Pectoralis Major Muscle Injuries: Evaluation and Management...Figure 5 Deformity and ecchymosis are evident in this right acute pectoralis major muscle injury. Note the signiﬁcant

Pectoralis Major Muscle Injuries:Evaluation and Management

Julio Petilon, MD, Donald R. Carr, MD, Jon K. Sekiya, MD, and Daniel V. Unger, MD

Abstract

Approximately 150 reported cases ofpectoralis major muscle tears havebeen reported since Patissier first de-scribed them in 1822.1,2 More than halfhave been identified in the past 30years. Initially caused by horse- andwork-related accidents, this injury hasbecome increasingly associated withstrenuous athletic activity, most no-tably football, wrestling, waterskiing,rugby, and weight lifting. Excludinginfants, the reported age range of pa-tients with this injury is from 16 to91 years, with the peak in athletesaged between 20 and 40 years. Withthe exception of reported cases in fe-male nursing home residents with anunknown mechanism of injury, pec-toralis major muscle injuries occur al-most exclusively in men.3 Weight lift-ing is the cause of almost half of theseinjuries, with the bench press beingthe most common inciting exercise.4

Because of the rarity of this con-dition, it may be missed at initial

presentation or misdiagnosed as asprain and managed nonsurgically.Hanna et al5 reported that 50% oftheir 12 patients with unrepairedtears were diagnosed late or initiallywere misdiagnosed. A marked per-centage of tears involve only thesternal head, leading to the impres-sion of an incomplete tear, when infact there is a complete tear of thesternal head. In a review of 29 cases,Park and Espiniella6 reported that90% of patients treated surgically(9/10) showed good to excellent re-sults, whereas only 58% of patientstreated nonsurgically (7/12) showedgood results. Zeman et al7 reportedexcellent results in four of four pa-tients treated surgically. The fivepatients treated nonsurgically re-ported strength deficits that limitedreturn to athletic activity. Given thetrend toward improved results withsurgical repair of complete tears,it is important to raise awareness

about pectoralis major muscle in-jury.6,7

The general population is increas-ingly interested in health and fitness,and strength training and participa-tion in strenuous sports activities areintegral to many people’s lifestyles,regardless of age or sex. As a result,ruptures of the pectoralis major mus-cle likely will be seen more often than

Dr. Petilon is Lieutenant, Medical Corps, UnitedStates Navy, and Flight Surgeon, Naval MedicalCenter Portsmouth, Portsmouth, VA. Dr. Carr isLieutenant Commander, Medical Corps, UnitedStates Navy, Bone and Joint/Sports Medicine In-stitute, Department of Orthopaedic Surgery, Na-val Medical Center Portsmouth. Dr. Sekiya is Lieu-tenant Commander, Medical Corps, United StatesNavy, Bone and Joint/Sports Medicine Institute,Department of Orthopaedic Surgery, Naval Med-ical Center Portsmouth. Dr. Unger is Captain, Med-ical Corps, United States Navy, and Chairmanand Residency Director, Bone and Joint/Sports Med-icine Institute, Department of Orthopaedic Sur-gery, Naval Medical Center Portsmouth.

None of the following authors or the departmentswith which they are affiliated has received anythingof value from or owns stock in a commercial com-pany or institution related directly or indirectlyto the subject of this article: Dr. Petilon, Dr. Carr,Dr. Sekiya, and Dr. Unger.

The views expressed in this article are those of theauthors and do not reflect the official policy or po-sition of the Department of the Navy, Departmentof Defense, or the United States Government.

Reprint requests: Dr. Sekiya, Naval Medical Cen-ter Portsmouth, 27 Effingham Street, Portsmouth,VA 23708.

Copyright 2005 by the American Academy ofOrthopaedic Surgeons.

Pectoralis major muscle tears are relatively rare injuries that primarily occur whilelifting weights, particularly when doing a bench press. Complete ruptures are mostcommonly avulsions at or near the humeral insertion. Ruptures at the musculo-tendinous junction and intramuscular tears usually are caused by a direct blow.The patient may hear a snap at the time of injury and report pain, weakness, swell-ing, or muscular deformity. Physical examination can reveal ecchymosis, a palpabledefect, asymmetric webbing of the axillary fold, and weakness on resisted shoulderadduction and internal rotation. A detailed history and physical examination canbe augmented by radiologic studies, including magnetic resonance imaging. Non-surgical treatment is now recommended only for the older, sedentary patient or forproximal muscle belly tears. Surgery, whether early or delayed, consistently yieldssuperior results compared with nonsurgical management. Prompt diagnosis and time-ly intervention likely will produce improved results.

J Am Acad Orthop Surg 2005;13:59-68

Vol 13, No 1, January/February 2005 59

in the past. Proper understanding ofthe anatomy, mechanism of injury,clinical findings, and managementoptions is essential to expedite diag-nosis and maximize the functionaloutcome of this rare but often debil-itating injury.

Anatomy and Function

The pectoralis major muscle arises asa broad sheet in two divisions. Thesuperior half, which forms the cla-vicular head, originates from the me-dial clavicle and the upper portion ofthe sternum. The inferior half, whichmakes up the sternal head, arisesfrom the distal end of the sternum,the aponeurosis of the external ob-lique muscle, and the costal cartilageof the first six ribs. These fibers thenconverge and rotate 90° onto eachother before uniting to form the ten-dinous insertion on the humerus, lat-eral to the bicipital groove. The mostinferior muscle fibers insert superior-ly and posteriorly to the clavicularhead, and the upper sternal fibers at-tach more distally (Fig. 1).

The pectoralis major muscle fibersare unique in that they are composedof different lengths and in that the rel-ative fiber length changes as the mus-cle length changes.8 It is thought that,because of its wide origin and variedfiber direction, the muscle does notretract far when ruptured.9 Some ear-ly authors thought those factors madecomplete ruptures infrequent.10

The investing fascia of the pecto-ralis major muscle is continuous withthe fascia of both the brachium andthe medial antebrachial septum. Clin-ically, this fascia presents as a palpa-ble cord extending through the axillaand continuing down the medial arm(Fig. 2). This presentation often is mis-taken for an intact pectoralis major ten-don on clinical examination and dur-ing intraoperative exploration (Fig. 3).

The tendon, which is approximate-ly 5 cm wide, 1 cm long on the an-terior surface, and 2.5 cm long on the

posterior surface,8,11 consists of twolaminae. The anterior lamina is cre-ated by the clavicular head, and theposterior lamina is formed by the ster-nal head. In their anatomic analysis,Wolfe et al8 describe a trilaminar ten-don (Fig. 4). The nerve supply is de-rived from the lateral (C5-C7) andmedial (C8-T1) pectoral nerves fromthe lateral and medial cords, respec-tively, which enter the muscle on itsdeep medial aspect. The lateral pec-toral nerve supplies the clavicularhead and medial portion of the ster-nal head. The medial pectoral nerveenters the deep surface of the pecto-ralis minor muscle, supplying it andthe lateral portion of the sternalhead.12 The pectoral branch of the tho-racoacromial artery is the main bloodsupply of the muscle.

The pectoralis major muscle is apowerful internal rotator, flexor, andadductor of the arm. Although some-times considered unnecessary fornormal shoulder function,13 it is im-portant for carrying out strenuous ac-tivities because it is a main source ofpower for the upper torso in compet-itive athletes.14 It also forms the an-terior axillary fold and is importantcosmetically to bodybuilders.

Pathogenesis

Rupture of the pectoralis major mus-cle is most commonly caused by anindirect mechanism, such as forcedabduction against resistance, involun-

Figure 2 The pectoralis major muscle cord is evident on the right chest wall in this patientwith a tear of the pectoralis major muscle. Note the asymmetry in the right chest wall com-pared with the left.

Figure 1 Anterior view showing the originand insertion of the pectoralis major and mi-nor muscles. Note the 180° rotation as the in-ferior fibers of the pectoralis major muscle in-sert superiorly.

Pectoralis Major Muscle Injuries

60 Journal of the American Academy of Orthopaedic Surgeons

tary contraction, and severe tractionon the arm.1,8,11,15 In weight lifting, theinjury occurs during the eccentricphase of contraction, when more ten-sion is generated.8,16 Patients may re-port feeling a “pop” or tearing sen-sation as they move from maximaleccentric contraction to concentriccontraction. In their cadaveric stud-ies mimicking the bench press mo-

tion, Wolfe et al8 reported that the in-ferior fibers of the muscle responddisproportionately during the final30° of humeral extension and are ata mechanical disadvantage whenplaced under external load, therebymaking them more vulnerable to in-jury. Further observations indicatethat the injury tends to occur at lowspeeds with the arms abducted andexternally rotated, placing the inferi-or fibers at maximal stretch.1 There-fore, during the bench press, the low-er sternal head fibers are subjected toan inordinate amount of stress andare the first fibers to rupture.

In one study, 83 of 94 patients re-ported an indirect mechanism of in-jury.1 The most common type of in-jury among these patients was avulsionof the tendon at the site of insertion.Of 86 surgically verified cases, 78 weredescribed as complete. In all, there were56 tendon avulsions, 21 ruptures atthe myotendinous junction, 4 bonyavulsions, 3 ruptures in the tendon sub-stance, and 2 muscle belly tears. Thisanalysis contradicted earlier reportsthat the muscle belly or myotendinousjunction was most commonly affect-ed.8,10 Muscle belly tears, unlike dis-tal tears, usually are associated withdirect trauma, such as motor vehicle

accidents and crushing injuries.Steroid use also may make a ten-

don more susceptible to injury.4,8 Ste-roid use and vigorous training mayincrease muscle strength at a rate towhich the tendon cannot adapt, leav-ing it at greater risk for injury. Anal-ysis of the effects of steroids on rattendons demonstrated that the ten-dons became stiffer, could not absorbas much energy, and failed with less-er elongation.17 Those effects seemedto be reversible with discontinuationof steroid use.

Diagnosis

History and PhysicalExamination

Most patients recall the specific in-cident related to the pectoralis mus-cle injury. They often report a tearingsensation with or without a pop, pain-ful limitation of motion, localized swell-ing, ecchymosis, and weakness. It isnot uncommon for patients to initiallytreat the injury as they would a sprainor strain, with rest and ice. However,persistent weakness and asymmetryonce the swelling and bruising haveresolved usually suggest the presenceof a more severe injury.

Figure 3 A, Intraoperative view demonstrating the cord connecting the medial brachial and antebrachial septum to the torn pectoralismajor tendon. B, Line drawing of the intraoperative view. Pec tendon = pectoralis major tendon.

Figure 4 The anterior lamina originates fromthe clavicular head and the posterior lamina,from the sternal head.

Julio Petilon, MD, et al


Findings on examination often cor-relate with the location of the injury.Patients with proximal tears or mus-cle belly tears may demonstrate ec-chymosis only over the anterior chestwall; those with the more commondistal tears present acutely with ec-chymosis and swelling over the armor axilla.Apalpable defect may be ob-scured by swelling, an intact fascialcovering, or the overlying (uninjured)clavicular head. However, the classicwebbed appearance of the thinned-out anterior axilla can be accentu-ated by abducting the arm to 90°,especially after the swelling has sub-sided. Comparison with the unin-jured side is essential to evaluate anyasymmetry. Chest wall deformity canbe enhanced by contraction of themuscle or by resisted adduction as themuscle is retracted medially. In chron-ic cases, retracting the muscle medi-ally may pull adherent overlying softtissue (Fig. 5). Shoulder motion alsomay be limited by pain. Weakness inadduction and internal rotation of thearm are usually clinically evident. Iso-kinetic testing with a dynamometercan help assess the patient’s strengthdeficits and assist in surgical selec-tion.18 Nevertheless, this conditionstill is primarily diagnosed clinically.When all of the findings are present,the assumption is that a completerupture of the pectoralis major mus-cle, particularly of the sternal head,has occurred.

Genetic abnormalities, such as Po-land’s syndrome and congenital ab-sence of the pectoralis major muscle(commonly the sternocostal head),may present as atrophy over the tho-rax and weakness in adduction andinternal rotation.19

ImagingConventional radiographs are rec-

ommended during the initial eval-uation to rule out bony avulsions,fractures, or dislocations. Humeralfractures may give evidence of an as-sociated pectoralis major muscle rup-ture when the distal fragment of a

two-part proximal humeral fractureis displaced posterolateral becausesuch displacement is in the oppositedirection of the natural deformingpull of this muscle.20 The character-istic finding of a pectoralis majormuscle rupture is soft-tissue swellingand absence of the pectoralis majorshadow.9,10,13,15,21,22 Radiographs can-not accurately determine the extentof the injury, however.

Ultrasound also has been used suc-cessfully, with good correlation at sur-gery.1,23 Tears are identified by unevenechogenicity and muscle thinning incomparison with the opposite side.Although computed tomographymay detect a pectoralis major mus-cle tear, it is limited by its inferior soft-tissue contrast quality. Magnetic res-onance imaging (MRI) is widelyaccepted as the modality of choicewhen attempting to confirm or eval-uate possible tears of the pectoralismajor muscle.

The use of MRI to accurately as-sess the grade of injury, site, and, insome cases, amount of retractioncorrelates very well with surgical

findings.24-27 MRI may be helpful inthe acute setting when clinical diag-nosis is difficult. In addition, the in-creased sensitivity of MRI may enableefficient diagnosis, thereby avoidingsurgical delay and the accompanyingpossibility of subsequent develop-ment of adhesions, muscle retraction,and atrophy.26 Diagnosing and surgi-cally treating this injury earlier mayallow athletes a timely return to com-petition.

MRI can help differentiate betweencomplete, partial, and intramusculartears in both acute and chronic cases.It also can help identify patients whowould benefit most from surgical re-pair (Fig. 6). The exact location of apectoralis major injury can be seen onMRI scans. MRI also may be used tomonitor interval healing, musclequality, and hematoma resolution be-fore returning a patient to competi-tive sports. Ohashi et al27 reportedthat T2-weighted axial images werethe most useful for acute and sub-acute tears because on T1-weightedimages, a fresh hematoma or hemor-rhage may be indistinguishable from

Figure 5 Deformity and ecchymosis are evident in this right acute pectoralis major muscleinjury. Note the significant deformity and loss of contour of the right anterior chest wall (ar-row) compared with the left side.



adjacent muscle, thereby making thediagnosis of injury more difficult. Incontrast, chronic injuries, which tendto produce more fibrous tissue andscarring, are best evaluated on T1-weighted axial images. Connell etal24 recommended using coronal im-ages to determine the grade of par-tial tearing.

ClassificationTietjen15 proposed a classification

system to assist in the diagnosis andmanagement of pectoralis major mus-cle injuries based on the extent andsite of injury. Type I injuries consistof muscle contusions and sprains andtype II injuries, of partial tears. TypeIII injuries, which consist of completetears, are further subdivided accord-ing to location: A, muscle origin;B, muscle belly; C, myotendinousjunction; and D, tendon. Accordingto Tietjen, patients with type IIIDinjury are the best candidates forsurgical repair; all others likely canbe initially managed nonsurgically.This classification system provides a

guideline for evaluating ruptures ofthe pectoralis major muscle, but therupture can be more simply definedas partial or complete with involve-ment of only the sternal or of bothheads, and as proximal or distal.

Management

Nonsurgical ManagementNonsurgical management is rec-

ommended for proximal tears (tearsat the sternoclavicular origin) andsome partial tears. In older or seden-tary individuals, nonsurgical man-agement may be sufficient, even forcomplete tears, because repair of thismuscle is not necessary for perform-ing normal activities of daily liv-ing.8,13,21,25,28 Complete tears and high-grade partial tears, however, do leavethe individual with a cosmeticallydisfiguring bulge or defect and a sig-nificant strength deficit.4,6,7,10,11,18,29

Furthermore, healing and return offunctional strength may be slow. Pa-tient age, activity level, and cosmeticdesires, as well as the type of tear, arevital to determine the proper meth-od of care. Although some partialtears can be managed nonsurgically,ecchymosis, swelling, and tendernessmake it difficult to determine the ex-tent of the injury in the acute setting.MRI or repeated clinical examinationsmay be needed as the acute inflam-mation resolves.

The patient is initially placed in asling for comfort and is directed torest and take analgesics as necessary.The patient is begun on early shoul-der mobilization and unresistedstretching exercises, then advanced toresisted strengthening exercises whenmobility is normal and pain has im-proved, usually at 6 to 8 weeks afterinjury. Patients should be instructedon proper weight lifting techniquesto decrease the risk of rupture or re-injury. One technique involves low-ering the weight to no more than 4to 6 cm above the anterior chest wall,which minimizes eccentric stresses

placed on the pectoralis major mus-cle.30 In addition, a narrower grip onthe bench press no wider than 1.5times the biacromial width also canreduce stress on the muscle.31

Surgical ManagementSurgical repair provides the great-

est outcomes in patient satisfaction,strength, cosmesis, and return to com-petitive sports.1,2,4,6-8,10,11,22,23,29,32,33 Anycomplete tear (including isolated ster-nal head tears) involving either themyotendinous junction or the tendoninsertion site should be repaired. Ameta-analysis of the literature on pec-toralis major muscle injuries revealedthat patients repaired surgically had88% excellent or good results com-pared with 27% for patients treatednonsurgically.1 Hanna et al5 per-formed a retrospective analysis on 21patients with 22 complete tears andreported objective results based onisokinetic testing. Peak torque re-turned to 99% of that of the uninjuredside in patients treated surgically ver-sus only 56% in patients treated non-surgically.

Some authors recommend acutediagnosis and repair within 8 weeksof injury for optimal results, assert-ing that delayed surgery is more dif-ficult and less predictable.1,10,22,29

However, repairs delayed from 3months to 13 years from initial inju-ry have been performed with compa-rable results.4,5,8,9,18,23,33-35 A retrospec-tive analysis by Schepsis et al4 on 17patients demonstrated no significantsubjective or objective difference be-tween acute and delayed repairs, bothof which did markedly better thannonsurgical treatment. Subjective re-sults were calculated based on a pa-tient questionnaire that assessed post-operative strength, pain, motion,cosmesis, and overall satisfaction. Theacute repair group scored 96%; thedelayed group, 93%; and the nonsur-gical group, 51%. On isokinetic ad-duction strength testing, results weregiven as strength percentages of theuninjured arm. The surgical group

Figure 6 T2-weighted coronal MRI scan ofa pectoralis major intramuscular tear (ar-row).



demonstrated greater success, withacute repairs averaging 102%; de-layed repairs, 94%; and the nonsur-gical group, 71%. Some authors at-tribute the success of delayed surgicalrepair only to those torn muscleswhose retraction was limited by ei-ther adhesion or an intact portion ofthe tendon.23,33-35

Surgical OptionsMost types of surgical repair have

provided good results. In almost allcases, the deltopectoral approach isused, with the patient in a modifiedbeach-chair position. Most techniquesrecommend some form of suturingthrough drill holes.4,6,10,11,18,35,36 Schep-sis et al4 described a technique inwhich a 5-cm trough is made lateralto the bicipital groove and medial toany remaining distal tendinous at-tachment. Using no. 5 nonabsorbablesutures, two sets of horizontal andvertical modified Kessler sutures areused to grasp the muscle and fascia.The sutures are then passed and tiedthrough four drill holes made 1 cmlateral to the trough. Any remainingdistal tendon is oversewn into themuscle. Schepsis et al4 performed thistechnique on six acute and seven de-layed repairs. This trough–and–drill-hole technique also has been usedsuccessfully in a 13-year-delayed re-pair35 and in a rupture associated withan anterior shoulder dislocation.37

In another series of 16 cases, tworows of drill holes were used at thesite of insertion, and sutures werepassed through the holes with a cro-chet hook.11 The sutures then werepassed into the torn tendon and tiedwith the arm in adduction and inter-nal rotation. In the one case in whichonly a partial tear with good tendonattachment was noted, a primary re-pair of the muscle to the tendon wasperformed. Greater mobilization wasrequired in the chronic cases becauseof adhesions, but this did not seemto increase the difficulty of repair. Painwas relieved in all cases. All but onepatient experienced full return of mo-

tion. Deformity was corrected in allbut the two patients who underwentdelayed repairs 5 years after initial in-jury and who did not have a com-pletely normal contour. Strength wasfully restored in 13 of the patients; theothers experienced marked improve-ments. Of the two patients with de-layed repairs, one improved in hor-izontal adduction strength from 50%to 80%, and the other improved from60% to 84%. Similar techniques haveprovided good results in other series,including one case of rerupture thatinitially was fixed with periosteal su-tures.9,36 Good outcomes have beenachieved in nine cases repaired by at-taching the ruptured end of the pec-toralis major tendon to the humeruswith periosteal sutures.10,22

Excellent results were reported intwo patients with delayed repairswho were treated by petaling the in-sertion site with an osteotome andthen fixing the tendon with two 4.5-mm cancellous screws and spikedplastic soft-tissue washers.2 An acuterepair of a complete tendinous tearwas managed by reattaching the ten-don to the humerus using three boneanchors and reinforcing the repair byoversewing the remaining distal tis-sue.26 The 19-year-old patient re-turned to collegiate football. Therewas concern about using this devicebecause of the thin cortex that is usu-ally present in this area, but the out-come did not seem to be altered.Barbed staples also have been usedas fixators.38

Rijnberg and Van Linge29 used di-rect suture approximation of the rup-tured ends of the pectoralis major mus-cle to repair an acute myotendinousjunction tear in a bodybuilder. The pa-tient returned to his training programin 6 months. Liu et al23 achieved ex-cellent results in one patient by su-turing the avulsed tendon to the clavi-pectoral fascia using nonabsorbable,interrupted heavy sutures. Muscle bel-ly tears, although not often treated sur-gically, also have been repaired direct-ly with good results.10

Surgical Technique

Acute Rupture (≤6 Weeks)The patient is placed in a modified

beach chair position with the affect-ed arm and shoulder prepared freeto allow range of motion (ROM) dur-ing the procedure. Ageneral anesthet-ic is preferred to achieve muscle re-laxation and to facilitate mobilizationof the torn muscle, particularly inchronic tears.Astandard deltopectoralincision is used. The proximal extentis made slightly medial to allow ac-cess to the potentially retracted ten-don. The distal incision is made slight-ly lateral to provide better access tothe pectoralis major insertion. The an-terior laminar fibers from the clavicu-lar head usually are intact. Addition-ally, the anterior fascia of the pectoralismajor tendon, which is continuouswith the brachial fascia and the me-dial antebrachial septum, is also usu-ally intact, giving the false appearanceof an intact tendon. Blunt dissectionis performed inferior and medial tothe clavicular insertion. Occasional-ly, the anterior fascia and cord to themedial antebrachial septum are incisedto allow better access to the rupturedsternal portion of the pectoralis ma-jor tendon, which lies posterior andusually is retracted medial to the cla-vicular insertion. The ruptured ten-don end is identified and freshenedwith a scalpel. The tendon is mobi-lized, and stay sutures are placed forimproved traction and tensioning.

The insertion of the pectoralis ma-jor tendon is identified just lateral tothe long head of the biceps at the in-ferior portion of the incision. The longhead of the biceps can be palpated inthe bicipital groove. If the clavicularhead is intact, the insertion will beposterior to the tendinous insertionof the anterior lamina, just lateral tothe bicipital groove (Fig. 7). If the cla-vicular insertion also is ruptured, lo-cating the commonly present resid-ual fibers lateral to the biceps helpsidentify the tendinous insertion of thepectoralis major muscle.



Fixation of the torn pectoralis ma-jor muscle and tendon to the humer-al insertion can be done with eithera suture anchor or a bone trough.When using a suture anchor, the in-sertion site, which is lateral to the longhead of the biceps (in the tendon foot-print), is prepared with a burr to cre-ate a 3-cm × 1-cm area of bleedingbone. Care is taken not to decorticatethe area, which would weaken the su-ture anchor strength. A suture anchor

with a strong no. 2 or no. 5 braidednonabsorbable suture is preferred.Three to five anchors are placed, anda grasping stitch (eg, Krackow, mod-ified Kessler) (Fig. 8) is suturedthrough the tendon with a single limbof the suture.39 The second limb of thesuture is then brought through thetendon with a single throw and usedas the post to tension and advance thetendon as the suture slides throughthe anchor. The arm is then held in

neutral rotation, and the suture is tied.The remaining sutures are evenlyspaced along the ruptured tendonand then tensioned and tied. Sutureanchors can be used in acute tears,which can be repaired under little ten-sion in patients with good bone qual-ity.

When using a bone trough, a burris used to create a 3-cm bony troughat the tendon insertion site. The su-perior portion of the trough is under-

Figure 7 A, Intraoperative view showing an acute rupture of the sternal head of the pectoralis major muscle 3 weeks after injury. Theforceps points to the acutely torn and retracted sternal head of the pectoralis major muscle. Note the intact clavicular head. B, Drawing ofthe intraoperative photograph. Arm = direction of the patient’s arm, Head = direction of the patient’s head.

Figure 8 A, The Krackow suture technique. Suture 1 is woven through the tendon in locking fashion. Suture 2 is a simple stitch placedthrough the tendon that is then used as the post to slide the tendon to the anchor or bone trough (inset). A total of four passes are placedin the tendon, two anteriorly and two posteriorly. B, The modified Kessler stitch, which can be used in multiple layers to repair intramus-cular tears. (Adapted with permission from Schepsis AA, Grafe MW, Jones HP, Lemos MJ: Rupture of the pectoralis major muscle: Outcomeafter repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.)



cut with the burr. A 2-mm drill bit isused to create three to five equallyspaced drill holes 1 cm distal to thetrough edge. A strong no. 2 braidednonabsorbable suture is woventhrough the tendon, similar to the su-ture anchor technique. Three or fourof these sutures are placed and passedthrough the drill holes using a suturepasser. The arm is held in neutral ro-tation, and the sutures are tied overthe bone bridge (Fig. 9). The bonetrough technique is preferable inchronic ruptures, in ruptures that arerepaired under some tension, and inpatients with poor bone quality.

Chronic Rupture (>6 Weeks)For chronic ruptures, a larger in-

cision extends both proximally anddistally to facilitate soft-tissue dissec-tion and tendon mobilization. A largeamount of scar tissue is usually en-countered, and it may give the im-pression of an intact tendon. The scartissue is carefully excised, and the dis-section is performed to delineate theinjury pattern. Blunt dissection isused to carefully separate the scarredand retracted ruptured tendon end.With chronic ruptures, adhesions tothe overlying subdermal layers, aswell as to the chest wall, typically arepresent. A combination of blunt andsharp dissection is performed to re-lease these adhesions and to mobilizethe retracted tendon. Care must betaken when mobilizing deep to themuscle because the medial and lat-eral pectoral nerves enter the muscleon its deep surface medially, andoverzealous dissection may injurethem. The tendon is repaired once thepectoralis major muscle tendon is ad-equately mobilized (Fig. 10). Usuallyit is not necessary to augment the re-pair with autograft or allograft tissue,even with repairs done as late as 18months after injury.

Intramuscular RupturesIntramuscular ruptures of the pec-

toralis major muscle, although rare,present a unique challenge. If surgery

is indicated, the injured muscle bellycan be repaired by using a modifiedKessler technique. Multiple no. 2braided nonabsorbable sutures areplaced in three layers beginning in theposterior fascia, followed by a mid-dle layer, and finally by placing athird layer through the anterior fas-cia and muscle39,40 (Fig. 8, B). Thesethree layers of interlocking graspingsutures evenly distribute the loadamong the sutures. The sutures arethen repaired to the remaining mus-cle or tendon on the insertion side ofthe injury. Unfortunately, dependingon the chronicity of the case, there isoften little or no remaining sternalhead muscle or tendon medially towhich to sew. In such cases, the mus-cle belly is sutured to the remainingclavicular head tendon to provide ad-ditional length and to prevent over-tightening the repair, which couldlead to failure.

Postoperative RehabilitationThe patient is kept in a sling for 4

to 6 weeks, depending on the type ofrepair and the tear pattern. The reha-bilitation protocol is the same for bothacute and chronic repairs. Repairsthat require mobilization of the mus-cle or that are repaired under sometension are usually protected in asling for 6 weeks. Passive pendulumexercises are begun immediately, andpassive forward elevation with thearm adducted is allowed to 130°. Thepatient is instructed to avoid activeabduction, forward elevation, and ex-ternal rotation. At 6 weeks, gentlepassive ROM is gradually progressedto full ROM over the ensuing 6 weeks.A gentle periscapular strengtheningprogram is also added at 6 weeks.Additionally, isometric strengtheningexercises are begun, although thepatient should avoid shoulder adduc-tion, internal rotation, and horizon-

Figure 9 The bone trough technique. The trough is placed in the footprint of the tendonrupture (inset) just lateral to the long head of the biceps tendon. A, The sutures are passedthrough the bone trough out four separate drill holes. B, The sutures are tied, pullingthe ruptured tendon into the bone trough. (Adapted with permission from KretzlerHH Jr, Richardson AB: Rupture of the pectoralis major muscle. Am J Sports Med 1989;17:453-458.)



tal adduction. At 3 months postoper-atively, ROM should be full or nearlyfull, with an emphasis placed on re-gaining strength. Pectoralis majormuscle strengthening is begun withsingle arm pulleys and bands and in-cludes horizontal adduction, internalrotation, forward elevation, andshoulder adduction exercises. Rota-tor cuff and periscapular strengthen-ing exercises also are included in thestrengthening program. At 6 monthspostoperatively, the patient may be-gin push-ups and dumbbell benchpresses with light weight and highrepetition. The patient is returned tofull activities between 9 and 12months, although high-weight, low-

repetition barbell bench pressing isdiscouraged indefinitely.

Summary

Rupture of the pectoralis major mus-cle is rare, but it can occur while lift-ing weights or participating in stren-uous athletic activity. The mechanismof injury is commonly indirect, sec-ondary to a sudden forceful overloadof a maximally contracted muscle. Inmost patients, the site of the tear isat either the myotendinous junctionor the tendinous insertion. The pa-tient usually is able to recall the spe-cific time of injury and presents with

ecchymosis and swelling about theshoulder and with pain and weaknessin adduction and internal rotation ofthe arm.

Diagnosis of pectoralis major mus-cle rupture is often made clinically, butfurther imaging or examination isoccasionally required. MRI is the im-aging modality of choice because itcan be used to accurately assess thesite and extent of rupture in both acuteand chronic cases. Nonsurgical man-agement is recommended only forproximal tears and elderly, sedentarypatients. For all other complete tears,surgery is advocated to return the pa-tient to full strength and function andto reduce cosmetic deformity.

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Figure 10 Intraoperative views demonstrating a chronic rupture of both heads of the pectoralis major muscle 11 months after injury.A, Two clamps are attached to the tendon of both heads of the pectoralis major muscle. B, The clavicular and sternal heads of the pectoralismajor muscle have been repaired back to the anatomic insertion. Arm = direction of the involved arm, Axilla = direction of the involvedaxilla, Clavicular = clavicular head of the pectoralis major muscle, Deltoid = deltoid muscle, Head = direction of the patient’s head, Sternal= sternal head of the pectoralis major muscle.



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Pectoralis Major Muscle Injuries: Evaluation and Management...Figure 5 Deformity and ecchymosis are evident in this right acute pectoralis major muscle injury. Note the signiﬁcant