Pectoralis Major Repair

Introduction

Although historically a rare injury, pectoralis major tendon rupture is becoming more common. Most physicians do not have experience in surgical management of pectoralis major tears. This article is intended to assist them by outlining a diagnosis and treatment plan, including specific physical examination and radiographic findings to help in diagnosis and detailed discussion of a preoperative plan and surgical technique. Postoperative care, rehabilitation, and possible complications are also presented.

Historical Perspective

Pectoralis major tendon ruptures have received increasing attention over the past several years. It had been a relatively uncommon injury, with only about 200 reported cases in the literature. The injury was originally described by Patissier as occurring in a butcher’s assistant in 1822.¹ It was not noted again until 1862, when Letenneur described another rupture.² The injury was only mentioned sporadically and, in 1950, Hayes could only find 22 reported cases in the literature.³

Over the last 30 years, the reported incidence has been increasing. Kretzler reported 19 cases in 1989,⁴ Wolfe 14 in 1992,⁵ and Hanna 22 in 2001.⁶ The largest published study in the English literature was reported by Aarimaa in 2004 and included 33 patients.⁷ Schunck reported on 51 operatively treated ruptures and 14 nonoperative, in the German literature in 1997.⁸

Meta-analyses performed by Bak ⁹ and subsequently Aarimaa ⁷ have postulated that the rising incidence of pectoralis ruptures may be related to the increasingly active population. The injury has been commonly associated with weight-lifting and athletics. The mechanism is usually indirect and classically described as occurring when the muscle transitions from an eccentric load to a concentric contraction. Blunt force and traction injuries have all been described.

Indications

Treatment for pectoralis major ruptures has been controversial. Studies have advocated conservative treatment,^6,10,11 operative repair,^4,12 and a combination of both.^5,13

Recent authors have advocated early repair of these injuries to preserve strength.^7,10,14,15 The pectoralis major functions to adduct, forward flex, and internally rotate the shoulder. Several studies have demonstrated significant strength deficits in conservatively treated injuries,^10,13,16 with return to near or normal strength after surgical repair.^6,12,17 Young and athletic patients generally will not tolerate persistent weakness, as well as the associated cosmetic deformity. However, older or low-demand patients with pectoralis ruptures can be treated conservatively with success.¹⁸

The patient typically presents after sudden onset of pain in the shoulder. A large ecchymoses may be present on the lateral chest but commonly extends onto the upper arm (Figure 1). Without a careful examination, the rupture can be misdiagnosed as a biceps tendon injury.¹⁹ Acutely, it may be difficult to see a deformity in the lateral chest secondary to swelling (Figure 2). Often, the avulsed tendon end is palpable on the chest wall. In more chronic injuries, the deformity is usually obvious. Skin retraction and loss of the anterior axillary fold is commonly seen. Sternal head ruptures can be differentiated from complete ruptures by careful clinical examination. With forward elevation, the clavicular head of the muscle can be both palpated and visualized (Figure 3). Resisted adduction or internal rotation will reveal the deficient sternal head (Figure 4).

Figure 1. Diffuse ecchymoses from pectoralis major rupture. Note discoloration on distal arm.

Figure 2. Lateral chest deformity is often masked due to swelling seen with an acute injury.

Figure 3. Intact clavicular head and retracted sternal head of pectoralis major, demonstrated with resisted forward elevation.

Figure 4. Example of the retracted appearance of a chronic sternal head pectoralis major tear.

Preoperative Planning

A careful clinic examination is frequently sufficient to identify the extent of the tendon injury in most patients. If there is doubt, several imaging modalities have been studied:

• Plain X-rays can reveal bone avulsions or loss of the pectoralis shadow.
• Ultrasound examination can demonstrate intra-muscular injury or loss of continuity of the tendon.¹²
• CT scan can outline the muscle, but has difficulty visualizing the distal soft tissue of the pectoralis.
• MRI has been demonstrated to reliably identify injury to the muscle and distal tendon.²⁰ (Figures 5a-b)

Figures 5a-b. Coronal and axial images of pectoralis major sternal head rupture.

Acute injury and edema of the pectoralis muscle and insertion, however, can make identification of a complete rupture difficult.²¹ The hematoma is easily identified in acute injuries but is not present in more chronic tears. It can also be a challenge to differentiate a sternal head rupture versus complete injury. Incomplete tendon injuries and medial muscle ruptures are not usually amenable to repair.

Several recent articles advocate pre-planning with MRI evaluation.^14,15 In our practice, we have not found MRI results to significantly affect our preoperative planning. Generally, most information required for surgical decision-making can be obtained from the physical examination.

We have found several cases of chronic myotendinous junction injury that could not be repaired, and this possibility must be discussed with the patient prior to surgery. We have also found a trend of differences in tendon rupture types with age. Ruptures in younger patients (<25 years of age) tend to be more lateral – at the bone/tendon junction – whereas in older patients, the injury more commonly occurs at the myotendinous junction.

Positioning

The patient is placed in the supine position, with the arm supported on a hand table. We have not found the beach-chair position to be necessary. The affected upper extremity, as well as most of the thorax, is draped free.

Technique

A 3- to 4-cm incision, at the distal end of the delto-pectoral interval, is more than adequate for exposure and repair (Figure 6). For sternal head ruptures, the dissection is carried medially around the intact clavicular head, not into the interval with the deltoid. With complete ruptures, no delto-pectoral interval will be present.

Figure 6. Incision for pectoralis repair.

In acute injuries, a large hematoma is frequently encountered, and the avulsed tendon easily identified. Even if retracted, minimal mobilization is needed. In more chronic injuries, a synovial tract is often present, leading medially to the retracted tendon end. The tendon is usually shortened and encased in scar. Aggressive scar release and mobilization is required to allow the tendon to reach the humeral insertion. Typically, the fibers of the sternal head of the pectoralis have an inferior-medial to superior-lateral obliquity. The clavicular fibers always have a superior-medial to interior-lateral obliquity (Figure 7).

Figure 7. A cadaveric demonstration of the different orientation of clavicular (C) head and sternal (S) head muscle fibers. The deltoid (D) muscle and biceps (B) tendon are also shown.

It is important to feel the inferior-lateral border of the muscle when pulling tension on the tendon. A fullness and firm edge should return to the anterior axillary fold. We use 1 mm cottony Dacron suture (Deknatel, Fall River, MA) in the tendon end, placing three or four sutures in a Modified Mason-Allen fashion (Figure 8). These sutures can be placed in the end of the muscle for a myotendinous injury, and reinforced as needed with soft tissue grafts or extra-cellular matrix grafts, such as the RESTORE® swine intestine submucosal graft (DePuy Orthopaedics, Johnson & Johnson, Warsaw, IN).

Figure 8. Modified Mason-Allen sutures placed in tendon end.

The insertion site of the pectoralis tendon is lateral to the bicipital groove (Figure 9). For sternal head injuries, the clavicular head of the muscle will have its intact insertion distal to the proposed repair site. The sternal head is brought deep and proximal to the clavicular head muscle when repaired to the insertion site. The insertion site is cleaned of any tendon remnants and can be roughened with a curette. We have not found it necessary to create a bone trough.

Figure 9. Pectoralis major tendon insertion site, located lateral to the bicipital groove.

A CurvTek drill (Arthrotek, Biomet, Warsaw, IN) is used to create bone tunnels at the repair site. Passing sutures are then pulled through the bone tunnels with a specific needle that matches the curve of the drill (Figure 10). The deep arm of each suture is passed through the bone tunnel. The arm is slightly adducted and internally rotated, and traction placed on the deep sutures. This pulls the tendon down to the bone.

Figure 10. Placing passing sutures through drill holes.

The superficial sutures are tied to deep sutures (Figure 11), creating a broad area of contact between the tendon and bone, with the security of tying the suture over a bone bridge. The wound is irrigated, subcutaneous tissue is closed with absorbable suture, and the skin is closed with running prolene suture.

Figure 11. Repaired pectoralis major tendon with sutures tied over bone bridge.

Pearls and Pitfalls

The primary concern is early recognition of the injury. Any patient presenting with acute onset of pain in the anterior shoulder after bench-pressing or a sudden traction injury should be carefully examined. The ecchymoses on the lateral chest and onto the arm is often pathognomonic. A careful physical examination should provide the necessary information to plan for surgical repair.

Cosmetic outcome is often a significant concern to these patients, particularly bodybuilders. We have not found extensile incisions to be needed. The repair can be performed through a relatively small incision, with an excellent cosmetic result.

Surgical repair must re-establish the tendon end into broad apposition to the bony insertion site. We have revised several suture anchor repairs that failed to heal. We feel that the single-point fixation of suture anchors is not strong enough and does not promote adequate tendon contact to bone (Figure 12). Suture repair through bone tunnels provides a broad area of tendon-bone contact (Figure 13).

Figure 12. A representation of forces seen with suture anchor fixation. Note the single point fixation to bone and the small area of contact.

Figure 13. A representation of forces seen with suture through bone tunnel fixation. Note the broad area of contact between the bone and tendon end.

It is important to caution high-demand patients who present with a chronic injury that a side-to-side difference may persist after the repair. Also, they may not be able to achieve prior weightlifting levels.

A more recent concern involves the use of steroids. Several studies have shown a possible correlation between prior steroid use and subsequent pectoralis major ruptures.^5,7,14 We try to identify these patients and caution them concerning healing potential and overall risk of future medical problems or injuries.

Postoperative Care

Postoperatively, patients are placed in a sling. They are cautioned to avoid abduction, external rotation, and resisted internal rotation. They are otherwise allowed to perform passive motion within these parameters. We feel that the repair through drill holes is sufficiently strong to allow early supervised motion.

Six weeks after surgery, the sling is discontinued; the patient is allowed full unrestricted motion and may begin light strengthening exercises. Nearly all patients have recovered full range of motion by 8 weeks. At 3 months after surgery, a “push-up” progression is started, with the goal to reach regular push-ups at 4 months. During this time, the patient returns to aerobic activity, and shoulder and arm weight training that does not involve the pectoralis.

Most patients progress to full activities after 6 months. We do not restrict subsequent weight training or limit the amount lifted.

Outcome

Most studies have demonstrated significant improvement in strength for repaired pectoralis major ruptures when compared with non-operatively treated injuries.^9,22 The two large meta-analysis reviews have both shown better outcomes with the acutely repaired tendons.^7,9 One defines acute repairs as less than 3 weeks,⁷ the other less than 8 weeks.⁹ A recent review article classifies acute repairs as less than 6 weeks.²³

However, several other studies have reported no difference in outcomes based on timing of the repair.^17,22 It has been our experience that all patients with acutely repaired tendon ruptures, less than 8 weeks, have returned to full activity. The majority of patients with repairs of chronically torn pectoralis tendons have had good pain relief, cosmetic appearance, and excellent return of strength.^5,16,22,24

In contrast, high-demand athletes – particularly elite weightlifters – with chronically repaired tendon ruptures have shown significant improvement, but have frequently not been able to return to pre-injury weight training levels. We feel that these injuries should be repaired in a timely fashion, preferably within 8 weeks of injury.

Complications

Surgical complications are relatively rare. Postoperative infection is the most obvious concern. In older patients, significant blood loss can occur in the hematoma, rarely requiring transfusion.¹⁸ Infection of the acute hematoma has also been reported.^1,25 In chronic repairs, some permanent cosmetic difference between the repaired side and the uninvolved side is to be expected. This may have functional consequence in high-demand athletes.

We have seen only two re-ruptures of repaired tendons, and there is one reported as occurring 3 years after repair.¹³ Neurologic injuries have not typically been seen. There has been an individual report of myositis ossificans ²⁶ and one of late rhabdomyosarcoma.²⁷

References

1. Patissier P,1822. “Maladies des bouchers. Traite des maladies des artisans.” 162-165
2. Letenneur M, 1862. “Rupture sous-cutanée due muscle grand pectoral: guérison completeen quinze jours.” Gazette de hôp Paris (34):54-56
3. Hayes WV, 1950. “Rupture of the pectoralis major muscle. Review of the literature and report of two cases.” J Int Coll Surg (14):82-88
4. Kretzler HH Jr, Richardson AB, 1989. “Rupture of the pectoralis major muscle.” Am J Sports Med (17):453-458
5. Wolfe SW, Wickiewicz TL, Cavanaugh JT, 1992. “Ruptures of the pectoralis major muscle. An anatomic and clinical anslysis.” Am J Sports Med (20):587-593
6. Hanna CM, Glenny AB, Stanley SN, et al, 2001. “Pectoralis major tears: comparison of surgical and conservative treatment.” Br J Sports Med (35):202-206
7. Aarimaa V, Rantanen J, Heikkila J, et al, 2004. “Rupture of the pectoralis major muscle.” Am J Sports Med (32):1256-1262
8. Schunck J, Knapp D, Hallbauer T, et al, 1997. “[Rupture of the pectoralis major muscle – case study and review of the literatuve].” Z Orthop Ihre Grenzget 135:535-538
9. Bak K, Cameron EA, Henderson IJ, 2000. “Rupture of the pectoralis major; a meta-analysis of 112 cases.” Knee Surg Sports Traumatol Arthrosc (8):113-119
10. Scott BW, Wallace WA, Barton MA, 1992. “Diagnosis and assessment of the pectoralis major rupture by dynamometry.” J Bone Joint Surg Br (74):111-113
11. Zeman SC, Rosenfeld RT, Lipscomb PR, 1979. “Tears of the pectoralis major muscle.” Am J Sports Med (7):343-347
12. Liu J, Wu JJ, Chang CY, et al, 1992. “Avulsion of the pectoralis major tendon.” Am J Sports Med (20):366-368
13. McEntire JE, Hess WE, Coleman SS, 1972. “Rupture of the pectoralis major muscle: a report of eleven injuries and review of fifty-six.” J Bone Joint Surg Am (54):1040-1046
14. Provencher MT, Handfield K, Boniquit NT, Reiff SN, Sekiya JK, Romeo AA, 2010. “Injuries to the pectoralis major muscle: diagnosis and management.” Am J Sports Med (38):1693-1705
15. Potter BK, Lehman RA Jr, Doukas WC, 2006. “Pectoralis major ruptures.” Am J Orthop (35):189-195
16. Roi, GS, Respezzi S, Dworzak F, 1990. “Partial rupture of the pectoralis major muscle in athletes.” Int J Sports Med (1):85-87
17. Quinlan JF, Molloy M, Hurson BJ, 2002. “Pectoralis major tendon ruptures, when to operative.” Br J Sports Med (36):226-228
18. Beloosesky Y, Grinblat J, Weiss A, et al, 2003. “Pectoralis major ruptures in the elderly.” Clin Orthop (413):164-169
19. Ramsey ML, 1999. “Distal biceps tendon injuries: diagnosis and management.” J Am Acad Orthop Surg (7):199-207
20. Connell DA, Potter HG, Sherman MF, et al, 1999. “Injuries of the pectoralis major muscle: evaluation with MR imaging.” Radiology (210):785-791
21. Ohashi K, El-Khoury GY, Albright JP, et al, 1996. “MRI of complete rupture of the pectoralis major muscle.” Skeletal Radiol (25):625-628
22. Schepsis AA, Graft MW, Jones HP, et al, 2000. “Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries.” Am J Spots Med (28):9-15
23. Petilon J, Carr DR, Sekiya JK, et al, 2005. “Pectoralis major muscle injuries: evaluation and management.” J Am Acad Orthop Surg (13):59-68
24. Anbari A, Kelly JD, Moyer RA, 2000. “Delayed repair of a ruptured pectoralis major muscle. A case report.” Am J Sports Med (28):254-256
25. Pai VS, Simison AJM, 1995. “A rare complication of pectoralis major rupture.” Aust N Z J Surg (65):694-695
26. Purnell R, 1988. “Rupture of the pectoralis major muscle; A complication.” Injury (19):284
27. Smith FC, 1988. “Rupture of the pectoralis major muscle: a caveat.” Injury (19):282-283