|Year : 2014 | Volume
| Issue : 1 | Page : 1-4
Pectoralis major rupture in athletes
Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||29-Apr-2014|
Associate Professor and Consultant Orthopedic Surgeon, College of Medicine, King Saud University, Riyadh
Pectoralis major muscle rupture is a rare type of injury that has become more prevalent in the past 3 decades. It is most commonly associated with weightlifting particularly bench press maneuver although it has been reported to occur in various strenuous sports activities participated in by recreational and professional athletes.
This paper is a review of literature which contains description of the anatomy and mechanisms of the injury, presenting signs and symptoms, initial investigations, classification of injury, management and rehabilitation.
هذا مقال استعراضى موضوعه تمزق العضلة الصدرية الكبيرة وهذا نوع نادر من الإصابة كثر حدوثه بصورةملحظة خلال العقود الثلاثة الماضية وكثيرا ما يحدث مترافقاً مع رفع الأثقال وخاصة مناورة ضغط المقعد Bench Press) Maneuver) رغم أنه تم مصادفتها في النشاطات الرياضية العنيفة المختلفة التي يقوم بها الرياضيون المحترفون أو الهواة .
وفى هذا المقال الاستعراضى تتم مراجعة للدراسات المنشورة ويتضمن وصفا للجوانب التشريحية وآلية الإصابة، وأعراض وعلامات الحالة، الفحوص الأولية وتصنيف الإصابة وعلاجها وإعادة التأهيل.
Keywords: Athletes, pectoralis major, rehabilitation, repair, rupture
|How to cite this article:|
Al-Ahaideb A. Pectoralis major rupture in athletes. Saudi J Sports Med 2014;14:1-4
| Introduction|| |
Injuries to the pectoralis major muscle are uncommon injuries. Pectoralis major rupture may be overlooked if the patient is not carefully screened by taking a detailed history and a thorough clinical examination of both the injured and uninjured sides. This article is a review of the pertinent anatomy of the pectoralis major muscle, the mechanisms by which the injury commonly occurs, the findings of the physical examination, the diagnostic workup and the nonoperative and operative methods of treatment.
| Anatomy|| |
The pectoralis major arises as a broad sheet of muscle demonstrating two divisions: A clavicular head which is the superior half originating from the medial clavicle and the upper portion of the sternum [Figure 1]. The inferior half arises from the distal end of the sternum, the external oblique fascia, and the cartilages of the first six ribs makes up the sternal head. These fibers cover and rotate 90° onto each other before uniting to form the tendinous insertion on the humerus, lateral to the bicipital groove. ,
The pectoralis major muscle is primarily responsible for adduction, internal rotation, and flexion of the humerus and dynamic stabilization of the shoulder. , It is important for carrying out strenuous activities, because it is the main source of power of the upper extremity in competitive athletes although sometimes it is considered unnecessary for normal shoulder function. ,,,,
| Causes of Rupture|| |
The most common activity that causes indirect injuries to the pectoralis major rupture is associated with weight-lifting particularly bench press exercises in which the arm is extended and externally rotated while under maximal contraction. ,,, Many other sporting activities that may cause a direct blow to the upper torso leading to rupture include sailboarding, snow and water skiing football and rugby, wrestling, power lifting and parallel bar dips, parachuting, hockey, rodeo, and boxing. ,,,,,,,,,,,,,,,,,, In association with vigorous strength training, several cases of pectoralis tendon rupture have been reported with the use of steroids for fast buildup of muscular tissue and strength that exceeds the adaptive capacity of tendons, leaving them susceptible to injury. 
Pectoralis major muscle rupture is a rare injury resulting from violent, eccentric contraction of the muscle that leads to both functional and cosmetic deficiency. It was first reported by Patissier in 1822.  Over the last 3 decades, there has been an increased incidence of injuries due to excessive muscle tension rather than direct trauma.  More than 200 cases describing rupture of the pectoralis major muscle in athletes associated with weight-lifting activities particularly bench presses during which the arm is abducted and externally rotated.  In this position, the inferior fibers of the tendon are placed at a mechanical disadvantage and undergo twice the excursion of the superior fibers. ,,, The injury occurs mostly in male athletes with age range of 20-50. 
Diagnosis is made based on history and physical examination. During the initial presentation of the condition, rupture of the pectoralis major may be missed or misdiagnosed as a sprain.  A thorough musculoskeletal examination should be performed to make a presumptive diagnosis. Patients usually report a tearing sensation often accompanied by an audible "popping" sound and severe pain at the site of the insertion of the pectoralis major on the humerus. Physical examination typically reveals swelling and ecchymosis in the upper chest and axilla and notably loss of the anterior axillary fold and normal pectoralis contour [Figure 2]. In most cases, due to extreme pain and swelling which causes physical examination almost impossible, makes it difficult to realize the extent of the pectoralis major rupture.
|Figure 2: Rupture of pectoralis major muscle tendon in the right shoulder|
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Several methods of imaging can be used in identifying a pectoralis major rupture. A shoulder radiograph should be performed to exclude fracture. A chest radiograph may reveal absence of the shadow of the pectoralis major muscle, which may indicate pectoralis major muscle rupture.  Ultrasound is recommended as an effective and inexpensive way to identify and even locate a pectoralis major muscle rupture.  Magnetic resonance imaging scans identify tears by their appearance and site and help determine whether the rupture was complete or incomplete [Figure 3] and provide useful information for properly determining the appropriate treatment regimen. 
|Figure 3: Incomplete distal pectoralis major rupture with retraction of almost 2 centimeters of the sternocostal head|
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An anatomical classification of pectoralis major muscle injuries was suggested by Tietjen  in 1980 for the purpose of making conservative versus surgical treatment recommendations. It described the extent and location of a pectoralis major injury. Contusions or sprains are classified as type I. A partial tear is classified as type II and a complete tear is type III. Type III can be further subclassified into a muscle origin rupture (IIIA), a muscle belly rupture (IIIB), a musculotendinous junction rupture (IIIC), and a muscle tendon avulsion (IIID). A further subclassification has been suggested by Bak et al., for a bony avulsion from the insertion (IIIE) and a muscle tendon substance rupture (IIIF).
Site of rupture
Bak et al., , noted in their study that the most frequent site for pectoralis major muscle injury in athletes especially the weight lifters is the tendon attachment to the humerus.
conservative treatment is indicated particularly in inactive persons and initially for partial tears which often do well without operative intervention. The conservative treatment consists of sling immobilization in the adducted and internally rotated position for comfort, ice, rest, and pain medication as needed. Range-of-motion exercises of the shoulder should be initiated to prevent spasm and secondary injury from the sling. ,
As for young and active patients, regardless of the chronicity of the injury, acute direct repair is an established treatment option and urgent referral to orthopedic surgeon is necessary. Current recommendations indicate that complete pectoralis major muscle ruptures in athletes should be repaired surgically. Numerous studies have shown that surgical intervention improves strength, return to full function, cosmesis, and that either nonoperative management or delayed surgical intervention leads to inferior outcomes. ,
Both the beach chair and supine positions can be effectively used when trying to repair pectoralis major muscle rupture. The commonly used surgical approaches are the deltopectoral approach and the anterior axillary approach, although the deltopectoral approach is favored by most surgeons because of familiarity. The surgeon must take extra care to avoid injuring the medial and lateral pectoral nerves posteriorly when mobilizing the retracted pectoralis major tendon.
A number of methods have been described for reattaching an avulsed tendon to its anatomical humeral insertion. These methods all differ in their exact technique, but the vast majority use drill holes, sutures, and/or suture anchors to reattach the pectoralis major tendon to its anatomical insertion site. The studies reported good outcomes with the drill hole technique, but the addition of a trough has been shown to provide the greatest amount of tension support. When determining suture type and size, consideration should be given to the amount of retraction and necessary tension for repair. A partial release of the inferomedial portion of the muscle has been described for the very retracted tendons. Alternatively, an Achilles or hamstring tendons can be used to provide the necessary extra length. However, all attempts should be made to use the pectoralis major tendon itself for primary repair. The tendon can often be brought to the humeral insertion site with sufficient mobilization and careful dissection. Both absorbable and nonabsorbable sutures have been used in the reported cases. A modified Mason-Allen and Krakow stitches have been used. Both provide security and excellent strength. Other less commonly reported methods of securing the tendon to the humerus include suture anchors, staples, and screws with spiked washers. All of these methods have had excellent postoperative results, leaving the choice of the best technique to the preference of the surgeon.
Different protocols have been described in the literature, but they are very similar to each other. Rehabilitation involves a gradual progression to the increase range of movement and muscle strength. The affected arm should be placed in a standard sling and immobilized for 4-6 weeks in adduction and internal rotation. Within 3-6 weeks, pendulum exercises are started. Immobilization is followed by passive then active range of motion exercises from 4 to 8 weeks. Light resistance and strengthening exercises can be done next for about 4 weeks. Patients can usually return to full activities in 3-6 months.
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[Figure 1], [Figure 2], [Figure 3]