A systematic review and comprehensive classification of pectoralis major tears

Optimizing pectoralis major tendon repair: a modified knotless suture anchor technique using high-strength suture and tape

Background

Rupture of the pectoralis major (PM) tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined.

Methods

We present a modified surgical technique utilizing knotless suture anchors for PM tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture.

Results

The utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques.

Conclusion

Our modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful PM tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care.

Optimizing Recovery: A Systematic Scoping Review of Upper Extremity Exercise Immediately after Cardiac Implantable Electronic Device Implantation

INTRODUCTION

Cardiac implantable electronic devices (CIEDs), including pacemakers, defibrillators, and resynchronization devices, significantly enhance patient outcomes, reduce sudden cardiac death, and improve health-related quality of life. CIED implantation is associated to persistent shoulder dysfunction in a considerable number of patients one-year post-implantation. This may result in disability, diminished quality of life, work absenteeism, and negative psychological effects. Restoring upper extremity function after CIED implantation should be a standard of cardiovascular care. Our systematic scoping review aimed to summarize available evidence, addressing vital questions about safety, effectiveness, exercise type, and time of exercise initiation immediately after CIED implantation.

METHODS

We conducted a comprehensive literature search in 5 electronic databases for original research in English, and a manual search on the references of included studies. We used Rayyan web application for study selection, and PRISMA-ScR to conduct and report the review. We assessed methodological quality using the Cochrane Risk of Bias Assessment Tool and Joanna Briggs Institute critical appraisal checklists.

RESULTS

This review included 6 studies that used upper extremity pendular, range of motion, stretching and strengthening exercises. Initiation time varied from the first postoperative day to the second postoperative week. All studies showed significant association between active upper extremity exercise and reduced dysfunction and disability after CIED implantation. There were no significant differences in complication rates between control and experimental groups.

CONCLUSION

A limited number of low-to-average quality studies suggest active upper extremity exercise immediately after CIED implantation is safe, effective at reducing dysfunction, and improves quality of life. Higher-quality studies are needed to validate these findings.

Distal insertion of the clavicular portion of pectoralis major muscle: anatomical study

PURPOSE

Several descriptions of the anatomy of the pectoralis major (PM) have been published. However, the precise description of its distal humeral insertion, which is involved in traumatic tears, remains controversial. The distal tendon is classically described as being made of two layers, one anterior (ALPM) and one posterior (PLPM), which regroup at their distal edge. The clavicular head (CH) participates in the ALPM according to most authors. However, others describe a more superficial termination in a close relationship with the deltoid humeral insertion. The objective of this anatomical work is to precisely describe the anatomy of the CH and its relationship with the rest of the distal PM tendon and the distal deltoid tendon.

MATERIALS

Twenty-three fresh cadaveric specimens were dissected (41 shoulders). The entire PM as well as the deltoid were exposed. Several measurements were collected to establish the relationships between the distal tendon of the CH and the PM, the deltoid and the bony landmarks.

RESULTS

In all cases, the CH muscular portion sits on the ALPM but does not participate in the connective structure of the PM distal tendon. The inferolateral part of its distal end gives a thin tendinous portion that inserts lower on the humerus in conjunction with the distal tendon of the deltoid. In 24.4%, this tendon was more difficult to isolate but was always observed.

CONCLUSIONS

The distal tendon of the PM only comes from the muscle fibres of its sternal head. The CH fibres do not contribute to this tendon but appear to terminate in a separate tendon fusing with the humeral insertion of the deltoid: the deltopectoral tendon. This could explain the different patterns of tears observed in clinical practice.

MSK Ultrasound: A Powerful Tool for Evaluating and Diagnosing Pectoralis Major Injuries in Healthcare Practice

Accurately diagnosing pectoralis major injuries, particularly in athletes, often presents a challenge for healthcare practitioners. Although pectoralis muscle injuries are relatively uncommon, the diagnosis of a tear may be overlooked without careful screening by a thorough physical examination of both the injured and uninjured sides. While magnetic resonance imaging (MRI) has traditionally held the gold standard, musculoskeletal ultrasound (MSKUS) has emerged as a viable alternative. This article delves into the power of MSKUS in evaluating and diagnosing pectoralis major injuries, highlighting its dynamic capabilities, real-time visualization, and cost-effectiveness in comparison to MRI. By equipping healthcare professionals with a thorough understanding of MSKUS's potential, this article aims to empower them to confidently diagnose and manage pectoralis major injuries, ultimately improving patient outcomes and facilitating a faster return to function.

Anabolic steroids and the evaluation of patients with acute PM tendon rupture using microscopy and MRI

This study presented a pioneering investigation of the changes in the magnetic resonance imaging images of pectoralis major muscle (PMM) tendon rupture. In all, 26 men were evaluated with acute total PMM rupture (<3 months since injury) with a mean age of 37.3 years (SD = 9.7 years) and 10 control patients with a mean age of 32.6 years (SD = 4.2 years). The evaluation of the tendon PMM injuries was based on the magnetic resonance imaging exam and the histological analysis. The magnetic resonance imaging of the surgically showed two (7.1%) contralateral sides were normal, 16 (57.1%) showed superior tendinopathy, and 10 (35.7%) had total tendinopathy. Inferior tendinopathy was not observed. The tendon histology revealed degenerative changes in 16 (66.7%) fragments, with 12 (50.0%) considered as mild (<25%), and four considered as (16.7%) high (>50.0%) tendinopathy. Total acute rupture of the PMM tendon among weightlifters might be associated with tendinous degeneration prior to injury.

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.

Myotendinous junction tears of the pectoralis major are occurring more frequently and discrepancies exist between intraoperative and radiographic assessments

Background

Pectoralis major (PM) tears have been shown to occur most frequently at the tendinous humeral insertion. However, no substantial updates on tear location have been published in 20 years or are based on relatively small sample sizes. The primary purpose of this study was to evaluate PM tear location based on magnetic resonance imaging (MRI). A secondary purpose was to evaluate agreement between MRI and intraoperative assessments of tear characteristics. We hypothesized that PM tears at the myotendinous junction (MTJ) occur at a higher rate than previously reported and that intraoperative and MRI assessments would demonstrate agreement in at least 80% of cases.

Materials and methods

An observational study of consecutive patients evaluated for a PM tear at a single institution between 2010 and 2022 was conducted. Patient demographics as well as MRI and intraoperative assessments of tear location, extent of tear, and muscle head involvement were collected from the electronic medical record. Agreement was calculated by comparing radiographic and intraoperative assessments per variable and reported as percentages. Data and statistical analysis were performed with SPSS software with a significance level set to P < .05.

Results

A total of 102 patients were included for analysis. Mean age was 35.8 ± 10.5 years and mean body mass index was 29.4 ± 4.8 kg/m2. 60.4% of the study population had tears of the MTJ, 34.9% of the tendinous humeral insertion, and 4.7% within the muscle belly, as determined intraoperatively. Complete tears had significantly higher agreement between MRI and intraoperative assessments relative to partial tears (83.9% and 62.5%, respectively; P ≤ .01).

Discussion

The majority of PM tears occurred at the MTJ. Preoperative MRI and intraoperative assessments agreed in 80% of cases, a value that was significantly higher for complete over partial tears. These findings demonstrate that tears of the MTJ are increasingly more common and support the use of MRI in preoperative planning for complete PM tears.

High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries

The pectoralis major muscle is the largest muscle of the anterior chest wall. The primary function of the muscle is to adduct and internally rotate the arm at the shoulder. The pectoralis major muscle is broken down into two main components or "heads" based upon muscle fiber origin: clavicular and sternal. Pectoralis major muscle injury results from direct trauma or indirect force overload. The inferior sternal head fibers are the most commonly torn. The pectoralis major tendon most commonly is torn at the humeral insertion. Magnetic resonance imaging and high-resolution ultrasound have value in diagnosing pectoralis major muscle injury and help guide clinical and surgical management. Non-operative versus operative management of pectoralis major tears is dependent upon accurate diagnosis of tear location and severity on imaging. Operative management is recommended for tears at the humeral insertion and for musculotendinous junction tears with severe cosmetic/functional deformity. The indications for surgical intervention have been further expanded to complete intra-tendinous tears, defined as the mid-tendon substance between the myotendinous junction and humeral insertion, and those located at the sternal head/posterior lamina. This paper reviews normal pectoralis major anatomy and the spectrum of injury on magnetic resonance imaging and ultrasound. The importance of regional anatomical landmarks in assessing for pectoralis major muscle injury will be described. Other pathologies, such as tumor and infection, can also affect the pectoralis major muscle and key imaging features will be discussed to help differentiate these entities. Operative and non-operative management of pectoralis major muscle injury is described with examples of pectoralis major repair on post-operative imaging.

A review of chronic pectoralis major tears: what options are available?

Rupture of the pectoralis major muscle typically occurs in the young, active male. Acute management of these injuries is recommended; however, what if the patient presents with a chronic tear of the pectoralis major? Physical exams and magnetic resonance imaging can help identify the injury and guide the physician with a plan for management. Nonoperative management is feasible, but is recommended for elderly, low-demand patients whose functional goals are minimal. Repair of chronic tears should be reserved for younger, healthier patients with high functional demands. Although operative management provides better functional outcomes, operative treatment of chronic pectoralis tears can be challenging. Tendon retraction, poor tendinous substance and quality of tissue, muscle atrophy, scar formation, and altered anatomy make direct repairs complicated, often necessitating auto- or allograft use. We review the various graft options and fixation methods that can be used when treating patients with chronic pectoralis major tears.

Functional Considerations in Bilateral, Simultaneous Tendon Injuries of the Upper Extremity: A Narrative Review of Current Literature

» Bilateral, simultaneous same-tendon injuries of the upper extremity are rarely encountered, yet their unique complexity poses a substantial challenge for treating orthopaedic surgeons.» In general, extremities with more tendon retraction should be repaired acutely while contralateral injuries can be treated in a staged or simultaneous manner depending on injury morphology, location, and anticipated functional impairment.» Combinations of accelerated and conventional rehabilitation protocols can be used for individual extremities to minimize the length of functional impairment.

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.

Reconstruction of Chronic, Retracted Pectoralis Major Tendon Tear With Achilles Tendon Allograft

Rupture of pectoralis major tendon (PMT) is an uncommon injury, but its incidence has been increasing in the past 2 decades. Although open repair of the torn tendon is the preferred choice of treatment in acute and chronic cases, this often is not possible for chronic retracted tendon injuries. While several techniques have been described for PMT reconstruction, these allografts and autografts are often smaller and less thick than the native PMT. In this study, we describe the use of the Achilles tendon allograft with unicortical suture buttons for the reconstruction of a chronic and retracted PMT. Furthermore, the advantages and disadvantages of this technique are discussed.

Pectoralis Major Tendon Rupture While Bouldering

Pectoralis major tendon ruptures are rare injuries. We present a case of a pectoralis major tendon rupture incurred while bouldering that required surgical repair. The diagnosis of pectoralis major tendon rupture relies predominantly on clinical examination. Among athletes, outcomes after surgical repair are superior to those after nonoperative therapy in most cases of complete tendon rupture. Although infrequent, pectoralis major tendon ruptures can occur while climbing, and early recognition and expedited surgical treatment are paramount to maximize functional recovery.

Pectoralis Major Muscle Belly Rupture in a 17-Year-Old Female Softball Player: A Case Report

CASE

We report the case of a healthy 17-year-old female softball player with a subacute full-thickness intramuscular tear of the pectoralis major (PM) muscle. A successful muscle repair was obtained using a modified Kessler technique.

CONCLUSIONS

Despite initially being a rare injury pattern, the incidence of PM muscle rupture is likely to increase as interest in sports and weight training increases, and although this injury pattern is more common in men, it is becoming more common in women as well. Furthermore, this case presentation provides support for operative treatment of intramuscular ruptures of the PM muscle.

Non-uniform excitation of pectoralis major induced by changes in bench press inclination leads to uneven variations in the cross-sectional area measured by panoramic ultrasonography

This study combined surface electromyography with panoramic ultrasound imaging to investigate whether non-uniform excitation could lead to acute localized variations in cross-sectional area and muscle thickness of the clavicular and sternocostal heads of pectoralis major (PM). Bipolar surface electromyograms (EMGs) were acquired from both PM heads, while 13 men performed four sets of the flat and 45° inclined bench press exercises. Before and immediately after exercise, panoramic ultrasound images were collected transversely to the fibers. Normalized root mean square (RMS) amplitude and variations in the cross-sectional area and muscle thickness were calculated separately for each PM head. For all sets of the inclined bench press, the normalized RMS amplitude was greater for the clavicular head than the sternocostal head (P < 0.001), and the opposite was observed during the flat bench press (P < 0.001). Similarly, while greater increases in cross-sectional area were observed in the clavicular than in the sternocostal head after the inclined bench press (P < 0.001), greater increases were quantified in the sternocostal than in the clavicular head after the flat bench press exercise (P = 0.046). Therefore, our results suggest that the PM regional excitation induced by changes in bench press inclination leads to acute, uneven responses of muscle architecture following the exercise.

Injuries of the Pectoralis Major: Diagnosis and Management

Pectoralis major ruptures are uncommon injuries that have become more prevalent over the past 20 years due to increased participation in weight lifting. Patients often present with localized swelling and ecchymosis, muscular deformity, thinning of the anterior axillary fold, and weakness in adduction and internal rotation of the affected arm. History and physical is often augmented with radiology, magnetic resonance imaging of the chest being the gold standard. Nonoperative management is reserved for old patients with low functional demands. Operative intervention is the treatment of choice with improved functional outcomes, cosmesis, and patient satisfaction.

The 'Cruciform Test': A diagnostic tool to detect pectoralis major rupture

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.

Muscle Injury Around the Shoulder

Acute shoulder tendon and intra-articular injuries are common and their imaging well described. However, a subset of patients present with more unusual acute shoulder muscle injury. Of these, pectoralis major muscle injuries are encountered the most often and are increasingly prevalent due to a focus on personal fitness, particularly bench-press exercises. Other muscle injuries around the shoulder are rare. This article reviews the anatomy, mechanism of injury, and the imaging findings in relation to injuries of these muscles around the shoulder. We focus on pectoralis major injury but also review proximal triceps, latissimus dorsi, teres major, and deltoid muscle injuries, providing imaging examples.

Pectoralis Major Rupture: A Case Report

Pectoralis major (PM) ruptures are relatively rare injuries occurring mostly in men 20 to 40 years of age. Weightlifting or bench pressing is the most common mechanism of injury. Although an uncommon injury, a high degree of clinical suspicion should be maintained since early surgical treatment has been shown to be beneficial. We present a case of a 51-year-old male with no known past medical history, who presented to the emergency department with sudden onset right chest pain after bench pressing (approximately 180kg). Physical examination revealed PM rupture with ecchymosis and loss of shoulder contour, as well as bulking over the right chest. He was otherwise neurovascularly intact. The right shoulder x-ray showed no fracture, dislocation or other bony abnormality. The diagnosis was confirmed by an urgent MRI scan which revealed a complete rupture of the sternal head of the PM, and the patient underwent right PM tendon repair nine days after the injury.

Surgically Treated Pectoralis Major Tears Impact the Play and Performance of National Football League Athletes

Purpose: To evaluate the return-to-play rate and performance level changes in National Football League (NFL) athletes after a surgically treated pectoralis major muscle (PMM) tear.

Methods: A descriptive epidemiologic study was conducted. All NFL players from 1933 to 2013 were reviewed for surgically treated PMM tears. Age at injury, height, weight, body mass index, date of injury, position played, draft selection, and total seasons played were recorded. Return to play was assessed for the entire cohort, as well as by position. Performance analysis before and after injury was also conducted for the entire cohort, as well as by position and draft selection. Data analysis was performed with the paired-samples t test, with P < .05 considered statistically significant.

Results: Our review of 80 NFL seasons from 1933 to 2013 provided a total of 55 instances of PMM tears. All instances occurred between the time frame of 2004 and 2012. After exclusions, 24 instances unique to 24 NFL athletes were confirmed by 2 separate investigators and these athletes were included as our final study cohort. Of the 24 players identified to have a surgically repaired PMM tear, 20 (83%) returned to play. The mean return-to-play period was 302 ± 128 days. The mean difference in performance scores before versus after PMM injury was 171.33 and was statistically significant, with P = .0330.

Conclusions: In this study, there was an 83% return-to-play rate after surgical repair of PMM tears. Although we found a statistically significant decrease in player performance after surgery, this difference was no longer seen after players were stratified by position type and draft selection.

Level of Evidence: Level IV, therapeutic case series.

Qualitative and Quantitative Anatomy of the Humeral Attachment of the Pectoralis Major Muscle and Structures at Risk: A Cadaveric Study

Background:

Surgical pectoralis major (PM) repair can offer improved functional outcomes over nonoperative treatment. However, there is a lack of literature on consensus of the anatomical site of the humeral attachment.

Purpose:

To provide qualitative and quantitative anatomic analysis of the PM by focusing on humeral insertion and relevant structures at risk.

Study Design:

Descriptive laboratory study.

Methods:

Eight fresh-frozen male cadavers were dissected. The relevant landmarks that were collected and measured included (1) PM footprint length at the humeral insertion (total, sternal head, and clavicular head insertions); (2) PM tendon length from the humeral insertion to the musculotendinous junction; (3) distance from the PM humeral insertion to the lateral (LPN) and medial (MPN) pectoral nerves; and (4) distance from the coracoid process to the musculocutaneous nerve (MCN) in anatomical position.

Results:

The total PM footprint length was 81.4 mm (95% CI, 71.4-91.3). The sternal and clavicular heads that make up the PM had footprint lengths of 42.1 mm (95% CI, 32.9-51.4) and 56.6 mm (95% CI, 46.5-66.7), respectively. The PM tendon was wider at the clavicular head (74.7 mm; 95% CI, 67.5-81.7) than the sternal head insertions (43.0 mm; 95% CI, 40.1-45.9). The distances from the PM humeral insertion to LPN and MPN were 93.2 mm (95% CI, 83.1-103.3) and 103.8 mm (95% CI, 98.3-109.4), respectively. The coracoid process to MCN distance was 68.5 mm (95% CI, 60.2-76.8).

Conclusion:

This study successfully quantifies anatomic dimensions of the PM tendon, its sternal and clavicular head insertions, and its location relative to nearby vital structures. Such knowledge can provide surgeons with a better understanding of the PM in relation to nearby neurovascular structures during anatomic PM repair and reconstruction to avoid debilitating complications.

Clinical Relevance:

Knowledge of the quantitative anatomy of the PM at the humeral footprint along structures at risk may aid surgeons with identifying the injured part of the PM and improve outcomes for anatomic repair and reconstruction.

Bilateral pectoralis major MRI in weightlifters: findings of the non-injured side versus age-matched asymptomatic athletes

OBJECTIVE

To evaluate magnetic resonance imaging (MRI) features of the contralateral side in weightlifting athletes with pectoralis major (PM) tears. We hypothesized that MRI of the non-injured side may present increased pectoralis major tendon (PMT) length and thickness and greater pectoralis major muscle (PMM) volume and cross-sectional area when compared with the control group.

METHODS

We retrospectively identified MRI cases with unilateral PM injury and reviewed imaging findings of the contralateral side. Also, we evaluated MRI from ten asymptomatic control weightlifting athletes, with PM imaging from both sides. Two musculoskeletal radiologists independently reviewed MRI and measured PMT length, PMT thickness, PMM volume (PMM-vol) and PMM cross-sectional area (PMM-CSA), as well as humeral shaft cross-sectional area (Hum-CSA) and the ratio between PMM-CSA and Hum-CSA (PMM-CSA/Hum-CSA). Data were compared between the non-injured side and controls. The MRI protocol from both groups was the same and included T1 FSE and T2 FATSAT axial, coronal, and sagittal images, one side at a time.

RESULTS

We identified 36 male subjects with unilateral PM injury with mean age 35.7 ± 8 years and 10 age- and gender-matched controls (p = 0.45). A total of 36 PM MRI with non-injured PM and 20 PM MRI studies were included in this study. PMT length and PMT thickness were significantly higher in contralateral PM injury versus control subjects (both P < 0.001). Also, PM-CSA and Hum-CSA were greater in the contralateral PM injury group (P = 0.032 and P < 0.001, respectively). PMT thickness > 2.95 mm had 80.6% sensitivity and 90.0% specificity to differentiate the non-injured PM group from controls.

CONCLUSION

Non-injured side MR imaging of patients with previous contralateral PM lesion demonstrates greater PMT thickness and length as well as PM-CSA and Hum-CSA than controls.

Pectoralis Major Rupture: Evaluation and Management

Pectoralis major tendon ruptures are being reported with increasing frequency and primarily occur in young, high demand, male patients. The injury results from an eccentric contracture of the muscle most commonly while performing the bench press maneuver during weight training. In the setting of both acute and chronic injury, physical examination is critical for a timely and accurate diagnosis. During physical examination, comparison with the opposite side is imperative, and findings may include swelling, ecchymosis, loss of the anterior axillary fold, and a decreased pectoralis major index. Surgical treatment of acute ruptures is superior to nonsurgical treatment and results in improved functional outcomes and high levels of return to work and sport. Repair of chronic tears is more challenging and may require reconstruction with autograft or allograft tissue. Despite advances in surgical technique, tendon rerupture, persistent pain, and wound infection remain a concern.

Automatic MRI segmentation of pectoralis major muscle using deep learning

To develop and validate a deep convolutional neural network (CNN) method capable of selecting the greatest Pectoralis Major Cross-Sectional Area (PMM-CSA) and automatically segmenting PMM on an axial Magnetic Resonance Imaging (MRI). We hypothesized a CNN technique can accurately perform both tasks compared with manual reference standards. Our method is based on two steps: (A) segmentation model, (B) PMM-CSA selection. In step A, we manually segmented the PMM on 134 axial T1-weighted PM MRIs. The segmentation model was trained from scratch (MONAI/Pytorch SegResNet, 4 mini-batch, 1000 epochs, dropout 0.20, Adam, learning rate 0.0005, cosine annealing, softmax). Mean-dice score determined the segmentation score on 8 internal axial T1-weighted PM MRIs. In step B, we used the OpenCV2 (version 4.5.1, https://opencv.org) framework to calculate the PMM-CSA of the model predictions and ground truth. Then, we selected the top-3 slices with the largest cross-sectional area and compared them with the ground truth. If one of the selected was in the top-3 from the ground truth, then we considered it to be a success. A top-3 accuracy evaluated this method on 8 axial T1-weighted PM MRIs internal test cases. The segmentation model (Step A) produced an accurate pectoralis muscle segmentation with a Mean Dice score of 0.94 ± 0.01. The results of Step B showed top-3 accuracy > 98% to select an appropriate axial image with the greatest PMM-CSA. Our results show an overall accurate selection of PMM-CSA and automated PM muscle segmentation using a combination of deep CNN algorithms.

Lesão muscular: Fisiopatologia, diagnóstico e tratamento

O tecido muscular esquelético possui a maior massa do corpo humano, correspondendo a 45% do peso total. As lesões musculares podem ser causadas por contusões, estiramentos ou lacerações. A atual classificação separa as lesões entre leves, moderadas e graves. Os sinais e sintomas das lesões grau I são edema e desconforto; grau II, perda de função, gap e equimose eventual; grau III, rotura completa, dor intensa e hematoma extenso. O diagnóstico pode ser confirmado por ultrassom (dinâmico e barato, porém examinador-dependente); e ressonância magnética (RM) (maior definição anatômica). A fase inicial do tratamento se resume à proteção, ao repouso, ao uso otimizado do membro afetado e crioterapia. Anti-inflamatórios não hormonais (AINHs), ultrassom terapêutico, fortalecimento e alongamento após a fase inicial e amplitudes de movimento sem dor são utilizados no tratamento clínico. Já o cirúrgico possui indicações precisas: drenagem do hematoma, reinserção e reforço musculotendíneos.

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.

The diagnostic performance of MRI signs to distinguish Pectoralis major tendon avulsions from Myotendinous injuries

BACKGROUND

Management of pectoralis major (PM) injuries is largely determined by the anatomic location of the injury, with tendon avulsions from the humerus requiring surgery while myotendinous (MT) injuries are typically managed non-operatively. Because physical examination cannot reliably make this distinction, MRI is often used for staging. However, correct classification can also be difficult with MRI where there is extensive soft tissue edema and distorted anatomy.

OBJECTIVE

To determine the diagnostic performance of primary and secondary MRI signs of PM injury for distinguishing tendon avulsions from MT injuries in a selected sample of patients that underwent surgical repair using a practical interpretation algorithm.

METHODS

In this retrospective study, 3 blinded observers independently assessed the MRI findings of 17 patients with PM injury (including 12 acute injuries, 4 chronic, and 1 of uncertain age) where subsequent surgery documented tendon avulsion (11) and MT injuries (6) by applying the primary MRI criteria of absent tendon at the humerus, retracted tendon stump, epicenter of edema, and the secondary finding of soft tissue edema contacting the anterior humeral cortex. Operative findings were used as the reference standard. Sensitivity, specificity, and positive and negative predictive value were recorded for each finding.

RESULTS

The primary MRI finding of lack of a visible tendon at the insertion (sensitivity 82-100%, specificity 100%) and the secondary finding of edema contacting the anterior humeral cortex (sensitivity 64-91%, specificity 67-100%) were both useful for the distinction of tendon avulsion from MT injury, particularly in acute injuries. The presence of a retracted tendon stump and the epicenter of edema were not reliable findings. The use of a decision tree including the secondary finding of humeral edema increased the sensitivity and specificity for 2 of the 3 observers.

CONCLUSION

MRI assessment of PM injury focused on the humeral insertion of the PM tendon allows accurate distinction of tendon avulsion from MT injury.

CLINICAL IMPACT

This study describes a practical approach to classifying PM injuries with MRI to distinguish injuries that require surgery from those that can potentially be managed conservatively.

Simultaneous repair of bilateral pectoralis major tendons: A case report

BACKGROUND

Injuries to the pectoralis major are infrequent, with only a few hundred cases currently recorded in the literature.

CASE SUMMARY

We report a case of a patient who sustained bilateral pectoralis major tendon ruptures. While other cases of bilateral pectoralis major tears have been reported in the literature, the operative management in this report differs. Due to delayed presentation of the patient right and left pectoralis major repairs were performed simultaneously.

CONCLUSION

Patients with delayed presentation of bilateral pectoralis major tendon ruptures can undergo simultaneous repair of both tendon with a good postoperative outcome and high patient satisfaction.

A case report of a rupture of the musculotendinous junction of the pectoralis major in an athlete

INTRODUCTION

The pectoralis major muscle (PM) is a large muscle on the anterior chest wall. The rupture of the PM is a rare entity in literature and most incidences had been reported frequently in weight lifting and contact sports. Acute repair of PM rupture yielded better outcome as compared to non-operative treatment in active individuals who wish to return to their sports.

CASE REPORT

We presented a case of a champion in bodybuilding who lifted a heavy weigh during his routine exercises, which caused a rupture in the musculotendinous junction of the left pectoralis major muscle.

DISCUSSION

As it is rare to meet ruptures in this site of pectoralis major, we decided to insert anchors into the humeral bone (as in avulsions and tendon's tears), and to duplicate the suturing levels in multiple directions (as in muscular belly ruptures).

CONCLUSION

Our aim here is to confirm that the rupture of the musculotendinous junction of the pectoralis major muscle is rare and difficult to deal, but the acute surgical treatment by inserting anchors into the humerus, and duplicating the suturing layers in multiple directions can give good results especially in athletes.

Surgical Management of Pectoralis Major Tears of the Sternal Origin Because of Seat Belt Trauma: A Report of 2 Cases

CASES

Two patients presented with medial chest pain and deformity after high-speed motor vehicle accidents (MVAs) in which they were restrained drivers. Physical examination revealed retraction of the pectoralis major from the sternum on resisted adduction and internal rotation of the arm. MRI confirmed tears of the pectoralis major from the sternal origin. Both patients underwent delayed surgical repair with excellent results.

CONCLUSION

Tears of the pectoralis major at the sternal origin are rare injuries that can result in significant deformity and pain. Surgical repair, even in a delayed fashion, can result in excellent patient outcomes.

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.

Chronic Pectoralis Major Rupture Reconstruction With Interpositional Acellular Dermal Allograft

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.

Upper extremity dysfunctions in patients with cardiac implantable electronic devices: a systematic review

Background/Aims

The prevalence of cardiac implantable electronic devices has risen considerably during recent years. This has revolutionised the treatment of cardiac arrhythmias, which in turn reduced the incidence of sudden cardiac death. There are several complications associated with cardiac implantable electronic device implantation. Upper extremity dysfunction is one of the complications associated with this procedure and it should be addressed, since it can affect activities of daily living. This systematic review analysed the prevailing evidence pertaining to the common upper extremity dysfunctions associated with receiving a cardiac implantable electronic device.

Methods

A comprehensive literature search was conducted using PubMed, Cochrane Central Register of Controlled Trials, EMBASE (through Cochrane) and Google Scholar for original research published in the English language. The Rayyan QCRI web application was used for study selection and the decision-making process. PRISMA guidelines were used to conduct and report this review. The methodological quality of the included studies was appraised using the Newcastle–Ottawa Scale and Joanna Briggs Institute critical appraisal tool for analytic cross-sectional studies and case reports.

Results

This systematic review included eight studies with a total of 696 participants. The most common upper extremity dysfunctions associated with receiving a cardiac implantable electronic device were pain and limitation of shoulder range of motion. Limitation of range of motion could be persisted even in the long term after having a cardiac implantable electronic device implanted.

Conclusions

Contributing factors of upper extremity dysfunctions included size of the device, pectoral site of implantation and upper extremity immobilisation practices. Upper extremity dysfunction is an overlooked complication, as it received a relatively low priority, although it may negatively impact quality of life.

Pectoralis Major Ruptures in the National Football League: Incidence, RTP, and Performance Analysis

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.

Pectoralis Major Injuries

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In the past 20 years, there has been a substantial increase in the prevalence of pectoralis major injuries, largely related to the rising popularity of weight-lifting and participation in contact sports.

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Treatment options are influenced by the severity of the injury, patient age, and the amount and type of physical activity.

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Although there is no consensus as to which treatment method is most effective, previous studies have demonstrated increased satisfaction among patients who undergo operative treatment.

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The average length of time from surgery to return to activity ranges from 6 to 24 months.

Isokinetic Strength and Functional Scores after Rehabilitation in Jiu-Jitsu Fighter with Repair Surgery of Pectoralis Major Muscle Rupture: A Case Report

A pectoralis major muscle rupture is a rare injury that mainly occurs during exercise. This study examined the application of rehabilitation, strength and passive range of motion (ROM) change, and subjective assessment for 1 year undertaken after repair surgery of pectoralis major muscle rupture in a Jiu-Jitsu fighter. We hypothesized that the application of ROM exercises and rehabilitation strategies contributed to muscle recovery and successful return to sports. The patient was a 34-year-old man who was injured after falling during a competitive event. The patient had pain and swelling in the front of the chest and shoulder, and the distal chest was deformed. Imaging revealed a complete rupture of the pectoralis major muscle. Reparative surgery was performed by a specialist. Immobilization was performed one week after the surgery. Passive ROM exercises began with the forward flexion 2 weeks after the surgery; abduction and external rotation ROM exercises at 4 weeks; low-intensity muscle strength exercises using tube bands at 6 weeks; machine-based pectoralis major muscle exercises at 3 months. Isokinetic equipment was used to measure horizontal adduction and internal rotation strengths, and the subjective shoulder functional and ROM scores were evaluated. Recovery of shoulder function and ROM occurred at 3 months and muscle recovery at 6 months. The participant was able to return to sports at 5 months and compete at 7 months. Although this study explored only one patient's post-operative recovery, it suggests that ROM and strength exercises may be effective post-operative strategies for restoring function and strength to enable a return to sports.

Regional differential stretching of the pectoralis major muscle: An ultrasound elastography study

Pectoralis major (PMa) muscle injuries are becoming more prevalent, and their incidence differs among the PMa regions, i.e., the clavicular, sternal, and abdominal regions. Therefore, identifying the position for effectively lengthening each PMa region is critical in preventing PMa injuries. The purpose of this study was to determine the effective stretching position for each PMa region through shear wave elastography, which can indirectly assess individual muscle lengthening. Fifteen men participated in this study. Twelve stretching positions were compounded with shoulder abductions (45°, 90°, and 135°), pelvic rotation (with or without), shoulder external rotation (with or without), and shoulder horizontal abductions. The shear modulus of each PMa region was measured through shear wave elastography in the stretching positions mentioned above. At the clavicular region, the shear modulus was higher for three stretching positions: shoulder horizontal abduction at 45° abduction during pelvic rotation and shoulder external rotation, shoulder horizontal abduction at 90° abduction, and shoulder horizontal abduction at 90° abduction while considering shoulder external rotation. For the sternal region, the shear modulus was higher in two stretching positions: shoulder horizontal abduction at 90° abduction while adding external rotation, and combination of pelvic rotation and external rotation. For the abdominal region, the shear modulus was higher in the shoulder horizontal abduction at 135° abduction with pelvic and external rotation. These results indicated that the effective stretching position was different for each PMa region.

[Acute rupture of the pectoralis major muscle at the musculotendinous junction : Case report of a rare injury and literature review]

Die Pectoralis-major-Ruptur (PMR) ist eine seltene Verletzung, die v. a. beim Kraftsport aufritt. Vorgestellt wird der Fall eines 31-jährigen Profibasketballspielers, der sich beim Bankdrücken eine Komplettruptur am muskulotendinösen Übergang des M. pectoralis major (PM) zugezogen hatte. Drei Wochen nach dem erlittenen Trauma erfolgte bei persistierenden Schmerzen und Kraftdefizit die Refixation des PM. Drei Monate postoperativ konnte der Patient bei vollem Bewegungsumfang schmerzfrei in den Basketballsport zurückkehren. Die Verletzungsentität wird vor dem Hintergrund der aktuellen Literatur diskutiert und das operative Vorgehen im Detail dargestellt.

Traumatic rupture of the pectoralis major muscle with associated thrombosis of the cephalic vein as part of a seat belt injury following a motor vehicle accident: A case report

Traumatic rupture of the pectoralis major muscle is a rare concomitant injury in polytrauma patients often resulting in delayed diagnosis. We present the case of a young male patient who, among other injuries, suffered a complete rupture of the right-sided pectoralis major muscle at the humeral insertion point following a motor vehicle accident. Duplex sonography demonstrated an associated thrombosis of the cephalic vein, which was treated initially with intravenous heparin, and long-term with low-molecular weight heparin according to current guidelines. An open refixation of the muscle belly at the humeral insertion point was performed two weeks after the initial trauma. Post-operative follow-up presented a good overall outcome in terms of function and aesthetics. The authors emphasize the need of continuous clinical re-evaluation in the treatment of severely injured patients in order not to overlook relevant injuries.

Athletic Injuries of the Thoracic Cage

A variety of sports require exposure to high-impact trauma or characteristic repetitive movements that predispose to injuries around the thorax. Appropriate prognostication and timely management are vital, as untreated or undertreated injuries can lead to pain, disability, loss of playing time, or early termination of sports participation. The authors review common athletic injuries of the thoracic cage, encompassing muscular, osseous, and vascular conditions, with an emphasis on mechanism, imaging features, and management. The authors also review pertinent soft-tissue and bony anatomy, along with relevant sports biomechanics. Generalized muscle trauma and more specific injuries involving the pectoralis major, latissimus dorsi, teres major, pectoralis minor, lateral abdominal wall and intercostals, serratus anterior, and rectus abdominis muscles are discussed. Osseous injuries such as stress fractures, sternoclavicular dislocation, costochondral fractures, and scapular fractures are included. Finally, thoracic conditions such as snapping scapula, thoracic outlet syndrome, and Paget-Schroetter syndrome are also described. Specific MRI protocols are highlighted to address imaging challenges such as the variable anatomic orientation of thoracic structures and artifact from breathing motion. Athletes are susceptible to a wide range of musculoskeletal thoracic trauma. An accurate imaging diagnosis of thoracic cage injury and assessment of injury severity allow development of an adequate treatment plan. This can be facilitated by an understanding of functional anatomy, sports biomechanics, and the unique injuries for which athletes are at risk. ^©RSNA, 2021.

Pectoralis Major Muscle Belly Repair in a Young Male Adult: A Case Report

CASE

A 29-year-old man sustained a near-complete laceration to the left pectoralis major muscle belly. The muscle and epimysium were repaired using the Kragh technique-a combination of running interlocked and Mason-Allen stitches. At the 6-year follow-up, the patient had an excellent outcome as measured by clinical scores (Short Form Survey-36, Disabilities of the Arm, Shoulder, and Hand, and American Shoulder and Elbow Surgeons Score), bench press, cosmesis, and magnetic resonance imaging.

CONCLUSIONS

Acute traumatic open pectoralis muscle belly tears may be successfully repaired in select patients using the Kragh technique with excellent postoperative function and cosmesis.

Electromyography of the Pectoralis Major Muscle after Surgical Reconstruction of Chronic Tendon Rupture

Objective  To evaluate the electrophysiological activity of the injured pectoralis major (PM) muscle of operated patients who perform weightlifting, more specifically bench press exercises, especially the activity of the clavicular and sternocostal portions of the PM.

Methods  All athletes in study I (10 patients) had unilateral complete ruptures during bench press exercises and a history of use of anabolic steroids, an association that is described in up to 86.7% of PM tendon ruptures. The control group included 10 men without PM tendon injury who did not perform bench press exercises. Description of the cross-sectional design. The p -values were obtained by multiple comparisons with Bonferroni correction.

Results  In the comparison between the control (C) group and the weightlifters during the postoperative period (POS), we found no evidence of differences in any measurements obtained in the clavicular and sternocostal portions of the PM muscle: clavicular average level ( p  = 0.847); clavicular standard deviation (SD) ( p  = 0.777); clavicular area ( p  = 0.933); clavicular median ( p  = 0.972); sternocostal average level ( p  = 0.633); sternocostal SD ( p  = 0.602); sternocostal area ( p  = 0.931); and sternocostal median ( p  = 0.633).

Conclusion  In the present study, the electromyographic activity of the PM muscle in weightlifters (bench press exercise) who underwent surgery was within the normal parameters for the clavicular and sternocostal portions studied.

[Rupture of the pectoralis major tendon and other extra-articular tendons of the shoulder : Recognition and treatment]

Ruptures of the pectoralis major (PM) tendon are rare but have increased in recent years, especially during fitness exercising, such as bench pressing. The pathomechanism is an eccentric load under pretension of the PM (falling onto the outstretched arm, injuries during ground combat, boxing and during downward movement when bench pressing). The rupture sequence starts from superior to inferior at the insertion site with initial rupture of the most inferior muscle parts, followed by the sternal part and the clavicular part. Most classifications are based on rupture location, extent and time of injury. In addition to clinical presentation and sonography, magnetic resonance imaging is now established as the gold standard in diagnosing PM pathologies. Surgical management is indicated for all lateral PM ruptures with relevant strength deficits. Treatment in the acute interval (<3 weeks) is the primary goal; however, even in chronic cases or after failed conservative management a secondary operative approach enables notable clinical improvement. Conservative therapy mostly affects patients who have muscular injuries close to the anatomic origin and smaller partial tears. Surgical management aims for anatomic reconstruction of the PM unit with restoration of the original tension to enable optimal strength transmission. Surgical refixation or reconstruction (with autograft/allograft) of acute and chronic PM ruptures shows excellent clinical results with high patient satisfaction. Latissimus dorsi (LD) and teres major (TM) tendon ruptures are rare injuries but can lead to significant impairments in high-performance athletes. In contrast to PM ruptures, LD and TM injuries are primarily treated conservatively with very satisfactory results.

Pectoralis major injuries in the military: a surveillance approach to reduce an underestimated problem

INTRODUCTION

Multiple studies report increasing cases of surgically treated pectoralis major (PM) muscle and tendon ruptures in military populations. Studies associate this with a growing popularity of weight-training and bench press exercises. Mild-to-moderate non-surgical PM traumas and overuse injuries have not been included in these studies despite evidence that these types of outpatient injuries account for the majority of the military's injury medical burden.

METHODS

To assess rates of all PM injuries (ruptures, tears, strains, overuse), regardless of form of treatment, a PM injury surveillance definition was derived from International Classification of Disease (ICD) diagnostic codes used in routine US Army injury surveillance. A detailed clinical examination of 2016 Active Duty Army medical records was used to identify ICD codes commonly associated with PM injuries. Cost data were calculated and the definition applied to medical data from 2016 through 2018to assess trends.

RESULTS

The estimated incidence of PM cases among soldiers was over 95% greater than if only considering severe surgical cases. Over 96% of army annual PM injury costs (direct medical and indirect from lost labour) were for outpatient services. PM injury incidence rates were not statistically different from 2016 to 2018.

CONCLUSIONS

The PM injury surveillance definition provides a consistent means to monitor trends over time and evaluate the effectiveness of prevention efforts. PM injuries have a larger military impact than previously recognised and prioritised prevention strategies are needed to reduce them. Future interventions could focus on the bench press given its observed association with PM injuries.