favorable physical dimensions for this indication, and
has a good reported outcome.
39
Repair techniques vary considerably in the literature,
specifically with regard to the fixation method. Reported
methods include transosseous suture fixation with the
possible addition of a bone trough, anchor fixation, and
cortical button fixation. Attachment of an avulsed tendon to
the clavipectoral fascia has also been described.
19
When the
rupture occurs at the muscular/musculotendinous portion,
direct repair to a tendon stump has been reported success-
fully.
28
Sherman et al
33
compared transosseous sutures,
suture anchors, and a cortical button technique, noting no
significant difference between fixation devices with regard
to cyclic loading or load to failure properties. Ultimate
failure of the constructs occurred at the suture-tendon
Lau
17
2013 9 35 NR 7 NR 2 NR NR Cohort of steer
wrestlers; 8 returned
to steer wrestling
de Castro
Pochini
6
2014 60 31.2 48.25 31 (22 chronic,
y
19 graft
reconstructions)
21 excellent
7 good
3 poor
29 8 good
12 fair
9 poor
NR Better outcome with
acute repair
Merolla
20
2014 12 34.6 60 12 (4 chronic,
allograft
reconstruction)
9 excellent
3 good
NA NA None Marginally greater
strength in acute
repairs
NR, not recorded; NA, not applicable.
Chronic >6 weeks. Chronic
y
>3 weeks.
)
Group I, patients had no clinical loss of power, full pain-free range of motion, and normal function at work and in sport; group II, patients had loss of power and/or ongoing pain and/or some
restriction of range of motion but were able to return to work and/or sport; group III, patients had clinical loss of power, restriction of movement, or ongoing pain, any of which led to an inability to
return to work or sport.
12
Pectoralis major ruptures 5
interface as one might expect. Rabuck et al
27
reported a
bone trough technique to provide the strongest repair
construct for PM repair. They did, however, encounter one
proximal humerus fracture during testing in their cadaveric
study. This complication has a precedent in the clinical
literature.
35
Given the small numbers, heterogeneous tech-
niques, and lack of controlled trials, it is impossible to
meaningfully determine the best fixation technique, but all
have been reported to be successful.
Operative techniquedauthors’ preference
The preoperative imaging is reviewed with particular
attention to the degree of retraction and presence of any
intact portion, usually the clavicular head. We use both
dynamic ultrasound and MRI in most cases.
The patient is placed in the supine position under gen-
eral anesthesia. An arm holder (TRIMANO; Arthrex,
Naples, FL, USA) is used to allow easy positioning of the
arm. Intravenous antibiotics are given at induction, and the
skin is prepared with antiseptic paint. The surgical site is
draped with the arm free and the axilla excluded with
povidone-iodine (Betadine)–impregnated occlusive drapes.
A skin crease oblique incision is made in the deltopec-
toral groove. We avoid axillary incisions because of the risk
of deep infection. In cases of rupture of both the clavicular
and sternal heads, dissection is undertaken medial to the
deltoid, preserving the cephalic vein. When the clavicular
head is intact, the torn or ruptured sternal head is found
underneath the clavicular portion, and one needs to dissect
medial to the clavicular head to identify it. In chronic cases,
a ‘‘zone of injury’’ is sought. This is a result of the resolved
hematoma where scarred adherent tissue encloses the torn
tendon/muscle and denotes the area of injury.
Figure 3 (A) Intraoperative image depicting the incision and approach medial to the deltoid to identify the pectoralis major. (B) The
pectoralis major tendon has been retrieved and mobilized to allow subsequent reattachment to the humeral insertion. (C) The humeral
footprint is identified lateral to the long head of the biceps, and the surface is prepared for subsequent anchor placement. (D) Suture
passage.
Figure 4 A schematic of anchor positioning. Note the subtle
difference in direction of the superior and inferior anchors
compared with the middle anchor. This is to demonstrate the
triangular anchor configuration on the curved bone surface.
6 U. Butt et al.
The retracted tendon is identified and mobilized over
stay sutures. In chronic cases, the tendon may be adherent
to the chest wall, and mobilization with blunt dissection is
undertaken. Dissection and mobilization should extend as
far medial as the sternum, both superficial and deep to the
PM, with particular care to avoid injury to the medial and
lateral pectoral neurovascular bundles.
31
The PM footprint at the lateral crista of the intertubercular
groove is lateral to the long head of the biceps. The footprint
will be more obvious in cases in which the anterior tendinous
layer (comprising mainly the clavicular head) is intact; but in
these instances, it is important to repair the posterior layer to
its correct site just superior and posterior to the intact anterior
layer. The footprint is prepared by superficial decortication.
Three bone anchors are placed in a triangular configuration,
the middle being somewhat more medial than the superior
and inferior anchors. One limb of the suture from an indi-
vidual anchor is passed through the PM tendon with a cru-
ciate stitch; the contralateral limb is then pulled through to
parachute the tendon down onto the footprint.
31
Standard
surgical knots are tied down to secure the repair. The steps
can be viewed pictorially in Figures 3 and 4.
The safe range of motion (before the repair is on tension)
is determined before wound closure by taking the arm
through gentle range of motion, and this is documented.
Postoperatively, the patient’s arm is rested in a sling.
31
Active
hand, wrist, and elbow exercises are allowed immediately.
Shoulder motion is initially restricted to passive motion
within a safe range determined at surgery (usually external
rotation to neutral and forward elevation to 60). Between 3
and 6 weeks, active assisted motion is instituted with the
physiotherapist, progressing to active motion after this time.
Rehabilitation is individualized on the basis of the chronicity,
size, and location of the tear; quality of tendon and repair; and
patient factors. Figure 5demonstrates the postoperative ap-
pearances after a successful repair.
Conclusion
Rupture of the PM is an uncommon condition. It occurs
mainly in the male population with eccentric loads
during bench press or similar setting with the arm in an
extended position. In either the acute or chronic setting,
the patient’s demographics and history combined with
the pathognomonic feature of loss of the anterior axil-
lary fold are diagnostic. MRI with dedicated sequencing
is the investigation of choice and can aid in diagnosis,
surgical planning, and prognostication. Early surgery
within 3 weeks is preferable, but good outcomes in the
chronic setting are achievable. With a detailed under-
standing of the anatomy, direct repair to bone is possible
with either transosseous or anchor repair techniques in
acute and the majority of chronic cases. In chronic cases
in which direct repair is not achievable, autograft or
allograft reconstruction should be considered.
Disclaimer
The authors, their immediate families, and any research
foundation with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
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