Insertion anatomy of the pectoralis major tendon

Pectoralis major rupture repair with Achilles tendon allograft in 22 bodybuilding athletes

BACKGROUND

Pectoralis major tendon rupture rate is increasing due to increased tendency to bodybuilding exercises, specially the bench press workout, and weight-lifting. The aim of this study was to determine the results of pectoralis major rupture repair with Achilles tendon allograft in bodybuilding athletes.

METHODS

In this case series study, 22 bodybuilding athlete patients (24 pectoralis major ruptures) were undergone open surgical repair during January 2016 till December 2020. 21 ruptures were chronic (2 ruptures were revision) and 3 ruptures were acute. Surgical method was based on Achilles tendon allograft used to augment the ruptured site for lengthening the shortened tendon.The results were analyzed using Bak's criteria and Constant score in pre operation visit and 6th and 12th months and in the last follow up.

RESULTS

All cases were male with the mean age of 32.1 ± 5.4. The mean duration time between injuries to surgery was 37 ± 46 month (1-182 months). Return to professional sport began at 10.9 ± 2.8 months after surgery in which 16 cases (66.7%) have returned to their pre surgery bench press workout records. No infection or hematoma occurred. At the final follow-up, Bak criteria demonstrated excellent, good and fair in 4, 18 and 2 shoulders respectively. The constant score increased from 87.9 ± 7.9 in pre operation visit to 92.7 ± 6.4 in the last follow up (P < 0.001).

CONCLUSIONS

It seems that our surgical method is an effective approach in cases with acute or chronic pectoralis major ruptures.

LEVEL OF EVIDENCE

Level IV.

The smoke sign: a secondary sign of unsuspected acute pectoralis major tendon injury on routine shoulder MRI

OBJECTIVE

To study the diagnostic utility of the "smoke sign" to detect unsuspected acute pectoralis major tendon injury on routine shoulder MRI.

MATERIALS AND METHODS

Retrospective study of 52 shoulder MRI in patients with (38) and without (14) acute pectoralis major injury confirmed on imaging. Two readers independently reviewed shoulder MRI for the presence of the "smoke sign"-feathery soft tissue edema lateral or anterior to short head biceps/coracobrachialis on fluid-sensitive coronal-oblique and sagittal-oblique images, respectively.

RESULTS

The smoke sign was present on shoulder MRI in 24/24 (100%) humeral avulsions, 4/4 (100%) tendon tears, 4/8 (50%) of myotendinous junction injuries, and 0/2 (0%) intramuscular injuries. The smoke sign was present in 0/14 examinations without acute pectoralis major injury.

CONCLUSION

While dedicated pectoralis MRI remains the preferred method for imaging pectoralis injury, the "smoke sign" can serve as an easy to recognize finding on routine shoulder MRI that can raise the suspicion of an acute pectoralis major tendon injury. Its detection should prompt evaluation of the pectoralis major tendon and recommendation for dedicated imaging to confirm and evaluate the full extent of injury.

Performance and Survivorship of National Football League Players with Pectoralis Major Injuries

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.

Pectoralis Major Tendon Tear: A Critical Analysis Review

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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.

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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.

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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.

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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.

Pectoralis major tendon and enthesis: anatomic, magnetic resonance imaging, ultrasonographic, and histologic investigation

BACKGROUND

This study evaluates the pectoralis major (PM) tendon humeral insertion, using imaging and histologic assessment in cadaveric specimens. Current descriptions of the pectoralis major tendon depict a bilaminar enthesis, and clarification of the anatomy is important for diagnostic and surgical considerations.

MATERIALS AND METHODS

Fourteen fresh-frozen whole upper extremity specimens were used in this study. Magnetic resonance (MRI) and ultrasonographic (US) imaging of the PM muscles, tendons, and entheses were performed, followed by anatomic dissection and inspection. Morphology of the lateral tendon and entheses were evaluated, focused on the presence of layers. In 11 specimens, the lateral 3 cm of the PM tendon was carefully dissected from the footprint, whereas in 3 specimens, the tendon and humeral insertion were preserved and removed en bloc. Histology was performed in axial slabs along the medial-lateral length of the tendon and also evaluated for the presence of layers.

RESULTS

The superior-inferior and medial-lateral lengths of the PM footprint were 75 ± 9 mm and 7 ± 1 mm respectively. In all specimens, the clavicular and sternal head muscles and tendons were identified, with the clavicular head tendon generally being shorter. The medial-lateral length of the clavicular head tendon measured 19 ± 8 mm superiorly and 9 ± 3 mm inferiorly. The medial-lateral length of the sternal head tendon measured 38 ± 8 superiorly and 41 ± 18 mm inferiorly. All specimens demonstrated a unilaminar, not bilaminar, enthesis with abundant fibrocartilage on histology. Three specimens demonstrated interspersed entheseal fat and loose connective tissue at the enthesis on MRI and histology.

CONCLUSION

The PM tendon humeral insertion consists of a unilaminar fibrocartilaginous enthesis. US, MRI, and histology failed to identify true tendon layers at the enthesis. Delaminating injuries reported in the literature may originate from a location other than the enthesis.

Surgical anatomy of the pectoralis major tendon insertion revisited: relationship to nearby structures and the pectoral eminence for defining the anatomic footprint

Background

Intraoperative identification of the normal pectoralis major (PM) footprint can be challenging to identify in the acute and chronic settings. The purpose of this study was to revisit the anatomic footprint of the PM tendon and to determine which nearby landmarks can be used to re-create the normal insertion site during anatomic repair or reconstruction.

Methods

Twenty-one fresh-frozen human cadaveric shoulder specimens were used to define the PM tendon width (ie, superior-to-inferior) and to determine the relationship between the superior aspect of the PM insertion and that of the latissimus dorsi (LD) and anterior deltoid (AD) tendons. An attempt was made to identify potential useful bony landmarks that can be used during anatomic repair or reconstruction of the PM tendon.

Results

The mean PM tendon width was 68.8 ± 4.4 mm. The superior margin of the LD insertion was 9.4 ± 5.9 mm above and the AD was 48.4 ± 7.1 mm below the superior margin of the PM tendon insertion, respectively. In 17 of 21 specimens (81%), the superior insertion of the PM tendon attached onto a bony prominence, named the pectoral eminence.

Conclusions

The LD and AD tendon insertions represent reliable soft tissue landmarks for identifying the superior extent of the PM tendon along its bony footprint. The pectoral eminence can also be used as an additional reference point in the majority of cases to facilitate anatomic restoration of the pectoralis tendon during repair and reconstruction. Surgeons should be familiar with the proximity of nearby neurovascular structures when performing PM repairs.