Rupture of the pectoralis major: a case report and review

Complete Pectoralis Major Tendon Rupture With Bony Avulsion in an Adolescent Male: A Case Report and Literature Review

Pectoralis major (PM) tendon ruptures are rare. Typically, they are caused by eccentric contractions from weight lifting. Due to the rarity of pectoralis major tendon ruptures, clinicians might misdiagnose this condition. We report a 16-year-old male with a right pectoralis major tendon rupture and an avulsion fracture after falling on a grass field playing soccer. He was initially misdiagnosed with biceps tendonitis, which highlights the importance of including pectoralis major tendon ruptures in one's differential diagnoses.

Pectoralis major rupture in body builders: a case series including anabolic steroid use

BACKGROUND

Rupture of the pectoralis major (PM) muscle is a rare injury, with increasing incidence over the last decades, mainly due to participation in weightlifting and contact sports. Surgical management of PM injuries has been related with superior functional outcome, faster return to activities, better cosmesis and higher level of patients' satisfaction. The aim of the study is to present our experience in the management of this rare clinical entity and to correlate the use of anabolic steroids in the occurrence of the injury and the impact of type of injury, method of reconstruction and anabolic steroids on the post-operative outcome.

CASES

We present a series of six male bodybuilding athletes who sustained PM rupture during weightlifting. We recorded the location & type of injury, the history and type of anabolic steroids use, the method of repair and the post-operative outcome.

TREATMENT AND OUTCOMES

The mean follow-up period was 16 (12-24) months. All patients treated surgically had excellent results according to Bak criteria and returned to full activity within 5.4 (5-7) months following surgical reconstruction. No post-operative complications were recorded, despite the continued use of anabolic steroids, however one patient died from myocardial infarction within a year of surgical treatment.

CONCLUSIONS

PM rupture is an injury with increasing incidence within bodybuilding athletes probably not related to the dominance of the limb. Fixation of the tendon with suture anchors results in excellent clinical outcome and patient's satisfaction postoperatively regardless the chronicity of the repair. Our observations in these cases suggest that anabolic steroids use may contribute to the injury due to an excessive upward adjustment of the athlete's goals in lifting weights and moreover the continuation of administration even in the recovery period does not seem to have a negative effect either on the time or on the level of adequate functional recovery postoperatively.

Return to Work After Pectoralis Major Repair

Background:

Pectoralis major repair (PMR) is an infrequent injury that occurs during resistance training, most commonly during the eccentric phase of muscle contraction. As the incidence of weight training continues to increase, it is important to understand the outcomes after PMR.

Purpose:

To evaluate the rate and duration of return to work in patients undergoing PMR.

Study Design:

Case series; Level of evidence, 4.

Methods:

Consecutive patients undergoing PMR from 2010 to 2016 at a single institution were retrospectively reviewed at a minimum of 1 year postoperatively. Patients completed a standardized and validated work questionnaire, as well as a visual analog scale for pain, American Shoulder and Elbow Surgeons survey, Single Assessment Numerical Evaluation, and a satisfaction survey.

Results:

Of the 60 eligible patients who had a PMR, 49 (81.7%) were contacted at the final follow-up. Of the 49 patients, 46 (93.9%) had been employed within 3 years before surgery (mean ± SD age, 40.4 ± 8.2 years; follow-up, 3.9 ± 2.8 years). Of these, 45 (97.8%) returned to work by 1.6 ± 2.1 months postoperatively, and 41 (89.1%) returned to the same level of occupational intensity. Patients who held sedentary, light-, medium-, or high-intensity occupations returned to work at a rate of 100.0%, 100.0%, 83.3%, and 66.7% by 0.8 ± 1.0, 0.8 ± 1.0, 1.3 ± 2.7, and 3.3 ± 2.7 months, respectively. Five of 6 patients (83.3%) with workers’ compensation returned to their previous occupations by 5.0 ± 1.6 months, while 100% of those without workers’ compensation returned to work by 1.1 ± 1.7 months (P < .001). Overall, 44 patients (95.7%) were satisfied with the procedure, and 40 (87.0%) would have the operation again if presented the opportunity. A single patient (2.2%) required revision PMR.

Conclusion:

Approximately 98% of patients who underwent PMR returned to work by 1.6 ± 2.1 months postoperatively. Patients with higher-intensity occupations took longer to return to their preoperative levels of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

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.

Injuries in Muscle-Tendon-Bone Units: A Systematic Review Considering the Role of Passive Tissue Fatigue

Background:

Low-cycle fatigue damage accumulating to the point of structural failure has been recently reported at the origin of the human anterior cruciate ligament under strenuous repetitive loading. If this can occur in a ligament, low-cycle fatigue damage may also occur in the connective tissue of muscle-tendon units. To this end, we reviewed what is known about how, when, and where injuries of muscle-tendon units occur throughout the body.

Purpose:

To systematically review injuries in the muscle-tendon-bone complex; assess the site of injury (muscle belly, musculotendinous junction [MTJ], tendon/aponeurosis, tendon/aponeurosis–bone junction, and tendon/aponeurosis avulsion), incidence, muscles and tendons involved, mechanism of injury, and main symptoms; and consider the hypothesis that injury may often be consistent with the accumulation of multiscale material fatigue damage during repetitive submaximal loading regimens.

Methods:

PubMed, Web of Science, Scopus, and ProQuest were searched on July 24, 2019. Quality assessment was undertaken using ARRIVE, STROBE, and CARE (Animal Research: Reporting In Vivo Experiments, Strengthening the Reporting of Observational Studies in Epidemiology, and the Case Report Statement and Checklist, respectively).

Results:

Overall, 131 studies met the inclusion criteria, including 799 specimens and 2,823 patients who sustained 3,246 injuries. Laboratory studies showed a preponderance of failures at the MTJ, a viscoelastic behavior of muscle-tendon units, and damage accumulation at the MTJ with repetitive loading. Observational studies showed that 35% of injuries occurred in the tendon midsubstance; 28%, at the MTJ; 18%, at the tendon-bone junction; 13%, within the muscle belly and that 6% were tendon avulsions including a bone fragment. The biceps femoris was the most injured muscle (25%), followed by the supraspinatus (12%) and the Achilles tendon (9%). The most common symptoms were hematoma and/or swelling, tenderness, edema and muscle/tendon retraction. The onset of injury was consistent with tissue fatigue at all injury sites except for tendon avulsions, where 63% of the injuries were caused by an evident trauma.

Conclusion:

Excluding traumatic tendon avulsions, most injuries were consistent with the hypothesis that material fatigue damage accumulated during repetitive submaximal loading regimens. If supported by data from better imaging modalities, this has implications for improving injury detection, prevention, and training regimens.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods

BACKGROUND

Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods.

PURPOSE/HYPOTHESIS

The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation.

STUDY DESIGN

Meta-analysis.

METHODS

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months' mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05.

RESULTS

Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 (P = .004) and satisfaction with cosmesis by 20.50% (P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair.

CONCLUSION

Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.

Magnetic Resonance Imaging of Pectoralis Major Injuries in an Active Duty Military Cohort: Mechanism Affects Tear Location

Background:

Pectoralis major (PM) tendon tears are common injuries in athletic patient populations, where operative repair is largely recommended for maximum functional recovery. The repair varies in difficulty and technique based on the location of the tear within the muscle-tendon unit. Magnetic resonance imagining (MRI) has been reported to be sensitive and specific for identifying the tear location, but the effect of injury mechanism on tear pattern has not been previously investigated.

Purpose:

To examine PM tears in a military patient population and assess the effect of injury mechanism (weightlifting vs high-energy trauma) on the tear pattern and accuracy of MRI interpretation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Active duty military servicemembers undergoing operative repair of PM tendon tears with corresponding preoperative MRIs from 2 medical centers were identified. Two musculoskeletal fellowship–trained radiologists reviewed imaging studies, reporting the location of the tear within the muscle-tendon unit and the severity of the tear (sternal head vs clavicular head vs both). Radiographic findings were compared against intraoperative findings. Mechanism of injury and timing from injury to imaging and surgery were assessed to determine whether they affected the accuracy of MRI interpretations.

Results:

A total of 72 patients were included (mean ± SD age, 33.7 ± 7.0 years; 100% male). Mechanisms of injury consisted of 46 weightlifting injuries and 26 high-energy injuries. Interrater reliability was poor for tear location (kappa, 0.162; P = .003) but substantial for extent of tear (kappa, 0.637; P < .0001). MRI had a 51.3% sensitivity and 63.6% specificity for identifying complete tears. MRI had a sensitivity of 73.9% and specificity of 72.2% for avulsion injuries and sensitivity of 75% and specificity of 79.3% for musculotendinous injuries. Mechanism of injury had no effect on extent of the tear but did affect the location of the tear, with a higher rate of avulsion injuries in the high-energy mechanism cohort (81% vs 40%; P = .02).

Conclusion:

The mechanism of injury was found to significantly affect the location of tendon tears. A higher rate of avulsion injuries was found in high-energy injuries than weightlifting injuries. MRI appeared to be less sensitive and specific than previous reports for traumatic PM tendon injuries.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment

Background:

The incidence of pectoralis major tendon tears is increasing, and repair is generally considered; however, a paucity of comparative data are available to demonstrate the superiority of operative treatment.

Purpose/Hypothesis:

The purpose of this study is to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared with nonoperative treatment.

Methods:

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed by use of MEDLINE, SPORTDiscus, CINAHL, Cochrane, EMBASE, and Web of Science databases. We included English-language studies that had a minimum of 6 months of average follow-up and 5 cases per study. The MINORS (Methodological Index for Non-Randomized Studies) was used to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect sizes were calculated from random-effects models. Continuous variables were assessed by use of mixed-model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed via the Freeman-Tukey log-linear transformation for variance stabilization and then assessed through use of a mixed model with a study level random effect and subsequently back-transformed. Significance was set at P < .05.

Results:

A total of 23 articles with 664 injuries met the inclusion criteria for comparison. All patients were male, with an average age of 31.48 years; 63.2% of injuries occurred during weight training, and the average follow-up was 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment, with relative improvements of functional outcome by 23.33% (0.70 improvement by Bak criteria which is scored 1-4; P = .027), full isometric strength 77.07% (P < .001), isokinetic strength 28.86% (P < .001) compared with the uninjured arm, cosmesis satisfaction 13.79% (P = .037), and resting deformity 98.85% (P < .001). The overall complication rate for operative treatment was 14.21%, including a 3.08% rate of rerupture.

Conclusion:

Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. Statistically significant improvements were noted in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity.

Narrative review of injuries in powerlifting with special reference to their association to the squat, bench press and deadlift

Pain and injuries are considered a common problem among elite athletes and recreational lifters performing the squat, bench press and deadlift. Since all three lifts engage multiple joints and expose the lifters’ bodies to high physical demands often several times a week, it has been suggested that their injuries might be related to the excessively heavy loads, the large range of motion during the exercises, insufficient resting times between training sessions and/or faulty lifting technique. However, no previous article has summarised what is known about specific injuries and the injury aetiology associated with the three lifts. Thus, the aim of this narrative review was to summarise what is known about the relationships between the powerlifting exercises and the specific injuries or movement impairments that are common among lifters and recreationally active individuals.

Thoracic wall trauma-misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging

Blunt injuries to the chest wall are an important chapter on emergency room (ER) departments, being the third most common injuries in trauma patients which ominous complications could appear. This article describes different types of traumatic events affecting the chest wall, which maybe misdiagnosed with conventional X-ray. Special emphasis has been done in computed tomography (CT) and multidetector CT (MDCT) imaging. This technique is considered the "gold-standard" for those traumatic patients, due to its fast acquisition covering the whole area of interest in axial plane, reconstructing multiplanar (2D, 3D) volume-rendered images with a superb quality and angiographic CT capabilities for evaluating vascular damage. Complementary techniques such as ultrasonography (US) and magnetic resonance imaging (MRI) may improve the diagnostic accuracy due to its great capacity in visualising soft-tissue trauma (muscle-tendinous tears) and subtle fractures. All these imaging methods have an important role in quantifying the severity of chest wall trauma. The findings of this study have been exposed with cases of our archives in a didactic way.

Outcome of repair of chronic tear of the pectoralis major using corkscrew suture anchors by box suture sliding technique

AIM

To assess the functional and clinical results of repair of chronic tears of pectoralis major using corkscrew and sliding suture technique.

METHODS

In this retrospective study, we reviewed the results of pectoralis major repair in 11 chronic cases (> 6 wk) done between September 2011 and December 2014 at our institute. In all cases repair was done by same surgeon using corkscrew suture anchors and box suture sliding technique. At 6 mo, after surgery magnetic resonance imaging was done to see the integrity of the repair. Functional evaluation was done using Penn and ASES scores. Pre and postoperative Isokinetic strength was measured.

RESULTS

Average follow-up was 48.27 ± 21.0 mo. The Wilcoxon signed rank test was used to evaluate the outcome scores. The average ASES score increased from an average of 54.63 ± 13.0 preoperatively to 95.09 ± 2.60 after surgery at their last follow-up. The average Penn score also increased from 5.72 ± 0.78, 2.81 ± 1.32 and 45.81 ± 1.72 to 9.36 ± 0.80, 8.27 ± 0.90 and 59 ± 1.34 for pain, satisfaction and function respectively. Follow up magnetic resonance imaging (MRI) (at 6 mo) showed continuity and the bulk of pectoralis major muscle in all cases. Average isokinetic strength deficiency in horizontal adduction at 60° was 13.63% ± 6.93% and at 120° was 10.18% ± 4.93% and in flexion at 60° was 10.72% ± 5.08% and at 120° was 6.63% + 3.74%. Results showed that both ASES and Penn score improved significantly (2 tailed P value = 0.0036).

CONCLUSION

We could conclude from this series that pectoralis major repair even in chronic cases using 5.5 mm corkscrew anchors give excellent functional and cosmetic results. In chronic cases the repairable length of the tendon is not available and sliding suture technique allows for fixation of worn out tendomuscular junction to bone without letting cutting through the muscle.

Acute Pectoralis Major Rupture Captured on Video

Pectoralis major (PM) ruptures are uncommon injuries, although they are becoming more frequent. We report a case of a PM rupture in a young male who presented with axillar pain and absence of the anterior axillary fold after he perceived a snap while lifting 200 kg in the bench press. Diagnosis of PM rupture was suspected clinically and confirmed with imaging studies. The patient was treated surgically, reinserting the tendon to the humerus with suture anchors. One-year follow-up showed excellent results. The patient was recording his training on video, so we can observe in detail the most common mechanism of injury of PM rupture.

Pectoralis major ruptures in professional American football players

BACKGROUND

Pectoralis major injuries are an infrequent shoulder injury that can result in pain, weakness, and deformity. These injuries may occur during the course of an athletic competition, including football. The purpose of this study was to determine the incidence of pectoralis major ruptures in professional football players and time lost from the sport following injury. We hypothesized that ruptures most frequently occur during bench-press strength training.

METHODS

The National Football League Injury Surveillance System was reviewed for all pectoralis major injuries in all players from 2000 to 2010. Details regarding injury setting, player demographics, method of treatment, and time lost were recorded.

RESULTS

A total of 10 injuries-complete ruptures-were identified during this period. Five of the 10 were sustained in defensive players, generally while tackling. Nine occurred during game situations, and 1 occurred during practice. Specific data pertinent to the practice injury was not available. No rupture occurred during weight lifting. Eight ruptures were treated operatively, and 2 cases did not report the method of definitive treatment. The average days lost was 111 days (range, 42-189). The incidence was 0.004 pectoralis major ruptures during the 11-year study period.

CONCLUSIONS

Pectoralis major injuries are uncommon while playing football. In the National Football League, these injuries primarily occur not during practice or while bench pressing but rather during games. When pectoralis major ruptures do occur, they are successfully treated operatively. Surgery may allow for return to full sports participation.

LEVEL OF EVIDENCE

IV, case series.

Defining the terms acute and chronic in orthopaedic sports injuries: a systematic review

BACKGROUND

Although many authors report on acute injuries and chronic injuries in the orthopaedic literature, the actual terms are seldom explicitly defined.

HYPOTHESIS

Much of the literature pertaining to sports injuries that are acute or chronic does not define these terms. It is believed that definitions will provide clarity and specificity in future literature.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of 116 articles was conducted to determine whether and how the terms acute and chronic were defined as they pertain to several commonly treated conditions: Achilles tendon rupture, distal biceps tendon rupture, pectoralis major tendon rupture, anterior cruciate ligament (ACL) tear, anterior shoulder instability, and acromioclavicular (AC) joint dislocation. Articles were isolated from various databases and search engines by use of keywords to identify relevant literature.

RESULTS

This study determined that the terms acute and chronic for each injury are defined, respectively, as follows: Achilles tendon rupture: <1 week, >4 weeks; distal biceps tendon rupture: <6 weeks, >12 weeks; pectoralis major tendon rupture: <6 weeks, >6 weeks; ACL tear: <6 weeks, >6 months; anterior shoulder instability: <2 weeks, >6 months; AC joint dislocation, <3 weeks, >6 weeks.

CONCLUSION

The current literature varies greatly in defining the terms acute and chronic in common sports injuries. The vast majority of authors imply these terms, based on the method of their studies, rather than define them explicitly. Injuries involving tendons showed greater consistency among authors, thus making a definition based on consensus easier to derive. The literature on ACL and shoulder instability in particular showed great variability in defining these terms, likely representing the more complex nature of these injuries and the fact that timing of surgery in the majority of patients does not particularly affect the complexity of the surgical approach and treatment.

CLINICAL RELEVANCE

Defining injuries as acute or chronic is clinically relevant in many cases, particularly concerning tendon injuries, where these terms have implications regarding the anatomic pathologic changes and tissue quality, which may necessitate augmentation and alter the initial surgical plan. In cases where these terms are less pertinent to operative treatment considerations, they bring clarity to the discussion of the acuity of the injury (as it pertains to time from insult).

Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears

Background:

Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment.

Purpose:

To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the “military press” starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique.

Results:

Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76).

Conclusion:

The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

Repair of pectoralis major ruptures: single-surgeon case series

Rupture of the pectoralis major is an uncommon injury that can lead to pain, loss of strength, and cosmetic deformity. The purpose of this study was to analyze the outcome of pectoralis major repairs by a single surgeon. Twenty-four patients who underwent pectoralis major repair by the senior author (M.D.L.) between May 2005 and March 2011 were retrospectively identified. Patients were assessed at least 6 months postoperatively with the use of various questionnaires, including the Penn Shoulder Score, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, and Single Assessment Numeric Evaluation (SANE). All patients were men with an injury to the sternal head of the pectoralis. Most (16/24; 67%) patients sustained the injury while bench or incline bench pressing. Nineteen (79%) patients were successfully contacted for follow-up. Of these, an average preinjury bench press of 318 lb (range, 145-525 lb) was restored to an average of 264 lb (range, 100-500 lb) at follow-up. Average preoperative Penn Shoulder Score was 60 points (range, 33-77 points), improving to 94 points (range, 64-100 points) at last follow-up (P=.011). Average postoperative ASES and SANE scores were 96 points (range, 60-100 points) and 93 points (range, 50-100 points), respectively. All but 1 patient were rated excellent (14/19; 74%) or good (4/19; 21%) by the Bak criteria. Operative treatment of pectoralis major rupture yields high patient satisfaction and allows predictable return of comfort, range of motion, cosmesis, and overall limb strength, with a slightly less predictable return of maximum bench press strength.

A systematic review and comprehensive classification of pectoralis major tears

BACKGROUND

Reported descriptions of pectoralis major (PM) injury are often inconsistent with the actual musculotendinous morphology. The literature lacks an injury classification system that is consistently applied and accurately reflects surgically relevant anatomic injury patterns, making meaningful comparison of treatment techniques and outcomes difficult.

MATERIALS AND METHODS

Published cases of PM injury between 1822 and 2010 were analyzed to identify incidence and injury patterns and the extent to which these injuries fit into a classification category. Recent work outlining the 3-dimensional anatomy of the PM muscle and tendon, as well as biomechanical studies of PM muscle segments, were reviewed to identify the aspects of musculotendinous anatomy that are clinically and surgically relevant to injury classification.

RESULTS

We identified 365 cases of PM injury, with 75% occurring in the last 20 years; of these, 83% were a result of indirect trauma, with 48% occurring during weight-training activities. Injury patterns were not classified in any consistent way in timing, location, or tear extent, particularly with regard to affected muscle segments contributing to the PM's bilaminar tendon.

CONCLUSIONS

A contemporary injury classification system is proposed that includes (1) injury timing (acute vs chronic), (2) injury location (at the muscle origin or muscle belly, at or between the musculotendinous junction and the tendinous insertion, or bony avulsion), and (3) standardized terminology addressing tear extent (anterior-to-posterior thickness and complete vs incomplete width) to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research.

Surgical and nonsurgical treatment of total rupture of the pectoralis major muscle in athletes: update and critical appraisal

The complete rupture of the pectoralis major tendon is an uncommon injury but has become increasingly common among athletes in recent years. This may be due to a higher number of individuals taking part in high-impact sports and weightlifting as well as the use of anabolic substances, which can make muscles and tendons vulnerable to injury. In recent literature, there are only few recommendations to rely on conservative treatment alone, but there are a number of reports and case series recommending early surgical intervention. Comparing the results of the two treatment regimens, there is clear evidence for a superior outcome after surgical repair with better cosmesis, better functional results, regaining of muscle power, and return to sports compared with the conservative treatment. In summary, anatomic surgical repair is the treatment of choice for complete acute ruptures of the pectoralis major tendon or muscle in athletes.