Acute pectoralis major tears in active duty US military personnel: Midterm outcomes of repairs performed in the forward-deployed setting

Differences in Disease Non-battle Injury Between Combatant Commands

INTRODUCTION

Disease and non-battle injury (DNBI) have historically been a major or primary medical burden in expeditionary military populations. The United States has multiple deployed populations conducting operations across the world. This study aims to determine if DNBI rates are different between military populations by comparing the United States Africa Command (USAFRICOM) and United States Central Command (USCENTCOM) areas of responsibility.

MATERIALS AND METHODS

The study period was from January 1, 2017 to December 31, 2021. Individual evacuation data including date, necessary specialty care, and combatant command (CCMD) were acquired via United States Transportation Command Regulating and Command & Control Evacuation System. Total population data was acquired from USAFRICOM and USCENTCOM headquarters. Total inpatient and outpatient encounters at each CCMD were acquired via Theater Medical Data Store. The proportions and evacuation rates of DNBI types within USAFRICOM and USCENTCOM were compared.

RESULTS

USCENTCOM had significantly higher proportions of outpatient and inpatient services for mental disorders, musculoskeletal diseases, and neurologic conditions compared to USAFRICOM. USCENTCOM had a significantly lower evacuation rate compared to USAFRICOM for every year analyzed: 2017 (P-value < .0001; relative risk [RR] = 0.834; 95% CI = 0.80-0.87), 2018 (P-value < .0001; RR = 0.818; 95% CI = 0.78-0.85), 2019 (P-value < .0001; RR = 0.785; 95% CI = 0.75-0.82), 2020 (P-value < .0001; RR = 0.889; 95% CI = 0.84-0.94), and 2021 (P-value < .0001; RR = 0.868; 95% CI = 0.83-0.91).

CONCLUSIONS

The evacuation rates of different categories of DNBI vary between CCMDs. There will be CCMD-specific factors that impact the effectiveness of initiatives to reduce the DNBI burden.

Pectoralis Major Tendon Tears During Airborne Operations: Are These Injuries Isolated?

INTRODUCTION

Pectoralis major tendon tears are an injury pattern often treated in military populations. Although the majority of pectoralis major tendon tears occur during eccentric loading as in bench press weightlifting, military service members may also experience this injury from a blunt injury and traction force produced by static line entanglement during airborne operations. Although these injuries rarely occur in isolation, associated injury patterns have not been investigated previously.

MATERIALS AND METHODS

After obtaining institutional review board approval, medical records were reviewed for all patients who underwent surgical repair of a pectoralis major tendon tear sustained during static line parachuting at a single institution. Radiology imaging, operative notes, and outpatient medical records were examined to determine concomitant injury patterns for each patient identified over a 4-year study period.

RESULTS

Twenty-five service members met the study inclusion criteria. All patients underwent presurgical magnetic resonance imaging. Of these 25 service members, 10 (40%) presented with a total of 13 concomitant injuries identified on physical exams or imaging studies. The most common associated injuries were injuries to the biceps brachii and a partial tear of the anterior deltoid. Biceps brachii injuries consisted of muscle contusion proximal long head tendon rupture, proximal short head tendon rupture, partial muscle laceration, and complete muscle transection. Additional concomitant injuries included transection of coracobrachialis, a partial tear of the inferior subscapularis tendon, antecubital fossa laceration, an avulsion fracture of the sublime tubercle, and an avulsion fracture of the coracoid process.

CONCLUSIONS

Military static line airborne operations pose a unique risk of pectoralis major tendon tear. Unlike the more common bench press weightlifting tear mechanism, pectoralis major tendon tears associated with static line mechanism present with a concomitant injury in 40% of cases, with the most common associated injury occurring about the biceps brachii. Treating providers should have a high index of suspicion for concomitant injuries when treating pectoralis major tendon tears from this specific mechanism of injury.

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.

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.

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.