Avulsion of the pectoralis major tendon

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.

Incidence of Pectoralis Major Injuries Has Increased 40% Over the Last 22 National Football League Seasons

Purpose

To examine trends in the incidence of pectoralis major (PM) injuries over the last 22 National Football League (NFL) seasons and identify risk factors for injuries requiring operative management.

Methods

Publicly available data from the 1998-1999 through 2019-2020 NFL seasons were reviewed to identify PM injuries, demographics, injury mechanisms, and management. Injury incidence was calculated using linear regression per 10,000 athlete-exposures, while risk factors for operative management were identified through multivariate logistic regression.

Results

There were 258 PM injuries. Mean athlete age at the time of injury was 27.1 years (range: 21-37) with a mean body mass index of 32.6 (range: 24.8-43.1). Overall incidence was 0.603 per 10,000 athlete-exposures, which was found to significantly increase with time by 0.039 per athlete-exposures per year (R² = .787, P < .001). Defensive athletes accounted for 64.7% of PM injuries. Repair was performed in 48.8% of athletes, with defensive linemen (odds ratio [OR] 3.78, CI 1.42-10.60, P = .009), defensive backs (OR 12.20, CI 2.13-76.60, P = .006), linebackers (OR 8.98, CI 2.58-33.60, P < .001), more recent time of injury (OR 1.11, CI 1.05-1.17, P < .001), and shorter NFL experience (OR .77 for older athletes, CI .59-.99), P = .047) at significant risk for operative treatment.

Conclusion

A total of 258 PM injuries were identified over 22 NFL seasons, with an overall incidence of 0.603 per 10,000 athlete-exposures, which was found to increase by 0.039 injuries per 10,000 athlete-exposures per year. Repair was performed in 48.8% of athletes, with more recent time of injury, shorter NFL experience, defensive linemen, defensive backs and linebackers at significantly higher risk for operative treatment.

Study Design

Cohort study; Level of evidence, 3

Pectoralis Major Tendon Tear: A Critical Analysis Review

»

Pectoralis major (PM) tendon tears are predominantly seen in young men, and the majority of tears occur as tendon avulsions involving the sternal head. Weightlifting, specifically bench-pressing, and sporting activities with eccentric overloading of the PM tendon are the 2 most common activities that result in PM injury.

»

Early surgical repair or reconstruction should be offered to younger, active patients with a complete PM tear; the majority of the patients undergoing surgical repair achieve good-to-excellent outcomes.

»

Nonsurgical treatment of a complete PM tear is an option but will result in cosmetic deformity and a deficit in adduction strength of the arm. Outcomes after nonsurgical treatment of complete PM tears are less satisfactory than those obtained after surgical treatment.

»

Currently, there is no consensus on the chronological definition of PM tears (acute versus chronic), the critical time limit for performing surgical repair, the ideal fixation device (cortical button, bone tunnel, or suture anchors), the indications for allograft use, and the ideal rehabilitation protocol after treatment of PM tears.

Pectoralis Major Tear: An Unusual and Rare Presentation

Introduction:

The pectoralis major is a very powerful muscle that forms the chest prominence and. It moves the shoulder forward and across your chest. It is best known as the muscle that you develop with the bench press exercise in gymnasium. The pectoralis major attaches to the humerus bone and is divided into two parts. The upper part is known as the “clavicular head” and the lower part the “sternal head,” based on their origins from the clavicle and sternal bones, respectively. Ruptures of the pectoralis major muscle are becoming more common due to the increase in power sports weight training.

Case Report:

A About 25-year-old male presented to Out Patient Department with bruising and swelling over the anterior wall of left axilla. The patient was engineer and amateur weight lifter. Clinically, the swelling was tender, and movements of left arm were restricted. Muscle tear was suspected and hence magnetic resonance imaging (MRI) was advised which showed tear of tendon of pectoralis major muscle. The patient was treated surgically and has got full range of movements of the arm.

Conclusion:

MRI is the mainstay for diagnosing pectoralis major tear. The earlier a repair is performed the easier the surgery and the better the outcome of surgery.

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.

High-Tensile Strength Tape Versus High-Tensile Strength Suture: A Biomechanical Study

PURPOSE

To determine which suture design, high-tensile strength tape or high-tensile strength suture, performed better at securing human tissue across 4 selected suture techniques commonly used in tendinous repair, by comparing the total load at failure measured during a fixed-rate longitudinal single load to failure using a biomechanical testing machine.

METHODS

Matched sets of tendon specimens with bony attachments were dissected from 15 human cadaveric lower extremities in a manner allowing for direct comparison testing. With the use of selected techniques (simple Mason-Allen in the patellar tendon specimens, whip stitch in the quadriceps tendon specimens, and Krackow stitch in the Achilles tendon specimens), 1 sample of each set was sutured with a 2-mm braided, nonabsorbable, high-tensile strength tape and the other with a No. 2 braided, nonabsorbable, high-tensile strength suture. A total of 120 specimens were tested. Each model was loaded to failure at a fixed longitudinal traction rate of 100 mm/min. The maximum load and failure method were recorded.

RESULTS

In the whip stitch and the Krackow-stitch models, the high-tensile strength tape had a significantly greater mean load at failure with a difference of 181 N (P = .001) and 94 N (P = .015) respectively. No significant difference was found in the Mason-Allen and simple stitch models. Pull-through remained the most common method of failure at an overall rate of 56.7% (suture = 55%; tape = 58.3%).

CONCLUSIONS

In biomechanical testing during a single load to failure, high-tensile strength tape performs more favorably than high-tensile strength suture, with a greater mean load to failure, in both the whip- and Krackow-stitch models. Although suture pull-through remains the most common method of failure, high-tensile strength tape requires a significantly greater load to pull-through in a whip-stitch and Krakow-stitch model.

CLINICAL RELEVANCE

The biomechanical data obtained in the current study indicates that high-tensile strength tape may provide better repair strength compared with high-tensile strength suture at time-zero simulated testing.

Pectoralis major tendon repair: a biomechanical study of suture button versus transosseous suture techniques

PURPOSE

Pectoralis major tendon avulsion injury benefits from surgical repair. The technique used and speed of rehabilitation in this demanding population remains subject to debate. We performed a biomechanical study comparing suture button (Pec Button™, Arthrex, Naples, FL) with a transosseous suture technique (FibreWire, Arthrex, Naples, FL).

METHODS

Freshly slaughtered porcine humeri were prepared to model a single transosseous suture or suture button repair. A static, tensile load to failure experiment and a cyclic, tensile load experiment to model standard (10,000 cycles) and accelerated rehabilitation (20,000 cycles) philosophies were tested. The mode of failure, yield and ultimate failure load, extension (clinical failure >10 mm) and the resistance to cyclic loading was measured.

RESULTS

The mode of failure was suture fracture in all the static load experiments with 10/11 occurring as the suture passed through the button and 7/11 as the suture passed through the bone tunnels. There was a significant difference in yield load, favouring transosseous suture [p = 0.009, suture button (SB) 673.0 N (647.2-691.7 N), transosseous suture (TOS) 855.0 N (750.0-891.4 N)] and median extension, favouring suture button [p = 0.009, SB 8.8 mm (5.0-12.4 mm), TOS 15.2 mm (13.2-17.1 mm)]. 2/3 transosseous suture and 0/3 suture buttons failed before completing 20,000 cycles. The difference in mean number of cycles completed was non-significant. The difference in mean extension was 5.1 mm (SB 6.7 mm, TOS 11.7 mm).

CONCLUSIONS

Both techniques show advantages. The difference in extension is likely to be more clinically relevant than load tolerated at failure, which is well above physiological levels. The findings do not support an accelerated rehabilitation model.

Pectoralis major ruptures: a review of current management

BACKGROUND

Rupture of the pectoralis major tendon is increasing in incidence, with a spike in the number of reported cases in the last decade. This is commonly attributed to an increased interest in health, fitness, and weight training combined occasionally with concomitant use of anabolic steroids. It is essential for the diagnosis to be recognized and for the patient to be referred to a surgeon with expertise in dealing with these injuries so that appropriate and informed care can be implemented.

METHODS

Based on a comprehensive review of the literature and expert opinion, we present a review of pectoralis major ruptures, including information pertaining to the anatomy and biomechanics of the musculotendinous unit and how this relates to the injury pattern and management; the clinical diagnosis and indications for additional imaging; and the indications for nonoperative and operative management along with the authors' preferred technique. A summary of outcomes is presented.

CONCLUSION

The combination of patient demographics and clinical features frequently yields an accurate diagnosis, but further imaging is helpful. Magnetic resonance imaging with dedicated sequencing is the investigation of choice and can aid in diagnosis, surgical planning, and providing important information about prognosis and outcome. Early surgery is preferable, but good outcomes in the chronic setting are achievable. With a detailed understanding of the anatomy, direct repair to bone is possible with either transosseous or anchor repair techniques in acute and the majority of chronic cases. In chronic cases in which direct repair is not achievable, autograft and allograft reconstruction should be considered.

Pectoralis major transosseous equivalent repair with knotless anchors: Technical note and literature review

Introduction:

Rupture of the pectoralis major (PM) tendon was initially described almost 2 centuries ago, but most of the reported injuries have occurred within the last 30 years. Options for repair have varied widely. The most common methods for repair depend on either transosseous sutures or suture anchors for fixation. Transosseous suture repair allows for docking the tendon into a trough at its anatomic insertion, but risks cortical breakage during suture passing. Our experience has confirmed the value and potential advantages of anchors for a secure fixation.

Aims:

To describe a variation of repair using knotless suture anchors and a burred trough to dock the tendon into its anatomic insertion.

Conclusion:

We describe a technique of a transosseous equivalent PM repair technique. To our knowledge, this is the first paper describing such a repair technique for PM rupture.

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.

Proximal humerus shaft fracture after pectoralis major tendon rupture repair

Surgical repair of a complete pectoralis major tendon rupture at the humeral insertion has superior results compared to nonoperative treatment. To our knowledge, a proximal humerus shaft fracture occurring at the site of the bone trough and cortical drill holes after a pectoralis major tendon rupture repair has not been reported in the literature.A 45-year-old man sustained an acute left pectoralis major tendon rupture at the humeral insertion while performing a bench press maneuver. He underwent acute surgical repair. Approximately 8 weeks postoperatively, the patient fell from a standing height and sustained a proximal humerus shaft fracture through the repair site at the bone trough. Three days after the fracture, the patient underwent open reduction and internal fixation of the proximal humerus shaft fracture and exploration of the pectoralis major tendon repair. The fracture was found to be at the level of the repair site, and the pectoralis major tendon was completely intact to the distal fragment. The fracture healed uneventfully, and the patient regained full motion and strength of his extremity with no limitations.Any type of surgical fixation that creates a hole in the humerus or decreases the cross-sectional area such as a bone trough creates a stress riser. Patients undergoing pectoralis tendon repair that involves violating the humerus with a bone trough or hole have a slight risk of postoperative humerus fracture, especially if sustaining an early traumatic event such as a fall.

Isokinetic muscle assessment after treatment of pectoralis major muscle rupture using surgical or non-surgical procedures

INTRODUCTION

Rupture of the pectoralis major muscle appears to be increasing in athletes. However, the optimal treatment strategy has not yet been established.

OBJECTIVES

To compare the isokinetic shoulder performance after surgical treatment to that after non-surgical treatment for pectoralis major muscle rupture.

METHODS

We assessed 33 pectoralis major muscle ruptures (18 treated non-surgically and 15 treated surgically). Horizontal abduction and adduction as well as external and internal rotation at 60 and 120 degrees/s were tested in both upper limbs. Peak torque, total work, contralateral deficiency, and the peak torque agonist-to-antagonist ratio were measured.

RESULTS

Contralateral muscular deficiency did not differ between the surgical and non-surgical treatment modalities. However, the surgical group presented twice the number of athletes with clinically acceptable contralateral deficiency (<20%) for internal rotators compared to the non-surgical group. The peak torque ratio between the external and internal rotator muscles revealed a similar deficit of the external rotation in both groups and on both sides (surgical, 61.60% and 57.80% and non-surgical, 62.06% and 54.06%, for the dominant and non-dominant sides, respectively). The peak torque ratio revealed that the horizontal adduction muscles on the injured side showed similar weakness in both groups (surgical, 86.27%; non-surgical, 98.61%).

CONCLUSIONS

This study included the largest single series of athletes reported to date for this type of injury. A comparative analysis of muscular strength and balance showed no differences between the treatment modalities for pectoralis major muscle rupture. However, the number of significant clinical deficiencies was lower in the surgical group than in the non-surgical group, and both treatment modalities require greater attention to the rehabilitation process, especially for the recovery of muscle strength and balance.

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.

Injuries to the pectoralis major muscle: diagnosis and management

Injuries to the pectoralis major muscle are relatively infrequent but result in pain, weakness, and deformity of the upper extremity. The usual injury mechanism is during eccentric shortening of the pectoralis major under heavy load, such as when performing a bench press exercise. The ability to detect and treat a pectoralis major rupture is important for both the clinician and the patient and is aided with knowledge of the anatomy, the clinical findings, and results of nonoperative and operative care. It is important to understand the physical demands and desires of the patient as well as to understand the outcomes of both nonoperative and operative care to make an informed decision regarding optimal treatment. This article highlights the importance of the clinical examination in identifying the injury, examines various surgical techniques to repair the rupture, and reports on potential complication and reinjury rates.

Pectoralis major muscle rupture in athletes: a prospective study

BACKGROUND

In the past 20 years, there has been an increase in the incidence of upper extremity tendinous injuries, especially in sports including strong physical activity, such as in weight lifting, as well as with the concurrent use of anabolic steroids. Today, there are more than 200 cases describing rupture of the pectoralis major muscle in athletes.

HYPOTHESIS

Surgical treatment will have a better outcome than nonsurgical treatment in total rupture of the pectoralis major muscle in athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Twenty athletes with pectoralis major muscle (PMM) rupture were studied; 10 had surgical treatment, and the other 10 were treated nonoperatively. The mean age was 32.27 years (range, 27-47 years); all of them were men. The average follow-up was 36 months (range, 48-72 months). Injuries were diagnosed by history, physical examination, and subsidiary tests. Functional evaluation and isokinetic evaluation were performed on all 20 patients.

RESULTS

The clinical evaluation revealed 70% (n = 7) excellent, 20% good (n = 2), and 10% poor (n = 1) outcomes for the cases treated with surgery and 20% good (n = 2), 50% fair (n = 5), and 40% poor (n = 4) outcomes for the cases treated nonsurgically. The isokinetic evaluation at 60-deg/s speed showed a decrease in strength of 53.8% in the nonsurgical group and 13.7% for the surgical group.

CONCLUSION

Total PMM rupture in athletes showed a better functional result after surgical treatment than after nonsurgical treatment.

Rupture of the pectoralis major: a case report and review

BACKGROUND

Rupture of the pectoralis major muscle is a rare clinical entity that is becoming more common due to the increasing popularity of weightlifting and recreational sports. Due to the rarity of this condition, it may be missed at initial presentation and inappropriately treated, potentially leading to increased disability.

OBJECTIVES

This case highlights the mechanism of injury, clinical features, diagnosis, and treatment of rupture of the pectoralis major.

CASE REPORT

The patient was a 31-year-old male bodybuilder who presented to the Emergency Department with acute pain and swelling in the left axilla after performing a bench press with a 400-pound barbell. The diagnosis of pectoralis major rupture was suspected and confirmed by magnetic resonance imaging, and early surgical repair was performed.

CONCLUSION

The most common mechanism of injury is excessive tension on a maximally contracted pectoralis major muscle. Weightlifting, specifically bench pressing, is a common cause. The diagnosis can usually be made based on a patient's history and physical examination, but shortly after injury, the diagnosis may be obscured by severe pain and swelling. Magnetic resonance imaging is the imaging modality of choice when the diagnosis remains unclear, and can avoid surgical delays. Early diagnosis and treatment within 3 to 8 weeks after the injury has the advantage of avoiding adhesions and muscle atrophy, and can prevent a delayed return to normal activities. Given the trend toward improved results with early surgical repair of complete rupture, it is important to raise awareness about pectoralis major muscle injury among Emergency Physicians to prevent missed or delayed diagnosis and repair.

Rupture of the pectoralis major muscle: surgical treatment in athletes

Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50% of these injuries occur in athletes, classically in weight-lifters during the 'bench press' manoeuvre. We present 13 cases of distal rupture of the pectoralis major muscle in athletes. All patients underwent open surgical repair. Magnetic resonance imaging was used to confirm the diagnosis in all patients. The results were analysed using (1) the visual analogue pain score, (2) functional shoulder evaluation and (3) isokinetic strength measurements. At the final follow-up of 23.6 months (14-34 months), the results were excellent in six patients, good in six and one had a poor result. Eleven patients were able to return to their pre-injury level of sports. The mean time for a return to sports was 8.5 months. The intraoperative findings correlated perfectly with the reported MRI scans in 11 patients and with minor differences in 2 patients. We wish to emphasise the importance of accurate clinical diagnosis, appropriate investigations, early surgical repair and an accelerated rehabilitation protocol for the distal rupture of the pectoralis major muscle as this allows complete functional recovery and restoration of full strength of the muscle, which is essential for the active athlete.

Pectoralis major tears: correlation of magnetic resonance imaging and treatment strategies

BACKGROUND

Controversy exists in the diagnosis and treatment of pectoralis major tear patterns.

HYPOTHESIS

Magnetic resonance imaging is useful in determining the grade and the location of pectoralis major tears and in guiding toward an appropriate treatment plan.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 1998 and December 2002, 27 patients were treated for pectoralis major tears. All patients were evaluated by history and physical examination. A clinical impression was formed regarding the location and grade of injury, and a treatment plan was established. All patients underwent magnetic resonance imaging, and images were reviewed by an orthopaedic surgeon and a board-certified musculoskeletal radiologist, resulting in a final treatment plan. The mean follow-up was 12 months. All patients were evaluated by questionnaire and clinical examination to assess pain, function, deformity, and overall satisfaction.

RESULTS

In 19 of 27 patients, the clinical impression and magnetic resonance imaging agreed regarding the location and the grade of the injury. A total of 19 patients underwent surgical repair, and 8 patients were treated nonoperatively. The magnetic resonance imaging result changed the treatment plan in 3 patients from operative to nonoperative.

CONCLUSION

The clinical impression appeared to overestimate the severity, the location, and the grade of the injury. Magnetic resonance imaging provided a more accurate assessment and, in conjunction with the clinical examination, helped to identify those patients who would benefit most from surgical repair.

Pectoralis major muscle injuries: evaluation and management

Pectoralis major muscle tears are relatively rare injuries that primarily occur while lifting weights, particularly when doing a bench press. Complete ruptures are most commonly avulsions at or near the humeral insertion. Ruptures at the musculo-tendinous junction and intramuscular tears usually are caused by a direct blow. The patient may hear a snap at the time of injury and report pain, weakness, swelling, or muscular deformity. Physical examination can reveal ecchymosis, a palpable defect, asymmetric webbing of the axillary fold, and weakness on resisted shoulder adduction and internal rotation. A detailed history and physical examination can be augmented by radiologic studies, including magnetic resonance imaging. Nonsurgical treatment is now recommended only for the older, sedentary patient or for proximal muscle belly tears. Surgery, whether early or delayed, consistently yields superior results compared with nonsurgical management. Prompt diagnosis and timely intervention likely will produce improved results.

Upper extremity injuries associated with strength training

Most injuries sustained during strength training are mild strains that resolve with appropriate rest. More severe injuries include traumatic shoulder dislocations, tendon ruptures of the pectoralis major, biceps, and triceps; stress fractures of the distal clavicle, humerus, radius, and ulna; traumatic fractures of the distal radius and ulna in adolescent weightlifters; and compressive and stretch neuropathies. These more severe injuries are usually the result of improperly performing a strength training exercise. Educating athletes regarding proper strength-training techniques serves to reverse established injury patterns and to prevent these injuries in the first place. Recognizing the association of anabolic steroid use to several of the injury patterns further reinforces the need for medical specialists to counsel athletes against their use. With the increasing use of supplements such as creatine, the incidence and nature of strength-training injuries may change further. Greater emphasis on the competitive performance of younger athletes undoubtedly will generate enthusiasm for strength training at earlier ages in both sexes. The importance of proper supervision of these young athletes by knowledgeable persons will increase. As the popularity of strength training grows, there will be ample opportunity to continue to catalog the injury patterns associated with this activity.

MR imaging assessment of the pectoralis major myotendinous unit: an MR imaging-anatomic correlative study with surgical correlation

OBJECTIVE

MR imaging is the optimal imaging technique to study the normal and abnormal conditions of the pectoralis major muscle and tendon unit. The purpose of this study was to use MR imaging to provide an anatomic survey of the normal pectoralis major tendon and its insertion and to compare these findings with surgically proven cases of rupture.

CONCLUSION

MR imaging shows the normal pectoralis major myotendinous unit has low signal intensity on both T1- and T2-weighted images. Reliable anatomic landmarks for visualization and examination of injuries to the muscle and myotendinous unit include the quadrilateral space, or the origin of the lateral head of the triceps, as the superior boundary and the deltoid tuberosity as the inferior boundary of the intact tendon of insertion. Failure to visualize a normal insertion within these boundaries should prompt a dedicated search by the radiologist for rupture and retraction of the tendon medially.

Delayed repair of a ruptured pectoralis major muscle. A case report

Repair of a pectoralis major muscle rupture at the tendinous insertion into the humerus was successfully performed 13 years after the initial injury. Repair was possible only because the ruptured sternal portion of the muscle was scarred to the intact clavicular portion and therefore had not retracted. The attachment of the avulsed sternal head to the intact clavicular head enabled successful restoration of strength and function, as well as normal contour and appearance of the pectoralis major muscle complex.

Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries

We retrospectively studied 17 cases of distal pectoralis major muscle rupture to compare the results of repair in acute and chronic injuries and to compare operative and nonoperative treatment. Thirteen patients underwent surgery (six acute injuries [less than 2 weeks after injury] and seven chronic injuries) and four had nonoperative management. The mean age of the patients at injury was 29, and 10 of the 17 injuries were the result of weight lifting. Follow-up ranged from 18 months to 6 years (mean, 28 months). All patients subjectively rated strength, pain, motion, function with strenuous sporting activities, cosmesis, and overall satisfaction. Objectively, patients were examined for range of motion, deformity, atrophy, and strength. Isokinetic strength testing was performed in eight patients: six treated operatively (three acute and three chronic) and two treated nonoperatively. Overall subjective ratings were 96% in the acute group, 93% in the chronic group, and only 51% in the nonoperative group. Isokinetic testing showed that patients operated on for acute injuries had the highest adduction strength (102% of the opposite side) compared with patients with chronic injuries (94%) or nonoperative treatment (71%). There were no statistically significant subjective or objective differences in outcome between the patients treated operatively for acute or chronic injuries, but these patients fared significantly better than patients treated nonoperatively.

Injuries of the pectoralis major muscle: evaluation with MR imaging

PURPOSE

To demonstrate that magnetic resonance (MR) imaging allows evaluation of injuries of the pectoralis major muscle.

MATERIALS AND METHODS

Fifteen men underwent MR imaging after injury of the pectoralis major muscle. Most of the patients (nine of 15) were injured while lifting weights, notably bench-pressing. The injuries were evaluated for abnormal morphology and signal intensity, specifically the site of injury, degree of tearing, and amount of tendon retraction.

RESULTS

Six injuries occurred at the musculotendinous junction, and five were treated conservatively; eight of the nine cases of distal tendon avulsion were treated with primary surgical repair. The MR imaging findings were confirmed in the nine cases treated surgically. Complete tears (three of 15) were less common than partial tears (12 of 15). The sternal and clavicular heads were torn in 10 patients, only the clavicular head was torn in two patients, and only the sternal head was torn in three patients. Acute tears (10 of 15) demonstrated hemorrhage and edema, whereas chronic tears (five of 15) demonstrated fibrosis and scarring. There was a variable amount of tendon retraction.

CONCLUSION

MR imaging allows accurate evaluation of injuries of the pectoralis major muscle and enables identification of patients who would benefit from surgical repair.

Rupture of pectoralis major during parallel bar dips: case report and review

Rupture of the pectoralis major muscle is an uncommon athletic injury that can result in both functional and cosmetic deficiency. To date, most ruptures occurring in athletes have occurred while performing bench press or overhead lifting maneuvers. We describe a case of a pectoralis major rupture occurring while performing weighted parallel bar dips. Despite the popularity of this exercise, injuries associated with this exercise are infrequently reported. This injury can be easily detected by having the patient perform specific maneuvers on physical examination to accentuate any defect that may be present. In most cases, this injury is surgically repaired, although conservative treatment can be a successful option. Treatment options are discussed and recommendations given. A partial or complete tear of the pectoralis major muscle is a rare event and is often not easily detected on physical examination. Surgical repair is currently recommended to restore previous levels of strength and to correct the resulting cosmetic defect. Repair is rarely necessary to perform the normal activities of daily living.

Weight training injuries: part 1: diagnosing and managing acute conditions

When patients present with acute weight training injuries, familiarity with the demands of the activity can help physicians get the most out of the patient history. Probable risk factors for injury include errors in technique (described in a sidebar), skeletal immaturity, and anabolic steroid abuse. Common acute injuries in weight training include sprains, strains, tendon avulsions, and compartment syndrome. Possible nonmusculoskeletal problems include retinal hemorrhage, radiculopathy, and various cardiovascular complications. Treatment of acute musculoskeletal injuries varies, but usually includes sports medicine mainstays such as prompt RICE. Chronic weight training injuries will be described in part 2 of this series.

Pectoralis Major Rupture: Presentation of Two Cases and Review of 74 Cases

Pectoralis major rupture is uncommon. Injury usually occurs from sporting activities. The incidence and management of pectoralis major rupture is not well known, despite 74 case reports in the English language literature over the past 34 years. Two cases of chronic pectoralis ruptures and their successful surgical management are described. A review of the literature shows that most injuries occur at the humeral insertion, and most are complete ruptures. Distinguishing between complete and partial ruptures is important. Complete ruptures are best treated surgically in the acute situation. When chronic complete ruptures present, surgical repair yields fair to good results. Acute partial ruptures can be effectively managed conservatively or with surgery. Chronic partial ruptures can be managed surgically with good results, following unsatisfactory conservative management in the acute situation.

Pectoralis major tendon avulsion in association with a proximal humerus fracture

We report a very rare case of an avulsion of the pectoralis major tendon in association with a two-part proximal humerus fracture. Pectoralis major tendon avulsion was confirmed intraoperatively during open reduction and internal fixation of the humerus fracture. In retrospect, the preoperative radiographic finding of posterolateral and proximal displacement of the humeral shaft suggested an injury to the pectoralis major. Because others have reported that the best treatment of a pectoralis major tendon avulsion is surgical repair, we feel that it is important to suspect such an injury in a proximal humerus fracture when this anatomic displacement is present.

Pectoralis Major Rupture

In brief Rupture of the pectoralis major brief muscle and tendon, which occurs most frequently among weight lifters but has been reported in many sports, can most often be diagnosed based on the history and physical exam. Surgical intervention for complete ruptures has a clear advantage over conservative therapy. Athletes of all levels can be expected to return to near preinjury levels of participation following surgery and a well-constructed, supervised rehabilitation program. This should involve immobilization followed by range- of-motion exercises and strength training of gradually increasing resistance.

Rupture of the pectoralis major muscle in a collegiate football player. Use of magnetic resonance imaging in early diagnosis

We have reported an unusual case of pectoralis major muscle rupture and repair. There were three interesting aspects of this case. First, the injury occurred in a football player with an unusual mechanism of injury. Second, MRI using special techniques was valuable in confirming the diagnosis acutely and in planning treatment. Finally, we reported on the use of suture anchors to secure the avulsed tendon. We recommend the early use of MRI for diagnosis and in planning treatment of suspected pectoralis major muscle ruptures.