Updated: 5/10/2021

Pectoralis Major Rupture

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  • SUMMARY
    • A rare acute injury caused by avulsion of the pectoralis major tendon and usually seen in weightlifters.
    • Diagnosis is generally made clinically and is confirmed with MRI studies.
    • Treatment is usually surgical repair when presenting acutely.
  • Epidemiology
    • Incidence
      • rare injury (< 1 per 100,000 per year) that is increasing in incidence
        • 75% of all reported cases have occurred since 1990
    • Demographics
      • almost exclusively seen in males (20-40 years of age)
      • often occurs in weightlifters
        • commonly during bench-pressing
    • Location
      • most commonly occurs as a tendinous avulsion
      • sternocostal head of the pectoralis major tendon is the most common site of rupture
    • Risk factors
      • anabolic steroid use
  • Etiology
    • Pathophysiology
      • mechanism
        • excessive tension on a maximally eccentrically contracted muscle
          • occurs during the downward portion of a bench press, with the arm in the final 30 degrees of humeral extension while pushing against heavy resistance
        • tendon fails in a predictable sequence
          • inferior fibers of sternocostal head fail first
          • then superior fibers of the sternocostal head 
          • finally the clavicular head
  • Anatomy
    • Pectoralis major
      • innervation
        • lateral pectoral nerve (C5-C7) 
          •  supplies lower muscle belly
        • medial pectoral nerve (C8-T1) 
          •  lateral pectoral nerve supplies upper portion
      • origin (two heads)
        • clavicular head
          • from medial clavicle and proximal sternum
        • sternocostal head
          • from distal sternum, costal cartilage ribs 1-6, external oblique aponeurosis
          • sternocostal portion is larger (>80% of muscle volume)
      • insertion
        • humeral shaft just lateral to the bicipital groove
      • action
        • shoulder adduction and internal rotation, to a lesser extent forward flexion (chiefly the clavicular head)
      • other
        • one of four muscles connecting the upper limb to the thoracic wall
          • other muscles include
            • pectoralis minor
            • subclavius
            • serratus anterior
    • Biomechanics
      • inferior fibers of sternal head at maximal stretch during final 30 degrees of humeral extension
        • position at which pectoralis major is most vulnerable to rupture (as with bench pressing)
  • Classification
    • Modified Tietjen (Anatomic) Classification
      Type
      Description
      I
      Muscle contusion or sprain
      II
      Partial tear
      III
      Complete tear (further subclassified by location)
      Location
      III-A
      Muscle origin
      III-B
      Muscle belly
      III-C
      Musculotendinous junction
      III-D
      Intra-tendinous rupture
      III-E
      Tendon avulsion off humerus (no bone)
      III-F
      Bony tendon avulsion off humerus 
  • Presentation
    • History
      • patient may report a sudden pop or tearing sensation with resisted adduction and internal rotation
    • Symptoms
      • pain and weakness of shoulder
    • Physical exam
      • inspection & palpation
        • swelling and ecchymosis of anterolateral chest wall and/or proximal medial brachium
          • if localized to the anterior brachium, then humeral attachment rupture is more likely than a musculotendinous junction rupture
        • "dropped nipple" sign
          • ipsilateral nipple will appear lower than the unaffected side due to medial retraction of muscle belly
        • palpable defect and loss of anterior axillary contour
          • accentuated by resisted adduction
      • motion & strength
        • weakness most pronounced in adduction and internal rotation
          • to a lesser extent forward flexion
  • Imaging
    • Radiographs
      • indications
        • limited utility
      • recommended views
        • standard shoulder trauma series (true AP, scapular Y, and axillary lateral)
      • findings
        • most often normal
        • may show loss of pectoralis major shadow or bony avulsion
    • MRI
      • indications
        • investigation of choice
          • can differentiate between complete and partial tears
      • views
        • requires dedicated sequence (standard shoulder MRI will not capture adequately)
        • T2 sequence better for acute injuries
        • T1 for evaluating chronic injuries
      • findings
        • useful in identifying the location and extent of the rupture (partial versus complete)
          • may show avulsion of the pectoralis major tendon from the humerus
          • integrity of clavicular head may mask partial rupture of sternocostal head
  • DIAGNOSIS
    • Complete tears
      • diagnosis can be made by history and physical exam and confirmed by MRI
    • Partial tears
      • generally require MRI to differentiate from complete tears
  • Treatment
    • Nonoperative
      • initial sling immobilization, rest, ice, NSAIDs, physical therapy
        • indications
          • low-demand, sedentary, and elderly patients
          • muscle belly tears, low-grade partial ruptures
        • outcomes
          • inferior to operative management for young, active individuals
          • cosmetic disfigurement, significant deficit in strength (most pronounced with isokinetic adduction) and peak torque, delayed recovery, poor patient satisfaction, lower return to competitive sports
    • Operative
      • open primary repair
        • indications
          • gold standard for acute tears in high level athletes, and most young, active patients
          • tendon avulsion, myotendinous junction tears
        • outcomes
          • reliable strength recovery, return to sport, and patient satisfaction
          • may show improvement regardless of location of tear
          • excellent success with all methods
            • some evidence suggests that cortical button fixation and transosseous suture repair with cortical trough are superior to suture anchor repair
      • reconstruction
        • indications
          • chronic tears that cannot be adequately mobilized for primary repair
            • primary repair may still be possible years after the injury
          • persistent strength deficit in chronic tears
        • outcomes
          • reliable strength recovery and patient satisfaction, albeit generally inferior to primary repair
          • still significantly better than nonoperative management in young, active patients
  • Techniques
    • Initial sling immobilization, rest, ice, NSAIDs, physical therapy
      • technique
        • sling in adduction and internal rotation, begin passive range of motion immediately as tolerated
        • active assisted and active motion over the first 6 weeks
        • transition to strengthening and unrestricted activity at 2-3 months
    • Open primary repair
      • approach
        • standard deltopectoral approach
      • repair technique
        • all repair techniques have been shown to have comparably excellent success
          • transosseous suture repair with cortical trough
          • cortical button fixation
          • suture anchor repair
            • both PEAK screw and all suture available
              • some evidence suggests that cortical button fixation and are superior to
              • direct repair may be indicated for tears at the muscle belly or myotendinous junction
    • Reconstruction
      • approach
        • standard deltopectoral approach
      • mobilization
        • need to release adhesions superficial and deep to pectoralis major
          • careful to avoid injury to the medial and lateral pectoral nerves during deep release
        • supplemental fascial release may be necessary to mobilize the muscle belly in chronic situations
      • graft options
        • Achilles allograft (most common)
          • advantages
            • avoids donor site morbidity, excellent load characteristics, favorable dimensions, and good surgical outcomes reported
        • Gracillis weave (allograft versus autograft)
  • Complications
    • Re-rupture (5-7%)
      • failure most often occurs at suture-tendon interface
    • Persistent pain 
      • incidence
        • most common complication
    • Residual weakness
    • Cosmetic deformity
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(SAE07SM.60) Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

QID: 8722
1

abduction and external rotation.

1%

(4/416)

2

abduction and internal rotation.

3%

(13/416)

3

adduction and external rotation.

2%

(9/416)

4

adduction and internal rotation.

93%

(388/416)

5

external rotation and forward flexion.

0%

(1/416)

L 1 E

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(OBQ07.249) At which of the following points during a bench press is the pectoralis major insertion at greatest risk of rupture?

QID: 910
1

Middle portion of upward motion

14%

(504/3554)

2

Point of maximum elevation

2%

(72/3554)

3

During downward deceleration

76%

(2699/3554)

4

When bar is touching chest

7%

(240/3554)

5

No difference in rupture rate is seen

1%

(24/3554)

L 3 D

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(OBQ07.49) A weightlifter feels a pop in his anterior left shoulder while doing a bench press exercise. Which nerve innervates the muscle that is disrupted as seen on the MRI shown in Figure A?

QID: 710
FIGURES:
1

Axillary

1%

(19/1811)

2

Musculocutaneous

4%

(73/1811)

3

Upper and lower subscapularis

7%

(122/1811)

4

Suprascapular nerve

3%

(53/1811)

5

Lateral and medial pectoral nerves

85%

(1538/1811)

L 2 D

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(SBQ05UE.11) A 24-year-old bodybuilder reports shoulder pain after an injury while bench pressing. Physical exam reveals ecchymosis and swelling in his right upper arm as shown in Figure A. He has weakness in internal rotation but has good strength in external rotation and abduction; his apprehension test is negative. When he puts his hands on his hips, his upper chest is asymmetrical. When is surgery indicated for this injury?

QID: 1796
FIGURES:
1

Surgery is not indicated; conservative management including ice, rest and NSAIDs are recommended

4%

(165/3907)

2

After a period of immobilization, followed by physical therapy, has failed

8%

(302/3907)

3

When the pectoralis major has avulsed from its humeral insertion

85%

(3323/3907)

4

Asymmetry of the upper chest wall without functional deficits

2%

(69/3907)

5

If swelling and ecchymosis are primarily located on the chest wall rather than the upper arm

1%

(20/3907)

L 2 D

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