Pectoralis Major Rupture
What is Pectoralis Major Rupture?
The pectoralis major muscle is the large muscle in front of the upper chest. There are two parts of the pectoralis muscle, the pectoralis major and the pectoralis minor. The pectoralis major is larger and works to push the arms in front of the body, such as a push-up or bench press exercise.
The Pectoralis major is a very powerful muscle that forms the chest prominence and. It moves the shoulder forwards and across your chest. It is best known as the muscle that you develope with the bench press exercise.
The pec major attaches to the humerus bone (upper bone of the arm) and is divided into two parts. The upper part is known as the ‘clavicular head’ and the lower part the ‘sternal head’, based on their origins from the clavicle and sternal bones respectively.
How does a pectoralis major muscle rupture occur?
These injuries generally occur during forceful activities. A large number of pectoralis major ruptures occur during weightlifting, particularly during a bench press exercise. Other causes of a pectoralis major rupture include football, wrestling, rugby, and other causes due to trauma.
It is postulated that anabolic steroid use can weaken the tendon, which is thought to be a contributing factor in many pectoralis major muscle ruptures in body-builders and weight-lifters. Nonetheless, these injuries can certainly occur in patients who have never used steroids. Ruptures of the pectoralis major muscle are becoming more common due to increased power sports weight training. It most commonly occurs during bench pressing and is felt like a painful snap at the front of the shoulder and chest. The muscle then ‘bunches up’ and deforms. Bruising and swelling are expected.
The Pectoralis major may tear/rupture in the following parts of the muscle:
1. Tendon rupture off the humerus bone (most common)
2. Tear at the junction of the muscle and tendon (musculotendinous junction)
3. Tear within the muscle belly itself
4. Muscle tearing off the sternum (very rare)
Ruptures of the pectoralis major muscle are becoming more common due to the increase in power sports weight training. It most commonly occurs during bench pressing and is felt as a painful snap at the front of the shoulder and chest. The muscle then ‘bunches up’ and deforms. Bruising and swelling is common.
- 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
Presentation and Treatment
- History: The patient may report a sudden pop or tearing sensation with resisted adduction and internal rotation
- Symptoms: pain and weakness of shoulder
- Physical exam: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.Three important signs1. “dropped nipple” sign: Ipsilateral nipple will appear lower than the unaffected side due to medial retraction of muscle belly.2. The Defect Sign: Palpable defect and loss of anterior axillary contouraccentuated by resisted adduction.3. Motion & strength: weakness most pronounced in adduction and internal rotation to a lesser extent forward flexionRemember
The pectoralis major muscle is not essential for normal daily shoulder function, but is critical for strenuous activities. Patients who wish to return to active athletic and manual activities are likely to benefit from surgical repair.
However, it is essential to bear in mind that this is an uncommon injury and the literature is limited. There is a lack of good high-quality evidence for surgical versus non-surgical management and early versus delayed repairs.
The decision on which pec major tears to repair and when depends on the type of tear, how old it is, how retracted it is, the demands and requirements of the patient and the expertise of the surgeon.
Acute (< 3 months)
– Tendon avulsion = repair as soon as possible directly to the bone
– Musculo-tendinous tear = Wait and see approach.
– Muscle tear = extremely rare and almost impossible to repair, but can use an augment
Chronic (> approx. 3 months):
– Tendon avulsion – if retracted laterally to the nipple line usually can still do a direct repair; if retracted medially to nipple line needs a graft reconstruction.
Imaging:
MRI is the gold standard to identify these symptoms.
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
- 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
Post-Operative Care:
A sling is worn for the first 3-6 weeks with the commencement of physiotherapy rehabilitation within one-week post-op.
This protocol (The Wrightington Protocol) is based on maintaining range of movement in the first phase and then gradually building strength in the middle to the last phase.
Pre-op
• ROM Exercises; should have full range of motion pre-op
• Maximise shoulder strength of deltoid, intact cuff muscles and scapula stabilisers.
Day 1 – 3 weeks
• Shoulder immobiliser
• Closed chain exercise as tolerated
• Passive / Active Assisted ROM in safe zone as tolerated
• Do not force or stretch
• Avoid pendular exercises and stick exercises
• Wrist/hand/finger exercises
• Elbow flex/ext, pro/supination
• Scapula setting exercises
• (Level 1 Exercises)
3-6 weeks:
• Do not force or stretch
• Gentle isometric exercises in neutral as pain allows
• Wean off sling
• Progress to Open Chain Exercises in safe zone as tolerated
• Do not force or stretch
• Avoid pendular exercises and stick exercises
• (Level 2 Exercises)
6 weeks +:
• Progress to open chain exercises in all ranges as tolerated
• progressive resistance
• sports-specific rehabilitation
• Avoid hyperextending in bench press or flyes or pec-deck.
• Avoid high weights with low reps and warm up slowly
• (Level 3 Exercises)
| Return to functional activities (guide to commence activity) | |
| Return to work | Sedentary job: as tolerated |
| Driving | approx. 6-8 weeks |
| Swimming | Breaststroke: from 6 weeks |
| Golf | can start from 3-6 Months |
| Lifting | Light lifting can begin at 3 weeks. Avoid lifting heavy items for 3 months. |
| Contact Sport | E.g. Horse riding, football, martial arts, racket sports and rock climbing: after 3 months |
Complications of Pec Major Surgery
1. Deep or superficial infection = 10%
2. Post-op stiffness at 3 months = 12%
3. Rerupture rate = 20% overall (higher with allograft and revisions)
4. Haematoma/bleeding = 2%