Introduction Overview a rare acute injury caused by avulsion of the pectoralis major tendon and usually seen in weightlifters. patients usually present with shoulder pain and weakness. when presenting acutely treatment is usually surgical repair. Epidemiology incidence increasing in incidence demographics almost exclusively seen in males (20-40 years of age) often occurs in weightliftersweightlifters location most commonly occurs as a tendinous avulsion sternocostal head of the pectoralis major tendon is the most common site of rupture Pathophysiology mechanism excessive tension on a maximally eccentrically contracted muscle tendon fails in a predictable sequence inferior fibers of sternocostal head fail first, then superior fibers of the sternocostal head, and finally the clavicular head Anatomy Pectoralis major innervation lateral (C5-C7) and medial (C8-T1) pectoral nerves medial pectoral nerve supplies lower muscle belly, lateral pectoral nerve supplies upper portion origin (two heads) clavicular head: medial clavicle and proximal sternum sternocostal head: 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 A Muscle origin B Muscle belly C Myotendinous junction D Tendon avulsion off humerus (no bone) E Bony tendon avulsion off humerus F Tendinous rupture 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 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 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 is most often suture-tendon interface Persistent pain (most common) Residual weakness Cosmetic deformity significant
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.60) Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral Review Topic | Tested Concept QID: 8722 Type & Select Correct Answer 1 abduction and external rotation. 1% (3/232) 2 abduction and internal rotation. 3% (6/232) 3 adduction and external rotation. 2% (5/232) 4 adduction and internal rotation. 93% (216/232) 5 external rotation and forward flexion. 0% (1/232) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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? Review Topic | Tested Concept QID: 710 FIGURES: A Type & Select Correct Answer 1 Axillary 1% (14/1343) 2 Musculocutaneous 4% (50/1343) 3 Upper and lower subscapularis 8% (102/1343) 4 Suprascapular nerve 3% (34/1343) 5 Lateral and medial pectoral nerves 85% (1137/1343) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ07.249) At which of the following points during a bench press is the pectoralis major insertion at greatest risk of rupture? Review Topic | Tested Concept QID: 910 Type & Select Correct Answer 1 Middle portion of upward motion 15% (465/3105) 2 Point of maximum elevation 2% (63/3105) 3 During downward deceleration 76% (2351/3105) 4 When bar is touching chest 6% (193/3105) 5 No difference in rupture rate is seen 1% (20/3105) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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? Review Topic | Tested Concept QID: 1796 FIGURES: A Type & Select Correct Answer 1 Surgery is not indicated; conservative management including ice, rest and NSAIDs are recommended 4% (138/3403) 2 After a period of immobilization, followed by physical therapy, has failed 7% (254/3403) 3 When the pectoralis major has avulsed from its humeral insertion 85% (2907/3403) 4 Asymmetry of the upper chest wall without functional deficits 2% (68/3403) 5 If swelling and ecchymosis are primarily located on the chest wall rather than the upper arm 0% (17/3403) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3
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