Pectoralis Major Injuries in the National Football League

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.

Defining the contemporary epidemiology and return to play for high ankle sprains in the National Football League

BACKGROUND

High ankle sprains and syndesmotic injuries are commonly sustained by National Football League players, yet there is apaucity of literature reporting the incidence, risk factors and return to play (RTP) rates for these injuries. The purpose of this study is to examine the epidemiology and trends in incidence of high ankle sprains across 11 NFL seasons.

METHODS

Publicly available data from the 2009-2010 through 2019-20 seasons were reviewed to identify injuries and collect player characteristics and return to play. Incidence of high ankle injuries was calculated per 10,000 athlete-exposures. Linear regression was performed for incidence of injuries. Risk factors for failure to RTP were identified through multivariate logistic regression, controlling foryear of injury, player position, body mass index (BMI), age at injury, and years of experience before injury.

RESULTS

A total of 533 high ankle sprains were identified in 498 players at an average age of 25.8 ± 3.1 and average BMI of 31.8 ± 4.6. The annual incidence of high ankle sprains in the NFL increased at alinear rate of 0.067per 10,000 player exposures (R² = 0.3357) in 2009, to 1.75per 10,000 player exposures to 2.49 in 2019-20. Most injuries were in offensive players (304/533 injuries, 57.0%). Overall, 89.7% (478/533) of players returned to play; average RTP time was 80.5 ± 132.9 days. Defensive players had afaster RTP (68.1 ± 114.6 days) compared to offensive players (90.1 ± 144.8 days) (p = 0.084). Higher age at injury was found to increase the risk of failure to RTP (p = 0.0088).

CONCLUSION

RTP rate was high following high ankle sprain aamongNFL players at 90%, with an average recovery period of 11 weeks. Defensive players experience RTP faster than offensive players. Future studies are needed to determine performance outcomes following RTP, along with which patients might benefit from surgery.

Video Analysis of Pectoralis Major Injuries in Professional Australian Football Players

Background:

There is little evidence regarding the mechanisms of pectoralis major (PM) injury and player outcomes in Australian Football League (AFL) players.

Purposes/Hypothesis:

The study aims were to investigate (1) the mechanisms of PM muscle injury in elite AFL players via video analysis and (2) the player profile, method of management, and clinical outcomes of the PM injuries sustained. We hypothesized that the majority of PM tears would occur in outer-range PM positions (hyperextension of the glenohumeral joint).

Study Design:

Case series; Level of evidence, 4.

Methods:

We analyzed video of the precipitating event for traumatic PM injuries during AFL competition or training over a 20-year period (2002-2021). The footage was analyzed by 4 experienced assessors, and the following were evaluated: mechanism of injury, injury variables (arm position, initial contact point, visual awareness, and use of taping), player characteristics (age at the time of injury, hand dominance, and history of injury), injury profile (location and size of tear), method of management (operative vs nonoperative), patient outcomes (time to return to full senior training/match play), and complication rates.

Results:

The mean ± standard deviation age of the players was 26.5 ± 3.1 years (range, 21-32 years). Overall, 22 PM injuries were identified in the AFL injury database for a rate of 1.1 per year; 16 of these injuries had accompanying video footage. We identified 3 mechanisms for PM injury: horizontal hyperextension (62.5%), hyperflexion-abduction (25.0%), and horizontal adduction (sustained tackling; 12.5%). The most common site of the tear was the insertion point of the sternocostal head (91.0%). Twenty players (91.0%) required surgical repair, with 75% undergoing surgery within 1 week (range, 0-26 weeks). The mean return to competition for the surgical repair group was 11.1 weeks (range, 8-15 weeks). The rerupture rate was 5.0% (1 repair; <4 weeks postoperatively in 2004).

Conclusion:

PM tears in elite male AFL players were due to 1 of 3 distinct mechanisms: horizontal hyperextension, hyperflexion-abduction, and horizontal adduction (sustained tackling). Players returned to play on average 11 weeks after injury. Knowledge regarding mechanisms of injury, player profile, and return-to-sport timelines is important for appropriate medical management and provides potential areas to target for prevention of PM injuries.

Pectoralis muscle injuries in Major and Minor League Baseball

BACKGROUND AND HYPOTHESIS

Although shoulder and elbow injuries in professional baseball players have been thoroughly studied, little is known about the frequency and impact of pectoralis muscle injuries in this population. The purpose of this study was to use the official league injury surveillance system to describe pectoralis muscle injuries in professional baseball players in Major League Baseball (MLB) and Minor League Baseball (MiLB). Specifically, (1) player demographic characteristics, (2) return to play (RTP), (3) injury mechanism, (4) throwing- and batting-side dominance, and (5) injury rate per athlete exposure (AE) were characterized to guide future injury prevention strategies.

METHODS

The MLB Health and Injury Tracking System database was used to compile all pectoralis muscle injuries in MLB and MiLB athletes in the 2011-2017 seasons. Injury-related data including diagnosis (tear or rupture vs. strain), player demographic characteristics, injury timing, need for surgical intervention, RTP, and mechanism of injury were recorded. Subanalyses of throwing- and batting-side dominance, as well as MLB vs. MiLB injury frequency, were performed.

RESULTS

A total of 138 pectoralis muscle injuries (32 MLB and 106 MiLB injuries) were reported in the study period (5 tears or ruptures and 133 strains), with 5 of these being recurrent injuries. Operative intervention was performed in 4 athletes (2.9%). Of the 138 injuries, 116 (84.1%) resulted in missed days of play, with a mean time to RTP of 19.5 days. Starting pitchers sustained the greatest proportion of pectoralis injuries (48.1%), with pitching being the most common activity at the time of injury (45.9%). A majority of injuries (86.5%) were sustained during non-contact play. Overall, 87.5% of injuries occurred on the player's dominant throwing side and 81.3% occurred on the player's dominant batting side. There was no significant difference in the rate of pectoralis injuries in the MLB regular season (0.584 per 10,000 AEs) vs. the MiLB regular season (0.425 per 10,000 AEs) (P = .1018).

CONCLUSION

Pectoralis muscle injuries are most frequently non-contact injuries, most commonly sustained by pitchers. An understanding of these injuries can guide athletic trainers and management in expectation management and decision making, in addition to directing future efforts at injury prevention.

Surgical repair of acute on chronic seven-year pectoralis major rupture near the distal myotendinous junction: A case report

The surgical fixation of an acute on chronic pectoralis major rupture with inciting injury 7 years prior has never been reported in the literature. Thus, we report the first case of an acute on chronic pectoralis major rupture repair in an active male patient who underwent successful surgical intervention and review the pathophysiology and treatment of pectoralis major tears.

Evaluation and Management of the Contact Athlete's Shoulder

Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.

Influence of Preseason Versus In-Season Play on Achilles Tendon Injuries in the National Football League

Background:

A ruptured Achilles tendon (AT) can sideline a player for 6 to 12 months and reduce their power rankings by more than 50%. Previous research has compared AT rupture rates in different game conditions.

Purpose:

To determine environmental and physiological risk factors for AT tears, given the minimal amount of research on AT ruptures in the National Football League (NFL).

Study Design:

Case series; Level of evidence, 4.

Methods:

NFL players with a diagnosed AT tear between 2009 and 2016 were selected as the study population for this retrospective analysis. Data on NFL injury were collected from an established database composed of publicly available information. Player profiles were employed to determine position, team, and game statistics at the time of injury. The proportion of NFL rookies was approximated by summing the number of draft picks and the number of signed, undrafted free agents and measured against the number of roster spots before the season.

Results:

Between 2009 and 2016, there were 101 documented AT tears. Of these, 64% (65/101) occurred before the official season, including preseason games. Of the 36 tears that occurred in-season, 34 were during games. Overall, 29% (19/65) of the preseason tears occurred in rookies and 100% (36/36) of the in-season tears affected nonrookies. Of the rookies with AT ruptures, 42.11% returned to play in the NFL, while 62.20% of the nonrookies came back to partake in future seasons. Despite an average age of 26.7 years, the tear distribution was bimodal with players aged 24 and 36 years exhibiting the highest rates of tear.

Conclusion:

In our review of AT tears in NFL athletes, a large percentage of the tears occurred in rookie players, especially during the preseason. We also found that tears during the season occurred in only nonrookies, suggesting that the preseason is when rookies experience the greatest risk for injury.

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

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

PURPOSE

The purpose of this study was to determine return-to-play (RTP), performance and career survivorship for National Football League (NFL) athletes sustaining pectoralis major (PM) injuries with comparison among grades of injury and between nonoperative and operative management.

METHODS

Publicly available data from the 1998-2020 NFL seasons were reviewed to identify athletes with PM injuries. Athlete characteristics were collected 1 season before and 2 seasons after injury. Percent of total games played in a season, player efficiency rating (PER), and Pro Football Focus (PFF) grades were compared for the preinjury season and 2 postinjury seasons. Kaplan-Meier survivorship plots were computed for RTP and postinjury career length, whereas a log-rank test was used to compare survivorship differences.

RESULTS

In total, 258 PM injuries were reported at a mean age of 27.1 ± 3.3 years. A total of 126 surgical repairs occurred in 48.8% (n = 126) of injuries, with athletes undergoing repair possessing a lower RTP rate and longer time to RTP compared to athletes treated conservatively (P < .001). Survival analysis revealed shorter career length for athletes sustaining PM tears compared to strains (P < .001), although no difference in career length was appreciated on the basis of injury management (P = .980). Defensive linemen and wide receivers had lower PER during their second postinjury seasons (P = .019 and .030, respectively), whereas defensive linemen had lower PFF grades during their second post-injury seasons (P = .044).

CONCLUSION

NFL athletes requiring PM repair may experience a lower likelihood of RTP, and longer RTP timing, likely because of higher-grade injuries. Defensive linemen and wide receivers experiencing PM injuries are at risk for diminished performance post-injury. Career length does not appear to be affected based on injury management.

LEVEL OF EVIDENCE

Level III, cohort study.

Pectoralis Major 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.

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.

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.