Pectoralis Major Tear or Rupture

The pectoralis major (pec major) muscle lies at the front of the chest. It helps bring the arm forward (during a press up and bench press), brings the arm from the side towards the chest (during a shoulder dip) and rotates the upper arm inwards (internal rotation). As well as being a powerful muscle it is important in contributing to the appearance of the chest and upper arm.

Because of the power and structure of the muscle and the increased participation in sports involving weight lifting and training the frequency of pectoralis major (pec major) injuries has increased dramatically in recent years.

Anatomy

The pectoralis major muscle (pec major) is a fan shaped muscle that originates from the collarbone (clavicle) and from the breastbone (sternum). It then passes to the upper arm (humerus) where it attaches just in front of the Long Head Biceps (LHB) tendon as it passes down the arm from the shoulder. The pectoralis major (pec major) has a number of heads or points of origin that converge to attach to the upper arm in 2 layers. Traditionally the muscle and its tendon were considered to twist to produce the dual layered insertion but more detailed anatomical studies suggest that the insertion pattern is produced by a layering of the tendon rather like the sticks or ribs of a Japanese hand fan.

Pectoralis muscle injury

Strains of the muscle in which the tendon attachment remains intact normally settle with conservative management in the form of rest, ice, rehabilitation, analgesics and anti-inflammatories. However, the tendon may tear or become detached from the arm bone (humerus).

Tears of the pectoralis major (pec major) muscle typically occur near the attachment of the tendon to the arm bone (humerus) and may be full thickness, affecting both layers of the attachment, or partial thickness, affecting only one layer. The tear may also be complete involving the full width of the tendon or incomplete effecting only a portion of the attachment. Once the attachment of the tendon is torn it will not reattach to the humerus itself and may require surgical re-attachment. Detachment of the origin of the pectoralis major (pec major) from the sternum is rare and does not typically require surgical treatment.

Cause

Tears of the pectoralis major (pec major) typically occur in active men aged 20 to 40 years. The tear is typically caused by an indirect injury to the arm. Typically it occurs during a forced contraction of the muscle during a sporting or weights related activity, such as a bench press (48% of all cases).

Although anabolic steroid use has been linked with tears of the pectoralis major there is no proven correlation.

Symptoms

Pain

A tear of the pectoralis major muscle is typically associated with the sudden onset of pain in anterior chest wall or upper arm during a forced contraction of the muscle, typically a bench press or similar activity. The pain is usually marked and prevents continuation of the activity or the weights to be dropped.

Weakness

There is usually associated weakness of the shoulder and arm.

Bruising

There may be significant bruising both to the chest wall and arm. This bruising may track down the arm to the elbow or wrist.

Deformity

There may be a significant change in the appearance of the chest wall and upper arm. The pectoralis major (pec major) muscle may be more prominent over the chest wall as the tendon rupture and retraction allows the muscle to bunch up. There may be a reduction or thinning of the fold of tissue in front of the armpit and upper arm (the anterior axillary fold) as the tendon retracts towards the chest.

Diagnosis and Investigation

The diagnosis may be apparent from the history and examination. In a complete tear the diagnosis tends to be more obvious but partial tears may be more difficult to identify. Further investigations may be undertaken to confirm the diagnosis and to exclude additional pathology.

Plain radiographs (X-Rays).

Radiographs of the shoulder are typically taken but are often unremarkable. These may demonstrate that the pectoralis major tendon has pulled off with a piece of bone (avulsion fracture).

Ultrasound scan (USS) or Magnetic Resonance Imaging (MRI) scan.

Scans may be arranged to identify structural damage to the pectoralis major muscle or injuries to the adjacent structures such as the rotator cuff.

Treatment

Rest and avoidance of exacerbating activities.

Rest will typically allow the pain associated with a pectoralis major (pec major) tendon tear to settle. Weakness and the cosmetic deformity will typically persist.

Analgesia Anti-inflammatory medication.

Anti-inflammatories eg: Ibuprofen, Diclofenac and VoltarolTM may be helpful in addition to simple painkillers (analgesia) eg: Paracetamol.

Rehabilitation and physiotherapy.

Physiotherapy may be helpful to maintain range of movement and

condition the shoulder. The weakness and cosmetic deformity will typically persist.

Operative treatment.

Pectoralis major (pec major) tendon detachments from the arm bone (humerus) do not reattach spontaneously or with non-operative management. In the absence of surgical repair weakness and cosmetic deformity are likely to persist. The injury typically occurs in young active individuals and surgery is frequently indicated.

The surgery typically involves a 5-7cm scar over the front of the upper arm. The torn tendon is identified and repaired back to the upper arm (humerus).

Pectoralis Major Repair (Pec Major Repair)

The pectoralis major (pec major) muscle lies at the front of the chest. It is a powerful muscle it is important in contributing to the appearance of the chest and upper arm. Because of the power and structure of the muscle and the increased participation in sports involving weight lifting and training the frequency of pectoralis major (pec major) injuries and in particular tears of the muscle have increased dramatically in recent years.

Link to additional information on pectoralis major (pec major tears).

Tears of the pectoralis major muscle typically require surgical repair.

The purpose of the surgery:

Tears of the pectoralis muscle typically affect the point of attachment of the muscle to the upper arm. The aim of the surgery is to re-attach the tendon and muscle to the bone and restore the anatomy allowing the muscle to function. Surgical repair is considered the treatment of choice particularly in those who wish to return to competitive or recreational athletic activities.

Alternative treatment options:

Pectoralis muscle tears may be managed with rehabilitation in an attempt to optimise the remaining muscle function. However, if the tendon is torn the outcome is likely to be better with surgical treatment. The results of surgery are themselves better if undertaken within 6 weeks of injury.

Anaesthetic:

The surgery is typically undertaken with the patient asleep with local anaesthetic in the region of the wound to reduce discomfort.

Incision and Dressings:

An incision approximately 5cm long is made over the front of the shoulder. At the end of the procedure the wound is typically closed with an absorbable suture under the skin. Paper Butterfly Stitches (SteriStripsTM) are usually used and the wound covered with padding and a splash proof OpsiteTM dressing.

Procedure:

The pectoralis muscle typically tears by the tendon becoming detached from the humerus or upper arm. The operation involves identifying the type and location of the tear and securing the torn tendon to the humerus from where it became detached. This can be achieved in a variety of ways. Once the tendon has been secured to the bone, the wound is closed in layers with absorbable sutures to the skin.

Rehabilitation:

Following surgery the arm is immobilised in a PolyslingTM. The sling is typically worn for a period of 4 to 6 weeks. A gradual and progressive rehabilitation program is pursued under the supervision of a physiotherapist. The aim of the rehabilitation is to increase the range of movement over the first 6 to 16 weeks and strength between 12 and 26 weeks, to allow a return to sport and full activities by approximately 6 months post surgery.

Admission and discharge:

You will normally be admitted on the day of surgery and it may be possible to go home the same day or the next day.

Risks associated with the operation:

All operations are associated with a degree of risk but significant complications associated with a pectoralis major (pec major) repair are uncommon. The following risks are those that are serious or most commonly reported in the literature.

Infection (<1%).

Infection in shoulder surgery is uncommon. If an infection were to develop it is typically a superficial infection, which can be treated with oral antibiotics. Rarely does an infection develop that requires re-admission to hospital and surgery to wash the infection out.

Anaesthetic Risks

Anaestheic complications are rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerbero-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE).

Damage to nerve or blood vessels (Neuro-Vascular Damage) (<1%).

Damage to nerves or blood vessels are rare. Damage to the axillary nerve may occur. Damage to this nerve may result in weakness and difficulty bringing the arm out to the side (abduction).

Stiffness.

After the surgery and a period of immobilisation the shoulder is likely to be stiff. This stiffness should improve with time and graduated rehabilitation. Initial stiffness may be protective of the repair. Rarely persistent stiffness requires treatment.

Recurrence or Re-rupture

Once the tendon is healed re-rupture is uncommon but remains a risk particularly with certain activities, such as forced bench-press. There is also a risk of rupture of the opposite pectoralis major (pec major) tendon independent of the treatment considered.

Further surgery (Re-operation)

Further surgery is unlikely to be necessary. Re-ruptures are uncommon but could require further intervention.

Complications.

Complications with surgery of this type are uncommon but may include failure of repair.

Rehabilitation.

Following the surgery the arm is typically immobilized in a sling for a period of 2 to 6 weeks. A progressive and supervised rehabilitation program typically allows range of movement and strength to be regained. It may be 3 to 6 months before you return to manual work or contact sports and heavy weights. Compliance with the rehabilitation program will affect the outcome of the surgery undertaken.

Surgical Outcome.

Surgery typically improves the pain, strength and the cosmetic appearance associated with a pectoralis major (pec major) rupture improving function and the probability of returning to sporting activities.