High Yield Topics

Pectoralis Major Tendon Rupture

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Ovid: 5-Minute Sports Medicine Consult, The


Pectoralis Major Tendon Rupture
Ramsey Shehab
Basics
  • Most commonly refers to complete avulsion of the pectoralis tendon at the humeral insertion (1)
  • Ruptures at the myotendinous junction, muscle belly, or bony avulsion are possible but less likely (2).
  • Associated with weightlifting (bench press) mostly, but possible with falls as well as direct trauma to tendon (3)
  • Pectoralis is a powerful adductor, internal rotator, and flexor of humerus.
  • Main source of power to the torso during strenuous activity
  • 2 heads:
    • Superior/clavicular: Originates at medial clavicle and upper sternum
    • Inferior/sternal: Originates at distal sternum, external oblique fascia, costal cartilage of 1st 6 ribs
  • Fibers converge, rotate 90 degrees, and insert lateral to bicipital groove on humerus.
  • Innervation: Medial and lateral pectoral nerves
  • Blood supply: Pectoral branch of thoracoacromial artery
Epidemiology
  • 1st reported in 1822 by P. Patssier
  • Increasing incidence with increase in health and fitness activities
  • More than 200 cases reported in medical literature
Risk Factors
  • Medications:
    • Steroid use: Muscle strength increases disproportionately to tendon strength leaving it vulnerable to injury (4).
    • Corticosteroid injection: Weakens tendon structure
  • Systemic diseases: Connective tissue disorders, collagen vascular disease, diabetes (1)
  • Advanced age
  • Disuse atrophy
Etiology
  • Indirect mechanism most common with excessive tension on a maximally contracted muscle (5)
  • Weightlifting (bench press specifically) is a common mechanism (3).
  • Direct trauma to muscle in wrestling, rugby, and auto accidents also reported (4)
Diagnosis
History
  • Men 20–40 yrs of age (2)
  • Usually report a pop or tearing in the shoulder (2,4)
  • Complain of pain/weakness in chest or shoulder (1,4)
Physical Exam
  • Swelling and ecchymosis in anterior shoulder/chest most common (4)
  • May have loss of axillary fold accentuated by abduction to 90 degrees (1)
  • Shoulder motion limited by pain
  • Weakness in abduction and internal rotation

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Diagnostic Tests & Interpretation
Imaging
  • Plain radiographs initially to rule out bony avulsions, fracture, or dislocations (1)
  • Characteristic finding on x-ray is soft tissue swelling and loss of pectoralis major shadow (1)
  • US can identify tears by uneven echogenicity and muscle thinning.
  • MRI is optimal; assesses grade, muscle retraction, acuity, and presence of adhesions in chronic tears (3)
Differential Diagnosis
  • Long head biceps subluxation
  • Proximal humerus fracture
  • Glenohumeral dislocation
  • Rotator cuff tear
Treatment
  • Acute treatment:
    • Analgesics
    • Ice
    • Sling immobilization
  • Long-term care:
    • Tear type, patient age, activity level, and cosmetic desires determine care (1).
    • Most partial tears, sternoclavicular tears, and muscle belly tears are treated nonsurgically (2).
    • Complete sternal tears require surgical repair to restore function and strength (3).
    • Conservative treatment may be enough in elderly/inactive population irrespective of type of tear (1).
Ongoing Care
  • Nonsurgical treatment:
    • Begin shoulder mobilization and unresisted stretching when tolerated (1).
    • Advance to resisted strengthening exercises at 6–8 wks post injury (1).
    • Unrestricted activity at 3–4 mos after injury (2)
    • Instruct in proper weightlifting technique to decrease re-rupture rate (5).
  • Surgical management:
    • Provides best outcomes in terms of patient satisfaction, strength, cosmesis, and return to sport (1,2)
    • Acute repair within 8 wks is optimal (3).
    • Delayed repairs do better than nonsurgical treatment (1).
References
1. Petilon J, Carr D, Sekiya J: Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005;13:59–68.
2. http://www.eorif.com/Shoulderarm/PectoralisRupture.html
3. Potter BK, Lehman RA, Doukas WC: Pectoralis major ruptures. Am J Orthop. 2006;35(4):189–195.
4. Hasegawa K, Schofer J: Rupture of the pectoralis major: a case report and review. J Em Med. 2008;01.025.
5. Dodds SD, Wolfe SW: Injuries to the pectoralis major. Sports Med. 2002;32:945–952.
Codes
ICD9
727.69 Nontraumatic rupture of other tendon
Clinical Pearls
  • Usually a complete avulsion of pectoralis major tendon at humerus
  • Most commonly occurs during weightlifting; specifically bench press
  • Patients may report a pop and present with swelling, ecchymosis, and palpable tendon deformity.
  • MRI is gold standard for diagnosis.
  • Type of tear, patient age, and activity level dictate treatment.
  • Surgical repair provides best outcomes in terms of strength, return to play, and patient satisfaction.


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