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Abstract and Figures

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. 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 musculotendinous 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. 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 transosseous 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. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Content may be subject to copyright.
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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8 U. Butt et al.
... J o u r n a l P r e -p r o o f Rupture of the pectoralis major (PM) tendon is an uncommon injury that is most frequently observed in young males between the ages of 20 and 40 years. 4 The incidence of PM tendon rupture has risen significantly in the past decade and has been attributed to the increasing popularity of weightlifting for fitness and anabolic steroid use. 4 Clinical manifestations of PM tendon rupture include pain, ecchymosis, asymmetry of the anterior axillary fold and shortening deformity of the retracted muscle. 4, 11 Magnetic resonance imaging can be helpful for diagnosis, but visualization of the torn PM tendon can be difficult, especially in the chronic presentation; therefore, careful history and clinical exam are important to avoid a misdiagnosis. ...
... 9 In cases of chronic rupture with limited muscle belly retraction, primary repair was still demonstrated to have the best clinical outcomes. 4,19 Techniques utilizing medial fascial release have been detailed in an effort to mobilize the myotendinous unit sufficiently to allow primary repair in these scenarios. 4 In the case of significant muscle belly retraction, primary approximation of tendon to the insertion site may not be possible, thus, reconstruction of the tendon is necessary. ...
... 4,19 Techniques utilizing medial fascial release have been detailed in an effort to mobilize the myotendinous unit sufficiently to allow primary repair in these scenarios. 4 In the case of significant muscle belly retraction, primary approximation of tendon to the insertion site may not be possible, thus, reconstruction of the tendon is necessary. ...
... However, over the last 20 years, PM injuries have become increasingly more common in both the general public and among NFL players. 3,19 Evidence suggests that the increased incidence of these injuries among the general public may be related to the increased interest in weight training, especially bench-press training. 3 In addition to the bench press, which has been associated with PM tears in 53% of military cadets 4 and 80% of athletes, 5 other factors that have been associated with PM ruptures include older age and anabolic steroid use. ...
... 3,19 Evidence suggests that the increased incidence of these injuries among the general public may be related to the increased interest in weight training, especially bench-press training. 3 In addition to the bench press, which has been associated with PM tears in 53% of military cadets 4 and 80% of athletes, 5 other factors that have been associated with PM ruptures include older age and anabolic steroid use. 4,5 Anabolic steroid use has been hypothesized to predispose individuals to PM tears because of disproportionate gains in maximal force production combined with a stiffer tendon that absorbs less energy and fails with less elongation. ...
... 19 The increase in rate of PM ruptures among NFL players mirrors the overall increased incidence of PM ruptures identified in the general population. 3 Several hypotheses have been suggested that explain the increase rate of PM tears in the general population. First, some attribute the rise in PM ruptures to the increased use of the bench press exercise associated with the popularization of health and fitness. ...
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Background While pectoralis major (PM) tears are rare injuries in National Football League (NFL) athletes (previous study reported only 10 PM ruptures between 2000 and 2010), the incidence of these injuries has increased over the past decade. The impact these injuries have on a player’s performance after return has not been measured. Purpose/Hypothesis To identify player characteristics that may predispose to PM tears and to determine the impact of this injury on return to play and performance. We hypothesized that there would be no difference in performance between the year before and after their injury. Study Design Descriptive epidemiology study. Methods NFL players who experienced PM tears between the years 2010 and 2018 were identified using publicly available reports. Several individual player characteristics were identified and recorded, and the return-to-play rates after injury were determined for each position. The pre- and postinjury Pro Football Focus grades of players who met inclusion criteria were compared. A paired t test analysis of the change in player performance was used for analysis. Results In this study, 63 ruptures were identified between 2010 and 2018. Linebackers had the highest incidence of PM tear compared with any other position. Of all injuries, 79.3% were sustained by defensive players. The majority of PM tears occurred during games. Only 6.9% of players who sustained the injury were suspended for performance-enhancing drug use during their professional career. A total of 85.7% of players returned to play in the NFL after injury. Among those who returned to play there were no significant changes in player performance from pre- to post-injury. Conclusion NFL players demonstrated 85.7% return-to-play rates and no significant drop-off in performance after PM ruptures. During the time period studied, there was an increase in incidence of PM ruptures compared with the previous decade. Further investigation is needed to determine potential causes for the increased incidence of PM ruptures in NFL players.
... 8 Butt et al demonstrated in their review article that acute ruptures have many available techniques for primary repair, such as direct repair, transosseous suture fixation with or without bone trough, anchor fixation, and direct repair to clavipectoral fascia. 9 However, if patients present late, retraction, poor tendinous substance, and the location of the tear can make repair or reconstruction of a chronic PMT rupture challenging. Direct repair techniques are often not possible. ...
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Background: Pectoralis major tendon (PMT) rupture commonly occurs in males 20 to 39 years of age. PMT rupture is most often associated with gym-based exercise, with attempted bench press being the most common causative event, but it is also associated with contact or impact sports. Delayed presentation, misdiagnoses, and chronic PMT rupture can result in a therapeutic dilemma. Case Series: We present 2 cases of chronic PMT rupture that were operatively managed using acellular dermal allograft as an interposition graft. Patients' final follow-ups were at 20 and 30 months, respectively. Strength in their pectoralis major muscle was well preserved on the contralateral side: 88% for patient 1 and 110% for patient 2. Conclusion: Our reported technique using an interpositional acellular dermal allograft is a good option to treat chronic PMT rupture.
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Objective: This study aims to assess a new technique used for pectoralis major reconstruction using bone tunnel and fixation with metallic anchors in the contralateral cortical bone. Methods: Patients who had undergone post-surgical reconstruction of the pectoralis major at least 24 months before were assessed by the UCLA Shoulder Score and the Simple Shoulder Test and compared with the contralateral side by manual goniometry. Subgroup analysis was also performed between grafted and non-grafted patients. Results: 13 patients fulfilled the inclusion criteria. The average UCLA score was 34.77 ± 0.12, compared with the standard 27 of good and excellent results p < 0.0001. The Simple Shoulder test mean was 11.92 ± 0.08. Grafted and non-grafted subgroups had no statistical differences for UCLA p = 0.58 and Simple Shoulder Test p = 1.00. Long term losses for elevation or external rotation were lower than 5º. No lesions recurred. All patients returned to their physical activities with no restrictions. Conclusion: The pectoralis major reconstruction technique using a bone tunnel and metallic anchors in the contralateral cortical bone was effective. However, its execution needs special care to avoid complications. Level of Evidence IV, Case Series.
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This paper presents a three-dimensional nonlinear biomechanical finite element model to simulate elderly breast deformation under arm abduction. The finite element model was constructed based on complex anatomical structures that consist of the soft tissues including torso, breast, pectoralis major muscle, and rigid bones including humerus, sternum, clavicle and ribs. The elderly breast was defined as material nonlinearity and geometric nonlinearity. The computational model can simulate and illustrate the deformation of soft tissues during arm abduction from 30° to 90°. The finite element model was validated by motion data. The Young’s modulus for the clavicular portion and the sternocostal portion of the pectoralis major muscle was characterized as 0.1 MPa and 0.08 MPa, respectively. Besides this, the finite element model presented here features the musculoskeletal system for breast deformation and reveals the synergistic relationship between the breast and the pectoralis major muscle. A questionnaire was conducted to analyze the importance of purchasing factors and the discomfort positions in a sports bra from the perspective of senior women. Combined with the finite element model results, this study provides a promising basis for the design of sports bras in an ergonomic way.
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Introduction Pectoralis major (PM) rupture is a severe injury that untreated can lead to a profound functional deficit. Early surgical repair can greatly improve outcomes and give a more predictable timetable for recovery, making this the goal of current treatment. Surgical intervention is also essential to return professional athletes to their previous level of competition. However, there is no single, reliable and easily reproducible test that can be used to establish the diagnosis. We describe ‘The Cruciform Test’; a method of identifying PM rupture that can be used for initial diagnosis either in clinic or a pitch-side environment, or to assess restoration of normal anatomy and function post-operatively. Methods We studied a series of 14 patients who underwent open PM repair in order to evaluate this method of assessment. Results All patients had a positive test pre-operatively. 5 were formally tested at post-operative follow-up and all had a negative result. Discussion The Cruciform Test is a simple and reproducible diagnostic tool that has potential as a clinical indicator of both PM rupture and successful repair. It can therefore contribute to earlier diagnosis, prompt surgical intervention and facilitate return to play at the earliest opportunity.
Article
»: Pectoralis major (PM) tendon tears are predominantly seen in young men, and the majority of tears occur as tendon avulsions involving the sternal head. Weightlifting, specifically bench-pressing, and sporting activities with eccentric overloading of the PM tendon are the 2 most common activities that result in PM injury. »: Early surgical repair or reconstruction should be offered to younger, active patients with a complete PM tear; the majority of the patients undergoing surgical repair achieve good-to-excellent outcomes. »: Nonsurgical treatment of a complete PM tear is an option but will result in cosmetic deformity and a deficit in adduction strength of the arm. Outcomes after nonsurgical treatment of complete PM tears are less satisfactory than those obtained after surgical treatment. »: Currently, there is no consensus on the chronological definition of PM tears (acute versus chronic), the critical time limit for performing surgical repair, the ideal fixation device (cortical button, bone tunnel, or suture anchors), the indications for allograft use, and the ideal rehabilitation protocol after treatment of PM tears.
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Purpose The purpose of this study was to determine return-to-play (RTP), performance and career survivorship for National Football League (NFL) athletes sustaining pectoralis major (PM) injuries with comparison among grades of injury and between nonoperative and operative management. Methods Publicly available data from the 1998–2020 NFL seasons were reviewed to identify athletes with PM injuries. Athlete characteristics were collected 1 season before and 2 seasons after injury. Percent of total games played in a season, player efficiency rating (PER), and Pro Football Focus (PFF) grades were compared for the preinjury season and 2 postinjury seasons. Kaplan-Meier survivorship plots were computed for RTP and postinjury career length, whereas a log-rank test was used to compare survivorship differences. Results In total, 258 PM injuries were reported at a mean age of 27.1 ± 3.3 years. A total of 126 surgical repairs occurred in 48.8% (n = 126) of injuries, with athletes undergoing repair possessing a lower RTP rate and longer time to RTP compared to athletes treated conservatively (P < .001). Survival analysis revealed shorter career length for athletes sustaining PM tears compared to strains (P < .001), although no difference in career length was appreciated on the basis of injury management (P = .980). Defensive linemen and wide receivers had lower PER during their second postinjury seasons (P = .019 and .030, respectively), whereas defensive linemen had lower PFF grades during their second post-injury seasons (P = .044). Conclusion NFL athletes requiring PM repair may experience a lower likelihood of RTP, and longer RTP timing, likely because of higher-grade injuries. Defensive linemen and wide receivers experiencing PM injuries are at risk for diminished performance post-injury. Career length does not appear to be affected based on injury management. Level of Evidence Level III, cohort study.
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Introduction: This anatomical study of the pectoral nerves and their innervation is to provide detail informations on the pectoral nerves and their variations in their course, to guide the cosmetic and plastic surgeons for their easy intra operative localization and to improve the understanding of the pectoral muscle innervation, which is very much required during breast reconstruction after modified radical mastectomy (MRM) in breast cancer; axillary dissection; removal of the pectoralis minor muscle, and in harvesting the pectoralis major for myocutaneous head and neck island flap surgeries. Materials and methods: A total of 50 pectoral region specimens (both right and left sided) from 25 embalmed adult human cadavers (20 female & 05 male) were studied by dissection method. Statistical analysis: The data were tabulated in Microsoft excel and analysed by using Statistical Package for Social Science (SPSS 17(th) version). Mean, Proportion, Standard deviation and Unpaired t-test were applied for analysing the data obtained. Result and conclusion: In all the specimens, the medial pectoral nerve pierces the pectoralis minor muscle; but as a single trunk in 76%, and as dividing branches in 34% specimens. The extent of costal attachment of the pectoralis minor muscle found to be less than 6.0 cm in cases of the medial pectoral nerve piercing the pectoralis minor muscle as a single trunk. The medial pectoral nerve after piercing the pectoralis minor, ramify within the muscle supplying it, finally runs along the lateral aspect (lower border) of the pectoralis minor muscle to supply the lower portion or distal segment of the pectoralis major muscle. Similarly, the lateral pectoral nerve runs along the upper border (medial aspect) of the pectoralis minor muscle (98%) and then runs under surface of the pectoralis major muscle along with the pectoral branch of thoracoacromial artery, supplying the upper portion or most of the proximal 2/3(rd) of the pectoralis major muscle. Therefore, when the pectoralis minor muscle is removed in a modified radical mastectomy or during dissection between the two muscles, there is partial denervation of the pectoralis major muscle with partial atrophy and decrease in muscle mass. If the lateral pectoral nerve also injured along with the medial pectoral nerve, it can result in total denervation of the pectoralis major muscle with severe atrophy and fibrosis. In breast augmentation implants placing behind the pectoralis major muscle, it is found to be more advantageous if the pectoralis major muscle is partially denervated for the better projection and contour. The distance of the branches of the medial pectoral nerve and the lateral pectoral nerve in the pectoral muscles from the lateral margin of the sternum being 8.8-10.8 cm and 5.8-10.2 cm respectively. The proximal segment or upper portion of the pectoralis major muscle has got separate independent vascular and nerve supply; therefore, it can be safely used as a myocutaneous flap in surgeries of head and neck or anterior chest wall.
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The effect of anabolic androgenic steroids on tendons has not yet been fully elucidated. Aim of the present study was the evaluation of the impact of anabolic androgenic steroids on the biomechanical and histological characteristics of Achilles tendons. Twenty-four male Wistar rats were randomized into four groups with exercise and anabolic steroids (nandrolone decanoate) serving as variables. Protocol duration was 12 weeks. Following euthanasia, tendons' biomechanical properties were tested with the use of a modified clamping configuration. Histological examination with light and electron microscopy were also performed. In the group of anabolic steroids and exercise the lowest fracture stress values were observed, while in the exercise group the highest ones. Histological examination by light and electron microscopy revealed areas of collagen dysplasia and an increased epitendon in the groups receiving anabolic steroids and exercise. These findings suggest that anabolic androgenic steroids reverse the beneficial effect of exercise, thus resulting in inferior maximal stress values.
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Background Early recognition of the clinical signs of ruptures of the pectoralis major muscle (PMM) in athletes by orthopaedic surgeons, physical therapists, and physical trainers may prove to be critical for patient access to surgical treatment while the injury is still in the acute phase. Hypothesis Total ruptures of the PMM may yield a better outcome with surgical treatment than with nonoperative treatment in athletes. Study Design Cohort study; Level of evidence, 2. Methods A prospective study was performed on 60 patients with total ruptures of the PMM. The patients were followed from 1997 to 2012, with a physical examination every 6 months for the first 2 years and every 12 months thereafter. The patients’ mean age was 31.21 years, and the mean length of follow-up was 48.25 months. The surgical treatment methods included reinsertion of the tendon in 51% of the patients and nonoperative treatment in 49% of the patients. All of the patients were evaluated using the Bak criteria. Results The bench-press exercise was associated with 80% of the PMM ruptures (48 patients). Forty-one of the patients with chronic ruptures were seen after 3 months (80%). The outcomes were poor in 9 patients from the nonoperative group (31%) and in 3 patients from the surgical group (9.7%); the outcomes were fair in 12 patients from the nonoperative group and in no patients from the surgical group. Excellent results were not observed in any patient from the nonoperative group and were observed in 21 patients from the surgical group (67.7%). The isokinetic evaluation at 60 deg/s showed a decrease in strength of 41.7% in the nonsurgical group and 14.3% for the surgical group, which was significant at P < .05. Conclusion Total ruptures of the PMM exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes.
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Background. Pectoralis major tendon ruptures have been reported in the literature as occupational injuries, accidental injuries, and sporting activities. Few cases have been reported with respect to rodeo activities. Purpose. To describe a series of PM tendon ruptures in professional steer wrestlers. Study Design. Case series, level of evidence, 4. Methods. A retrospective analysis of PM ruptures in a steer wrestling cohort was performed. Injury data between 1992 and 2008 were reviewed using medical records from the University of Calgary Sport Medicine Center. Results. Nine cases of pectoralis major ruptures in professional steer wrestlers were identified. Injuries occurred during the throwing phase of the steer or while breaking a fall. All athletes reported unexpected or abnormal behavior of the steer that contributed to the mechanism of injury. Seven cases were surgically repaired, while two cases opted for nonsurgical intervention. Eight cases reported successful return to competition following the injury. Conclusion. Steer wrestlers represent a unique cohort of PM rupture case studies. Steer wrestling is a demanding sport that involves throwing maneuvers that may predispose the muscle to rupture. All cases demonstrated good functional outcomes regardless of surgical or non-surgical treatment.
Article
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Over the past few decades, there has been increased awareness of pectoralis major muscle injuries necessitating further evaluation of management options and, in particular, surgical repair. Injury typically occurs when an eccentric load is applied to the muscle, such as with bench pressing, and failure usually occurs through the tendon. Although nonoperative management is sometimes appropriate, given the injury's propensity for young, active male patients, surgical intervention is often warranted. Because the injury typically occurs at the muscle-tendon interface, surgery focuses on repair of the avulsed tendon into its anatomic attachment site. We describe the use of a unicortical suture button to repair the ruptured tendon. This technique achieves the goals of strong fixation and anatomic repair of the tendon back into its native footprint.
Article
Pectoralis major (PM) tendon rupture is an uncommon injury whose incidence has risen in recent decades mainly as a result of the increasing number of sports-practising individuals. This study evaluates clinical and ultrasound (US) outcomes after surgical repair of acute and chronic PM tendon rupture. Twelve men with PM tendon rupture (9 right and 3 left shoulders) were enrolled. Mean age was 34.6 years, and mean follow-up was 60 months (range 12-108). Rupture was diagnosed by magnetic resonance imaging. Eight patients underwent direct tendon repair (acute group) and 4 had allograft reconstruction (chronic group). Pain, range of motion, strength recovery and return to sports were assessed. Postoperative X-ray and US scans were obtained in all patients. Final outcomes were graded as excellent, good, fair or poor. Isometric strength in adduction/abduction, flexion, internal rotation (IR) and external rotation was recorded. There were 9 excellent and 3 good outcomes. A comparative strength assessment failed to show significant differences in any plane. Mean strength was not significantly different between affected and unaffected arm. Slight but significantly lower strength in IR with the arm adducted (p = 0.0306) was found in chronic patients. On US, all PM tendons appeared to be anatomically intact and continuous with the humerus. Prompt surgical repair ensures satisfactory outcomes in patients with complete PM rupture; however, delayed allograft repair provides good results with only slight strength impairment. Fresh insights are provided on the role of US in evaluating PM anatomy and tendon attachment to bone.
Article
Bony avulsion of the pectoralis major muscle is a rare but potentially devastating injury for athletes. Pectoralis major rupture typically occurs in 20 to 39 year-old males. The shoulder region is one of the most frequently injured areas in Judo athletes. The purpose of this case report is to describe diagnosis and treatment following a pectoralis major bony avulsion due to an atypical mechanism of injury in a young Judo athlete. A 19-year-old military cadet and competitive judo athlete reported to a direct-access sports physical therapy clinic 7 weeks after incurring a shoulder injury during a judo match. He complained of shoulder pain and weakness with the inability to perform pushups. He presented with horizontal adduction weakness and visible discontinuity of the pectoralis muscle with resisted adduction. Radiographs demonstrated a bony avulsion of the pectoralis major from its humeral attachment. The patient underwent surgical repair of the lesion the next week and was able to resume most military cadet activities within 5 months post-operation. Bony avulsions are exceptionally rare injuries, and are even more uncommon in athletes under the age of 20. It is important for clinicians to perform a thorough history and physical examination in order to avoid missing this diagnosis. Surgery is likely the best option for a young athletic population; while conservative management may be optimal for the older, inactive population. 4.
Article
Rupture of the pectoralis major muscle is a rare injury, with less than 200 reported cases in the literature since its initial description in 1822 by Patissier. The majority of these cases have been documented over the past few years, showing the growing appreciation and awareness of this injury. Injuries are most commonly sustained by young men during athletic or weightlifting activity, which comprise a large proportion of our military population. Ruptures usually occur when the muscle is eccentrically contracting under an extensive load. However, direct trauma to the muscle may also result in injury. Acute symptoms often consist of swelling, ecchymosis and pain over the affected axilla and pectoral region, and diminished strength. On physical examination, typical findings include an abnormal contour of the axilla and reduced adduction and internal rotation strength. Clinical diagnosis can be supported with imaging. Magnetic resonance imaging is the modality of choice, adequately showing the location and extent of injury. Tears are most common at the tendon or myotendinous junction. In young active individuals, ruptures of the pectoralis major muscle have the best results after surgical repair, acutely or delayed. Conservative treatment is usually reserved for muscle belly tears or elderly, sedentary individuals.
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We have reported an unusual case of pectoralis major muscle rupture and repair. There were three interesting aspects of this case. First, the injury occurred in a football player with an unusual mechanism of injury. Second, MRI using special techniques was valuable in confirming the diagnosis acutely and in planning treatment. Finally, we reported on the use of suture anchors to secure the avulsed tendon. We recommend the early use of MRI for diagnosis and in planning treatment of suspected pectoralis major muscle ruptures. Language: en