Everything pectoralis major: from repair to transfer

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.

Surgical repair and rehabilitation of a ruptured pectoralis major muscle in a professional footballer - A case report

BACKGROUND

Pectoralis Major ruptures normally occur in activities and sports such as powerlifting and American football or rugby. It is a rarely reported phenomena in professional footballers. Surgery is normally considered the choice of management to enable a safe return to play with conservatively managed ruptures often resulting in significant strength deficits. This case report highlights the management of a pectoralis major rupture in a professional footballer.

CASE PRESENTATION

A 27-year-old professional footballer sustained a left pectoralis major rupture after falling to the floor. A subsequent MRI reported a 5cm retraction of the pectoralis major tendon from its attachment at the humerus. Following a consultation with an orthopaedic surgeon the player underwent a pectoralis major surgical repair. Following surgery, the player underwent a rehabilitation programme under the care of the club physiotherapist. Return to play testing included a handheld dynamometer test, closed kinetic chain upper extremity test and progressive falling activities. The player returned to full contact training after 87 days.

CONCLUSION

This case study demonstrates a successful return to professional football following a pectoralis major rupture and supports the notion that surgical repair of these injuries produces a favourable outcome in professional athletes when returning to sport.

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.

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.

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.

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.

Computational analysis of subscapularis tears and pectoralis major transfers on muscular activity

BACKGROUND

Pectoralis major is the most common muscle transfer procedure to restore joint function after subscapularis tears. Limited information is available on how the neuromuscular system adjusts to the new configuration, which could explain the mixed outcomes of the procedure. The purpose of this study is to assess how muscles activation patterns change after pectoralis major transfers and report their biomechanical implications.

METHODS

We compare how muscle activation change with subscapularis tears and after its treatment by pectoralis major transfers of the clavicular, sternal, or both these segments, during three activities of daily living and a computational musculoskeletal model of the shoulder.

FINDINGS

Our results indicate that subscapularis tears require a compensatory activation of the supraspinatus and is accompanied by a reduced co-contraction of the infraspinatus, both of which can be partially recovered after transfer. Furthermore, although the pectoralis major acts asynchronously to the subscapularis before the transfer, its activation pattern changes significantly after the transfer.

INTERPRETATION

The capability of a transferred muscle segment to activate similarly to the intact subscapularis is found to be dependent on the given motion. Differences in the activation patterns between intact subscapularis and the segments of pectoralis major may explain the difficulty in adapting psycho-motor patterns during the rehabilitation period. Thereby, rehabilitation programs could benefit from targeted training on specific motion and biofeedback programs. Finally, the condition of the anterior deltoid should be considered to improve joint function.

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.

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.

Sports Medicine-Related Breast and Chest Conditions-Update of Current Literature

ABSTRACT

This article reviews the most up-to-date evidence-based recommendations pertaining to breast and upper chest conditions, specifically for the sports medicine physician. Because of the unique circumstances of the team physician, they can see a wide breadth of pathology. Athletes may not have a primary care physician and may prefer to present to their team physician for breast and upper chest conditions. It is often more comfortable and convenient for athletes to seek treatment in the team setting. Therefore, it is important that the medical professional be aware of not only common pathology but also of that which is rarer. Any delay in evaluation can result in unnecessary morbidity and lead to complications or extended time lost from sport. Consequently, it also is important to facilitate an atmosphere encouraging early presentation and workup.