Pectoralis Major Tears: Evaluation and Treatment
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A torn or ruptured pectoralis major muscle can dramatically impair the mobility and strength of the shoulder and upper body, along with causing a cosmetic asymmetry of the muscle contour at the armpit area. This muscle injury is most commonly seen in athletic males between the ages of 20 and 40, it’s a painful injury that has become increasingly common over the last couple of decades.
At Modern Orthopaedics of New Jersey we are familiar with and experienced in treating injuries to the pectoralis major muscle. If you suspect that you may have injured your pectoralis major, the information below will provide you with an overview of diagnosis and treatment options:
Introduction to Pectoralis Major Tears
Commonly referred to as “pecs”, your pectoralis major muscles are powerful, fan-shaped chest muscles that extend from your breastbone (sternum) and collarbone (clavicle) symmetrically across your chest region. Pectoralis major tendons insert into the upper arm bone (humerus) and form the muscular front wall of the armpit.
The Function of the Pectoralis Muscles
Well known as the muscles you develop by doing bench press exercises, the pectoralis major muscles are responsible for elevation, internal rotation, and adduction. In simple terms, this means that they help you move your arms forward and backward, rotate them at the shoulder, and extend them.
As a large muscle that contributes substantially to upper arm strength and mobility, the pectoralis major muscle works in conjunction with many other muscles to help you carry out daily movements and activities. It is particularly pivotal in actions such as throwing a ball or doing pushups.
Defining Pectoralis Major Tears
A tear or rupture of the pectoralis major muscle involves a partial or complete tendon tear near the point where it inserts into the bone.
The pectoralis major muscle has two heads—one at the sternum (sternal head) and the other at the clavicle (clavicular head). In many cases, only the sternal head is ruptured.
Pectoralis major tears can happen in 4 general forms:
- Tendon tear away from bone
- Musculotendinous junction tear (where the tendon
- Mid-muscle tear
- Tear from muscle origin at sternum (rare)
The type of petoralis major tear is usually determined by obtaining an MRI. When a pectoralis major muscle or tendon tears completely, the muscle retracts, making anatomic healing of complete tears impossible without surgical intervention.
Causes and Risk Factors of Pectoralis Major Tears
A torn pectoralis major is a rare injury that typically occurs when the amount of force being put on the muscle is more than it can tolerate. When excessive tension is placed on a contracted pectoralis major muscle (such as during the negative phase of a bench press exercise, when a heavy weight is being lowered towards the chest), traumatic injury can be the result.
The most common cause of pectoralis major tears is weight training, an increasingly popular fitness activity. Prime culprits are bench press and chest press exercises. Major injuries have also been reported in boxing, football, rodeo, water skiing, wrestling, rugby, and other sporting activities (particularly contact sports).
Other causes may include:
- Repetitive activities involving the pectoralis major muscle
- Muscle imbalances, tightness, or weakness
Potential Risk Factors
Athletes who continually put substantial strain on their pectoralis major muscles are at risk for this type of injury, which most commonly occurs in young males between the ages of 20 and 40 years old. A 2017 study suggested that pectoralis major tears may be more prevalent in athletes who use anabolic steroids. Individuals with abnormal biomechanics or conditions associated with muscle imbalances or degeneration may also be at higher risk.
What Pectoralis Major Tears Feel Like
Most patients describe the injury as feeling like something “giving” or “ripping” in their armpit area during strenuous lifting, followed by severe pain and weakness. In some cases an audible pop or snap may be heard as the tendon tears away from the bone.
Symptoms of Pectoralis Major Tears
If you’ve sustained a traumatic injury to your anterior armpit area (between your shoulder and chest), a pectoralis major tear may have occurred. Look for some or all of the following symptoms:
- Pain in the chest and upper arm (though not necessarily severe)
- Weakness with chest press
- Swelling and Bruising at the armpit, upper arm and/or chest wall area
- Asymmetrical appearance of the pectoralis major muscles.
- “Dropped nipple sign” – sagging of the nipple on the affected side (see picture)
- Dimple formation near the armpit (see picture)
Complications From Pectoralis Major Tears if Left Untreated
Leaving a pectoralis major tear completely untreated is not recommended. That being said, some patients may opt for non-surgical treatment, allowing the muscle to scar in a retracted position.
This approach does not restore the pectoralis major to its original level of function and strength, resulting in weakness and a permanent cosmetic deformity, where the armpit fold will often remain permanently asymmetrical.
Diagnostic Process for Pectoralis Major Tears
Depending on the mechanism of injury, you may feel fairly certain that you’ve torn or ruptured your pectoralis major, but a clinical diagnosis is still important. Your orthopedic surgeon will evaluate the injury, provide treatment options, and check for other related injuries that may also impact your recovery.
Diagnosis of a pectoralis major tear typically begins with a physical examination. In addition to inspecting your chest for swelling and bruising and noting any asymmetry between the two sides of your chest, your orthopedic surgeon may palpate your chest to locate any gaps in the pectoralis major tendon, check your range of motion, strength, and ability to rotate your arm.
Even if your orthopedic surgeon is confident you have sustained an injury to your pectoralis major, diagnostic imaging will likely still be ordered.
X-rays won’t show a pectoralis major tendon tear, but may be helpful in ruling out other injuries. Most often, your orthopedic surgeon will also order either an ultrasound or MRI.
The results will be used to confirm the diagnosis, evaluate the pattern of the pectoralis major tear, rule out other injuries, and create a comprehensive treatment plan.
Non-Surgical Treatments for Pectoralis Major Tears
Some patients opt to treat pectoralis major tears non-surgically, particularly if the tear is not complete. Though surgery is the only way to fully restore the function of the muscle, patients who are older, less active, or have injured a non-dominant arm, may decide that the loss of some arm strength and mobility will not dramatically impact their lifestyle.
Non-surgical treatment options for pectoralis major tears largely focus on increasing the strength of other muscles to maximize shoulder, arm, and upper body function. They include:
- Anti-inflammatory medications
- Physical therapy
Surgical Treatments for Pectoralis Major Tears
Surgical treatment options for pectoralis major muscle tears involve reconnecting the pectoralis major tendon to the humerus bone. This is done by placing suture anchors into drill holes into the humerus bone at the insertion site of the pectoralis major tendon.
Pectoralis major repair surgery is typically an outpatient procedure that involves regional or general anesthesia and usually takes approximately an hour and a half to 2 hours. It has a high success rate and can restore 99% strength of the opposite uninjured side. Surgery will also restore the normal contour of the armpit area (see picture).
Timing of surgery
Ideally a pec repair is performed within 8 weeks of the injury. If there is further delay in the treatment, substantial scarring of the muscle may make it less pliable and possibly unable to pull out to length. In these situations, a tendon graft may be warranted to bridge the gap. A cadaveric Achilles tendon or similar is commonly used in these scenarios.
Results of Surgical versus Non-surgical Management for Pectoralis Major Tears
Several studies have evaluated the results of surgical versus non-surgical management of pectoralis major tears.
Hanna et al. evaluated 22 tears. Ten of the 22 tears were repaired, 12 of the 22 tears were not repaired. Surgically repaired pectoralis majors had a peak torque of 99% of the uninjured side versus non-repaired pectoralis major tendons that had a peak torque of 56% or the uninjured side.
Bak et al. performed a meta-analysis of the literature on pectoralis major muscle injuries and demonstrated that surgically repaired pectoralis major tendons had 88% excellent or good results versus 27% excellent or good results for patients treated without surgery.
Hanna C M , Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med. 2001 Jun;35(3):202-6.
Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc. 2000;8(2):113-9.
Postoperative Care for Pectoralis Major Tear Surgery
After pectoralis major rupture repair surgery, patients must wear a sling for several weeks to promote wound healing and avoid further injury. Many patients return to desk work after a period of about one to two weeks and driving after about 4 to 6 weeks. At three months post-surgery, most patients can re-establish a resistance training routine and at six months post-surgery most restrictions will be completely lifted.
Physical rehabilitation is an important element of recovery after pectoralis major repair surgery. Physical therapy typically begins while patients are still in a sling and often continues over a six to twelve month period. Exercises focus on increasing strength and range of motion. The exercise program can be completed under the guidance of a licensed physical therapist with experience rehabbing pectoralis major repairs. Toward the latter part of the recovery, exercises may be self-directed, may be performed at home, and does not require any specialized equipment.
Physical rehabilitation after surgery can feel slow, but is an incredibly important element of successful surgical outcomes in the long run. Pectoralis major rehabilitation is no exception.
For most patients it takes between six months and a year to fully recover from a pectoralis major repair. After that, strength and mobility should be able to rival pre-injury levels. The risk of reinjury after surgery is very low (about 5%).
Risks and Complications of Pectoralis Major Tears Treatment
Surgical risks are minimal with pectoralis major repairs but, as with any surgery, can include bleeding and infection. For specific questions or concerns, speak directly with your orthopedic surgeon.
Potential Complications and How To Mitigate Them
The more time that elapses between the pectoralis major injury and surgery, the easier the surgery. If too much time elapses (several months), graft reconstruction may be required. Optimally, surgical repair of the pectoralis major will take place within 1-2 weeks after injury. To ensure timely treatment, schedule an appointment with your orthopedic surgeon as soon as possible if you suspect your pectoralis major may have been compromised due to injury.
At Modern Orthopaedics of New Jersey, our award-winning surgeons are leading experts in upper extremity repair and rehabilitation. If you are experiencing shoulder or arm pain, contact us directly today to book an appointment and receive the exceptional treatment your body deserves.
Lorraine Stern, MD, FAAOS
HIP & KNEE REPLACEMENTS, ORTHOPEDIC TRAUMA
Meet Dr. Stern
Dr. Lorraine Stern specializes in state-of-the-art advanced robotic surgery for the hip and knee replacments. Learn more about specialties, training and treatment philosphy by visiting Dr. Stern's full profile page.
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