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

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.

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.

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.

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.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods

BACKGROUND

Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods.

PURPOSE/HYPOTHESIS

The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation.

STUDY DESIGN

Meta-analysis.

METHODS

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months' mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05.

RESULTS

Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 (P = .004) and satisfaction with cosmesis by 20.50% (P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair.

CONCLUSION

Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment

Background:

The incidence of pectoralis major tendon tears is increasing, and repair is generally considered; however, a paucity of comparative data are available to demonstrate the superiority of operative treatment.

Purpose/Hypothesis:

The purpose of this study is to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared with nonoperative treatment.

Methods:

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed by use of MEDLINE, SPORTDiscus, CINAHL, Cochrane, EMBASE, and Web of Science databases. We included English-language studies that had a minimum of 6 months of average follow-up and 5 cases per study. The MINORS (Methodological Index for Non-Randomized Studies) was used to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect sizes were calculated from random-effects models. Continuous variables were assessed by use of mixed-model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed via the Freeman-Tukey log-linear transformation for variance stabilization and then assessed through use of a mixed model with a study level random effect and subsequently back-transformed. Significance was set at P < .05.

Results:

A total of 23 articles with 664 injuries met the inclusion criteria for comparison. All patients were male, with an average age of 31.48 years; 63.2% of injuries occurred during weight training, and the average follow-up was 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment, with relative improvements of functional outcome by 23.33% (0.70 improvement by Bak criteria which is scored 1-4; P = .027), full isometric strength 77.07% (P < .001), isokinetic strength 28.86% (P < .001) compared with the uninjured arm, cosmesis satisfaction 13.79% (P = .037), and resting deformity 98.85% (P < .001). The overall complication rate for operative treatment was 14.21%, including a 3.08% rate of rerupture.

Conclusion:

Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. Statistically significant improvements were noted in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity.

Everything pectoralis major: from repair to transfer

Background: Pectoralis major ruptures are increasing in incidence primarily due to an increase in awareness, activity level among young males between 20 and 40 years of age, and use of anabolic steroids. Although the majority of pectoralis major ruptures are acute injuries, many chronic ruptures are unrecognized and it is imperative to understand the proper evaluation of these injuries, as well as the appropriate treatment for acute and chronic ruptures.Purpose: Pectoralis major ruptures can lead to deformity and physical disability if left untreated. This review paper discusses both acute and chronic ruptures as well as indications for nonoperative treatment and operative treatment to give the reader the best understanding of this diagnosis and proper management.Methods: A systematic review of the literature was performed using a search of electronic databases. Search terms such as pectoralis major rupture, pectoralis major repair, pectoralis major tendon transfer, and pectoralis major nonoperative treatment were used. Case reports, systematic reviews, prospective and retrospective studies were included to provide a comprehensive review. The only exclusion criteria consisted of studies not published in English. This review article includes the anatomy and biomechanics of the pectoralis major muscle, proper evaluation of the patient, operative and nonoperative treatment of acute and chronic pectoralis major ruptures, and outcomes of the recommended treatment.Conclusion: Nonoperative treatment is indicated for patients with medical comorbidities, older age, incomplete tears, or irreparable damage. Patients treated non-operatively have been shown to lose strength, but regain full range of motion. Patients with surgery before 6 weeks reported better outcomes than patients with surgery between 6 and 8 weeks. The chronicity of the rupture (>8 weeks) increases the likelihood of reconstruction, involving the use of autografts or allografts. Patients treated with delayed repair had significantly better strength, satisfaction, and outcomes than patients with nonoperative treatment. The pectoralis tendon can also be transferred in patients with rotators cuff tears, atrophy, or significant functional limitation. Tendon transfers have been shown to have unpredictable outcomes, but overall satisfactory results.

The effects of Pilates vs. aerobic training on cardiorespiratory fitness, isokinetic muscular strength, body composition, and functional tasks outcomes for individuals who are overweight/obese: a clinical trial

Background

Some studies have been conducted to verify the effects of Pilates for individuals who are obese, but conclusive results are not yet available due to methodological concerns. The present study aims to verify and compare the effects of Pilates and aerobic training on cardiorespiratory fitness, isokinetic muscular strength, body composition, and functional task outcomes for individuals who are overweight/obese.

Methods

Of the sixty participants, seventeen were allocated to the control group, since the intervention protocol (Pilates or walking sessions) was during their working hours. The remaining 44 participants were randomly allocated to one of two experimental groups (Pilates (n = 22)) or aerobic groups (n = 21).The Pilates and aerobic groups attended 60-min exercise sessions, three times per week for 8 weeks. The aerobic group performed walking training at a heart rate corresponding to the ventilatory threshold. The Pilates group performed exercises on the floor, resistance apparatus, and 1-kg dumbbells. The control group received no intervention. All volunteers were evaluated at the beginning and end of the intervention. The following assessments were conducted: food intake, cardiorespiratory maximal treadmill test, isokinetic strength testing, body composition and anthropometry, abdominal endurance test, trunk extensor endurance test, flexibility test and functional (stair and chair) tests.

Results

There was no significant difference pre- and post-intervention in calorie intake [F(2, 57) = 0.02744, p = 0.97)]. A significant improvement in oxygen uptake at ventilatory threshold (p = 0.001; d = 0.60), respiratory compensation point (p = 0.01; d = 0.48), and maximum effort (p = 0.01; d = 0.33) was observed only in the Pilates group. Isokinetic peak torque for knee flexor and extensor muscles did not change for any groups. Lean mass (p = 0.0005; d = 0.19) and fat mass (p = 0.0001; d = 0.19) improved only in the Pilates group. Waist and hip circumference measurements decreased similarly in both experimental groups. Abdominal test performance improved more in the Pilates group (p = 0.0001; d = 1.69) than in the aerobic group (p = 0.003; d = 0.95). Trunk extensor endurance and flexibility improved only in the Pilates group (p = 0.0003; d = 0.80 and p = 0.0001; d = 0.41, respectively). The Pilates group showed greater improvement on the chair and stair tests (p = 0.0001; d = 1.48 and p = 0.003; d = 0.78, respectively) than the aerobic group (p = 0.005; d = 0.75 and p = 0.05; d = 0.41, respectively).

Conclusion

Pilates can be used as an alternative physical training method for individuals who are overweight or obese since it promotes significant effects in cardiorespiratory fitness, body composition, and performance on functional tests.

Isolated traumatic pectoralis minor tendon tear in a young adult diagnosed with MRI

This is a rare case of an isolated pectoralis minor partial-thickness tendon tear in a 24-year-old man who was involved in a major trauma. The purpose of this paper is to report the clinical signs, symptoms, cross-sectional imaging findings, and management of an isolated pectoralis minor tendon tear. Furthermore, this case represents a novel traumatic mechanism of injury, as opposed to the classic sports-related pectoralis minor tendon tear injury. The current limited body of literature on isolated pectoralis minor tendon tears is reviewed.

Pectoral nerves I block is associated with a significant motor blockade with no dermatomal sensory changes: a prospective volunteer randomized-controlled double-blind study

PURPOSE

The pectoral nerves (PECS) I block, first described in 2011 for surgery involving the pectoralis muscle, has principally been used for breast cancer surgery. No formal evaluation of its differential motor- and sensory-blocking abilities has been reported. We hypothesize that the PECS I block will produce a motor block of the pectoralis muscles with diminished upper limb adduction strength as measured with a handheld dynamometer.

METHODS

We conducted a PECS I block in a randomized placebo-controlled trial in six healthy subjects who received 0.4 mL·kg^-1 of 0.9% saline (placebo) on one side and bupivacaine (0.25% with 1:400 000 epinephrine) on the other. We measured both upper limb adduction strength with a dynamometer and sensory skin levels over the thorax.

RESULTS

The mean (standard deviation [SD]) adductor strength evaluated before the block was 119.4 (20.7) Newtons (N). After the PECS I block with bupivacaine, the mean (SD) strength of 54.2 (16.3) N was compared with 116.0 (30.4) N in the placebo group (difference in means 61.8 N; 95% confidence interval [CI], 27.8 to 95.8 N; P = 0.005), showing a 54.6% (95% CI, 43.6 to 65.6%) reduction in adductor strength. There was no difference in dermatomal skin sensory testing between the placebo and bupivacaine sides.

CONCLUSIONS

This study shows that a PECS I block produces motor blockade as shown by reduced upper limb adductor strength without any overlying dermatomal sensory loss.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03040167) 2 February 2017.

Surgical treatment of pectoralis major muscle rupture with adjustable cortical button

OBJECTIVE

To assess the tendon reconstruction technique for total rupture of the pectoralis major muscle using an adjustable cortical button.

METHODS

Prospective study of 27 male patients with a mean age of 29.9 (SD = 5.3 years) and follow-up of 2.3 years. The procedure consisted of autologous grafts taken from the semitendinosus and gracilis tendons and an adjustable cortical button. Patients were evaluated functionally by the Bak criteria.

RESULTS

The surgical treatment of pectoralis major muscle tendon reconstruction was performed in the early stages (three weeks) in six patients (22.2%) and in 21 patients (77.8%), in the late stages. Patients operated with the adjustable cortical button technique obtained 96.3% excellent or good results, with only 3.7% having poor results (Bak criteria). Of the total, 85.2% were injured while performing bench press exercises and 14.8%, during the practice of Brazilian jiu-jitsu or wrestling. All weight-lifting athletes had history of anabolic steroid use.

CONCLUSION

The early or delayed reconstruction of ruptured pectoralis major muscle tendons with considerable muscle retraction, using an adjustable cortical button and autologous knee flexor grafts, showed a high rate of good results.

The effects of preventive rubber band training on shoulder joint imbalance and throwing performance in handball players: A randomized and prospective study

OBJECTIVES

To investigate the effects of a strength training program (STP) using rubber band exercises.

METHODS

Twenty-five athletes were divided into two groups: muscular imbalance in the dominant (D) and in the non-dominant (ND) upper limbs. Each group was subdivided into experimental and control groups. Experimental groups performed eighteen sessions of STP. Athletes were submitted to ball throwing and isokinetic strength tests to assess the muscular strength of the shoulder rotator muscles and conventional and functional balance ratios.

RESULTS

STP improved external rotator peak torque (18.0 ± 0.8 to 21.3 ± 1.0 Nm, p < 0.01) and total work (29.3 ± 0.9 to 34.5 ± 1.5 J, p < 0.01) in the D experimental group, while only total work (34.8 ± 2.5 to 37.6 ± 3.1 J, p < 0.03) improved in the D control group. The ND experimental group also presented significant improvement in external rotator peak torque (18.8 ± 0.8 to 21.1 ± 1.3 Nm, p < 0.01) and total work values (29.0 ± 1.4 to 34.6 to 1.6 J, p < 0.01) while there was no strength improvement in the ND control group. The ND experimental group showed an improvement in conventional (61.5 ± 3.5 to 72.7 ± 3.0%, p = 0.03) and functional (1.0 ± 0.1 to 1.6 ± 0.08, p < 0.01) ratios. STP did not improve the conventional ratio in the D experimental group. However, STP produced a large effect size. The D experimental group presented an improvement in ball velocity (49.0 ± 2.4 to 52.5 ± 2.2 km/h, p = 0.04) in standing position throwing.

CONCLUSIONS

STP improves muscular strength of external rotator muscles and muscular balance.

Functional and Volumetric Analysis of the Pectoralis Major Muscle After Submuscular Breast Augmentation

BACKGROUND

Dual plane breast augmentation is a technical variation of the submuscular plane described as a technique that reduces contour deformities due to contraction of the pectoralis major muscle and lower risk of double-bubble deformity associated with breast ptosis. Despite improvement in the aesthetic aspect, there is still no consensus whether this technique affects the function of the pectoralis major muscle.

OBJECTIVES

The aim of this study was to correlate functional with volumetric changes associated with dissection of the muscle origin in submuscular breast augmentation.

METHODS

Thirty women who desired to undergo breast augmentation were selected prospectively and randomly allocated to 2 groups: 10 patients in the control group and 20 patients in the interventional group, who underwent submuscular breast augmentation. Magnetic resonance imaging and volumetric software were used to assess muscle volume and isokinetic dynamometry was used to assess function of the pectoralis major muscle. Preoperative measurements were compared with those at 3, 6, and 12 months after surgery.

RESULTS

Magnetic resonance imaging revealed significant decrease in muscle volume at 6 and 12 months follow-up. The isokinetic test conducted during adduction showed a significant difference in muscle strength between groups from baseline to the 12-month follow-up, and between the 3- and 12-month follow-up. No significant differences in muscle strength during abduction were observed from baseline to the 3-, 6-, and 12-month follow-up.

CONCLUSIONS

Submuscular breast augmentation reduced muscle strength during adduction 12 months after surgery, but without a significant correlation with volumetric muscle loss.

LEVEL OF EVIDENCE 2

Analisys of pectoralis major tendon in weightlifting athletes using ultrasonography and elastography

OBJECTIVE

To evaluate tendinopathy of the pectoralis major muscle in weightlifting athletes using ultrasound and elastography.

METHODS

This study included 20 patients, 10 with rupture of the pectoralis major muscle and 10 control patients. We evaluated pectoralis major muscle contralateral tendon with ultrasonographic and elastography examinations. The ultrasonographic examinations were performed using a high-resolution B mode ultrasound device. The elastography evaluation was classified into three patterns: (A), if stiff (more than 50% area with blue staining); (B), if intermediate (more than 50% green); and (C), if softened (more than 50% red).

RESULTS

Patients' mean age was 33±5.3 years. The presence of tendinous injury measured by ultrasound had a significant different (p=0.0055), because 80% of cases had tendinous injury versus 10% in the Control Group. No significant differences were seen between groups related with change in elastography (p=0.1409).

CONCLUSION

Long-term bodybuilders had ultrasound image with more tendinous injury than those in Control Group. There was no statistical significance regarding change in tendon elasticity compared with Control Group.

Incidence Rate and Results of the Surgical Treatment of Pectoralis Major Tendon Ruptures in Active-Duty Military Personnel

BACKGROUND

Pectoralis major tendon ruptures are commonly described as rare injuries affecting men between 20 and 40 years of age, with generally excellent results after surgical repair. However, this perception is based on a relatively small number of case series and prospective studies in the orthopaedic literature.

PURPOSE

To determine the incidence of pectoralis major tendon ruptures in the active-duty military population and the demographic risk factors for a rupture and to describe the outcomes of surgical treatment.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

We utilized the Military Health System Data Repository (MDR) to identify all active-duty military personnel surgically treated for a pectoralis major tendon rupture between January 2012 and December 2014. Electronic medical records were searched for patients' demographic information, injury characteristics, and postoperative complications and outcomes. Risk factors for a rupture were calculated using Poisson regression, based on population counts obtained from the MDR. Risk factors for a postoperative complication, the need for revision surgery, and the inability to continue with active duty were determined using univariate analysis and multivariate logistic regression.

RESULTS

A total of 291 patients met inclusion criteria. The mean patient age was 30.5 years, all patients were male, and the median follow-up period was 18 months. The incidence of injuries was 60 per 100,000 person-years over the study period. Risk factors for a rupture included service in the Army, junior officer or junior enlisted rank, and age between 25 and 34 years. White race and surgery occurring >6 weeks after injury were significant risk factors for a postoperative complication. Among the 214 patients with a minimum of 12 months' clinical follow-up, 95.3% were able to return to military duty. Junior officer/enlisted status was a significant risk factor for failure to return to military duty.

CONCLUSION

Among military personnel, Army soldiers and junior officer/enlisted rank were at highest risk of pectoralis major tendon ruptures, and junior personnel were at highest risk of being unable to return to duty after surgical treatment. Although increasing time from injury to surgery was not a risk factor for treatment failure or inability to return to duty, it did significantly increase the risk of a postoperative complication.

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.

Outcomes Following Suture-Anchor Repair of Pectoralis Major Tears: A Case Series and Review of the Literature

BACKGROUND

Rupture of the pectoralis major muscle (PMM) is an uncommon injury that occurs during physical exercise and high-impact contact sports; it may result in pain, weakness, and disability. Surgical repair is currently the preferred treatment of PMM rupture. Our study assesses subjective and functional outcomes of patients following repair of acute and chronic PMM ruptures.

METHODS

Retrospective review identified twenty patients who underwent PMM repair by the senior author (BRW) between 2003 and 2011. Injury and surgical data was reviewed for all 20 patients. Six patients were assessed minimum 1-year post operatively for clinical outcomes, (SF-36, DASH, and ASES), physical exam (ROM & cosmesis), and Cybex isokinetic strength testing.

RESULTS

All patients were men with an average age of 30 years (range 20-55) at time of injury. The average time from injury to surgical repair was 3.8 months (range <1-28 months), and average follow up was 16.5 months (range 0-99). The majority of patients suffered injury while bench pressing (12/20; 60%) or wrestling (3/20; 15%). The most common intra-operative findings were partial sternal tears (9/20; 45%) followed by complete sternal tears (4/20; 20%). Six (30%) of twenty patients consented for on-site follow-up and clinical assessment. Average preoperative physical component scores from SF-36 improved from 43 (range 37.8-52.7) to 53.1 (range 48.1-55.8) at follow up. Average preoperative DASH scores decreased from 74 points (range 68.7-83.3) to 5.3 points (range 1.7-8.3) at follow-up. Average pre-operative ASES scores improved from 82.8 points (range 71.7-96.7) to 96.7 points (range 91.7-98.3) at follow up. Average isokinetic strength deficiency in horizontal adduction at 60°/s was 15% (range 16%-29%) and average at 120°/s was 9% (range 2%-21%). According to the Bak criteria, overall results were excellent in two patients (33%), good in two (33%), while two (33%) had a fair result.

CONCLUSION

Surgical repair of PMM rupture by suture anchor fixation provides high patient satisfaction and predictable return of strength, cosmesis, and overall function. Suture anchor fixation produced similar clinical outcomes and return of strength when compared to other surgical repair methods. Our results demonstrate isokinetic strength deficiency similar to historical results.

LEVEL OF EVIDENCE

Level 4: Retrospective Case Series.

Surgical treatment of pectoralis major tendon rupture (outcome assessment)

PURPOSE

Rupture of pectoralis major (PM) occurs most commonly as a result of an indirect mechanism associated with extensive tension on a maximally contracted muscle. Patients with PM tendon ruptures, classically present a history of sudden severe pain in arm and shoulder at the time of injury. Treatment options vary from conservative to operative. In cases with total or near-total injuries, surgical treatment by anatomic repair is generally advised, since conservative treatment may lead to poor results. The present paper reports 24 cases of surgically-treated ruptured PM while assessing the results.

METHODS

Between 2005 and 2010, 32 cases of unilaterally distal ruptured PM were surgically treated by the same surgeon and same technique, in two teaching hospitals of Tehran University of Medical Sciences. All cases were followed postoperatively by physical examination and functional criteria.

RESULTS

Since eight of the cases were lost from follow up, 24 cases were followed for at least one year. According to modified Kakwani system, 6 of our patients (25%) rated as excellent, 15 cases(62.5%) rated as good, 2 cases (8.33%) rated as fair and 1 case (4.1%) rated as poor.

CONCLUSION

In conclusion, we see that 87.5% of the patients had good to excellent results, according to modified Kakwani classification, after one year of follow up. So it seems that surgical repair of the pectoralis major ruptures will help the patients to return to their previous activities more frequently and we believe, to achieve better functional outcome. Meticulous surgical technique and attention to rehabilitation program are more important than delay in surgery.

Assessment of functional impairment after knee anterior cruciate ligament reconstruction using cardiorespiratory parameters: a cross-sectional study

BACKGROUND

A dynamic sub-maximum exercise with the same absolute intensity, performed with different muscle groups, may present exacerbated cardiorespiratory responses. Therefore, cardiorespiratory responses to unilateral exercise may identify bilateral differences. The purpose of this study was to verify whether the cardiorespiratory responses to lower limb exercise display counter-lateral differences, and if they could be used to assist athletes and health professionals involved in rehabilitation.

METHODS

Nine individuals participated in this cross-sectional study. They had been treated in a private rehabilitation clinic and submitted to intra-articular reconstruction of the anterior cruciate ligament. The cycling exercise with the same sub-maximal intensity and with one lower limb was used to gather data. Cardiorespiratory responses to exercise were compared between exercises performed with the involved and uninvolved limb after five minutes of exercise.

RESULTS

Cardiorespiratory responses to exercise performed with the involved limb presented higher values after five minutes of cycling: oxygen uptake (+7%), carbon dioxide production (+10%), minute ventilation (+20%), breathing frequency (+19%), ventilatory equivalent for oxygen (+14%), end-tidal pressure of O2 oxygen (+4%), end-tidal pressure of O2 carbon dioxide (-9%) and heart rate (+9%).

CONCLUSIONS

The exacerbated responses, including increase of the ventilatory equivalent and decrease of end-tidal pressure of carbon dioxide, indicate that this exercise protocol may be useful in the characterization of the functional deficit of the surgical limb during rehabilitation.

Clinical considerations for the surgical treatment of pectoralis major muscle ruptures based on 60 cases: a prospective study and literature review

BACKGROUND

Early recognition of the clinical signs of ruptures of the pectoralis major muscle (PMM) in athletes by orthopaedic surgeons, physical therapists, and physical trainers may prove to be critical for patient access to surgical treatment while the injury is still in the acute phase.

HYPOTHESIS

Total ruptures of the PMM may yield a better outcome with surgical treatment than with nonoperative treatment in athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective study was performed on 60 patients with total ruptures of the PMM. The patients were followed from 1997 to 2012, with a physical examination every 6 months for the first 2 years and every 12 months thereafter. The patients' mean age was 31.21 years, and the mean length of follow-up was 48.25 months. The surgical treatment methods included reinsertion of the tendon in 51% of the patients and nonoperative treatment in 49% of the patients. All of the patients were evaluated using the Bak criteria.

RESULTS

The bench-press exercise was associated with 80% of the PMM ruptures (48 patients). Forty-one of the patients with chronic ruptures were seen after 3 months (80%). The outcomes were poor in 9 patients from the nonoperative group (31%) and in 3 patients from the surgical group (9.7%); the outcomes were fair in 12 patients from the nonoperative group and in no patients from the surgical group. Excellent results were not observed in any patient from the nonoperative group and were observed in 21 patients from the surgical group (67.7%). The isokinetic evaluation at 60 deg/s showed a decrease in strength of 41.7% in the nonsurgical group and 14.3% for the surgical group, which was significant at P < .05.

CONCLUSION

Total ruptures of the PMM exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes.

The pectoralis major footprint: An anatomical study

Objective

To study the insertion of the pectoralis major tendon to the humerus, through knowledge of its dimensions in the coronal and sagittal planes.

Methods

Twenty shoulders from 10 cadavers were dissected and the pectoralis major tendon insertion on the humerus was identified and isolated. The dimensions of its “footprint” (proximal to distal and medial to lateral borders) and the distance from the top edge of the pectoralis major tendon to apex of the humeral head structures were measured.

Results

The average proximal to distal border length was 80.8 mm (range: 70–90) and the medial-to-lateral border length was 6.1 mm (5–7). The average distance (and range) from the apex of the pectoralis major tendon to the humeral head was 59.3 mm.

Conclusions

We demonstrate that the insertion of the pectoralis major tendon is laminar, and the pectoralis major tendon has an average footprint height and width of 80.8 mm and 6.1 mm, respectively.

Are shoulders with a reverse shoulder prosthesis strong enough? A pilot study

BACKGROUND

It has been suggested that limited active ROM of reverse shoulder prostheses relates to lack of strength. However, the postoperative strength has not been quantified.

QUESTIONS/PURPOSES

We therefore measured joint torques in patients with reverse shoulder prostheses and correlated torques with functional scores.

METHODS

We recruited 33 patients (age, 72 ± 8 years) with a reverse prosthesis (37 shoulders, 21 primary and 16 revisions). We obtained Constant-Murley, DASH, and Simple Shoulder Test ([D]SST) scores, and performed two isokinetic protocols (abduction/adduction and external/internal rotation) at 60° per second. Minimum followup was 4 months (average, 23 months; range, 4-63 months).

RESULTS

Twenty-three patients (24 shoulders; 13 primaries, 11 revisions) were able to perform at least one of the defined tasks. Mean abduction and adduction torques were 15 Nm ± 7 Nm and 16 Nm ± 10 Nm (19%-78% of normal shoulders). External and internal rotation tasks could be performed by only 13 patients (14 shoulders; nine primary, five revisions) generating 9 Nm ± 4 Nm and 8 Nm ± 3 Nm, respectively (13%-71% of normal shoulders). We found moderate correlations between Constant-Murley, DASH and (D)SST (D = Dutch translation) scores and abduction and external rotation.

CONCLUSIONS

Patients with a reverse prosthesis had reduced strength when compared with normal values reported in the literature (only 65% of patients could perform the protocol). This effect was greatest for external rotation and might explain clinical outcomes with which a moderately strong relationship was observed. Our observations suggest limited strength is a major factor in reduced ROM.

Isolated tear of the pectoralis minor tendon in a high school football player

Multiple pectoralis major tendon tears have been reported in the literature; however, isolated rupture of the pectoralis minor tendon is rare and has been reported 3 times (4 patients).This article describes a case of an isolated pectoralis minor tendon tear in a male high school football player after a traumatic injury. The patient was injured while making a tackle and leading with his arm and chest. He presented with left anterior shoulder and chest wall pain with direct tenderness on palpation over the coracoid. Magnetic resonance imaging of the chest revealed an isolated tear of the pectoralis minor tendon with slight retraction and significant edema in the muscle belly. The patient returned to full activities after conservative management.Although rare, the diagnosis of pectoralis minor tendon rupture should be considered in patients who sustain a contact injury to the shoulder with tenderness on palpation over the coracoid. The mechanism of injury can be related to a direct anterior force to the shoulder, forced external rotation of the arm in slight abduction, or with the arm in extension and shoulder in flexion (eg, blocking in football). The diagnosis can be confirmed with magnetic resonance imaging when edema exists on the medial aspect of the coracoid and extends into the muscle belly. Physical therapy with scapular stabilization exercises and avoidance of abduction and active adduction can be successful in returning these patients to their previous activity levels.