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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 of pectoralis major muscle tears have been reported since Patissier first de- scribed them in 1822. 1,2 More than half have been identified in the past 30 years. Initially caused by horse- and work-related accidents, thisinjury has become increasingly associated with strenuous athletic activity, most no- tably football, wrestling, waterskiing, rugby, and weight lifting. Excluding infants, the reported age range of pa- tients with this injury is from 16 to 91 years, with the peak in athletes aged between 20 and 40 years. With the exception of reported cases in fe- male nursing home residents with an unknown 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 these injuries, with the bench press being the most common inciting exercise. 4 Because of the rarity of this con- dition, it may be missed at initial presentation or misdiagnosed as a sprain and managed nonsurgically. Hanna et al 5 reported that 50% of their 12 patients with unrepaired tears were diagnosed late or initially were misdiagnosed. A marked per- centage of tears involve only the sternal head, leading to the impres- sion of an incomplete tear, when in fact there is a complete tear of the sternal head. In a review of 29 cases, Park and Espiniella 6 reported that 90% of patients treated surgically (9/10) showed good to excellent re- sults, whereas only 58% of patients treated nonsurgically (7/12) showed good results. Zeman et al 7 reported excellent results in four of four pa- tients treated surgically. The five patients treated nonsurgically re- ported strength deficits that limited return to athletic activity. Given the trend toward improved results with surgical 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 are integral to many people’s lifestyles, regardless of age or sex. As a result, ruptur es of the pectoralis major mus- cle likely will be seen more often than Dr. Petilon is Lieutenant, Medical Corps, United States Navy, and Flight Surgeon, Naval Medical Center Portsmouth, Portsmouth, VA. Dr. Carr is Lieutenant Commander, Medical Corps, United States 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 States Navy, Bone and Joint/Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Med- ical CenterPortsmouth. Dr . Unger is Captain, Med- ical Corps, United States Navy, and Chairman and ResidencyDir ector, Bone and Joint/Sports Med- icine Institute, Department of Orthopaedic Sur- gery, Naval Medical Center Portsmouth. None of the following authors or the departments with which they are af filiated has received anything of value from or owns stock in a commercial com- pany or institution related directly or indirectly to the subject of this article: Dr. Petilon, Dr. Carr, Dr. Sekiya, and Dr. Unger. The views expressed in this article are those of the authors and do not reflect the official policy or po- sition of the Department of the Navy, Department of 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 of Orthopaedic Surgeons. Pectoralis major muscle tears are relatively rare injuries that primarily occur while lifting weights, particularly when doing a bench press. Complete ruptures are most commonly 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 palpable defect, asymmetric webbing of the axillary fold, and weakness on resisted shoulder adduction and internal rotation. A detailed history and physical examination can be augmented by radiologic studies, including magnetic resonance imaging. Non- surgical treatment is now recommended only for the older, sedentary patient or for proximal muscle belly tears. Surgery, whether early or delayed, consistently yields superior r esults 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 of the anatomy, mechanism of injury, clinical findings, and management options is essential to expedite diag- nosis and maximize the functional outcome of this rare but often debil- itating injury. Anatomy and Function The pectoralis major muscle arises as a broad sheet in two divisions. The superior half, which forms the cla- vicular head, originates fr om the me- dial clavicle and the upper portion of the sternum. The inferior half, which makes up the sternal head, arises from the distal end of the sternum, the aponeurosis of the external ob- lique muscle, and the costal cartilage of the first six ribs. These fibers then converge and rotate 90° onto each other before uniting to form the ten- dinous insertion on the humerus, lat- eral to the bicipital groove. The most inferior muscle fibers insert superior- ly and posteriorly to the clavicular head, and the upper sternal fibers at- tach more distally (Fig. 1). The pectoralis major muscle fibers are unique in that they are composed of differ ent lengths and in that the r el- ative fiber length changes as the mus- cle length changes. 8 It is thought that, because of its wide origin and varied fiber direction, the muscle does not retract far when ruptured. 9 Some ear- ly authors thought those factors made complete ruptures infrequent. 10 The investing fascia of the pecto- ralis major muscle is continuous with the fascia of both the brachium and the medial antebrachial septum. Clin- ically, this fascia presents as a palpa- ble cord extending through the axilla and 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 isapproximate- 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 two laminae. The anterior lamina is cre- ated by the clavicular head, and the posterior lamina is formed by the ster- nal head. In their anatomic analysis, Wolfe et al 8 describe a trilaminar ten- don (Fig. 4). The nerve supply is de- rived from the lateral (C5-C7) and medial (C8-T1) pectoral nerves from the lateral and medial cords, respec- tively, which enter the muscle on its deep medial aspect. The lateral pec- toral nerve supplies the clavicular head and medial portion of the ster- nal head. The medial pectoral nerve enters the deep surface of the pecto- ralis minor muscle, supplying it and the lateral portion of the sternal head. 12 The pectoral branch of the tho- racoacromial artery is the main blood supply of the muscle. The pectoralis major muscle is a powerful internal rotator, flexor, and adductor of the arm. Although some- times considered unnecessary for normal shoulder function, 13 it is im- portant for carrying out strenuous ac- tivities because it is a main source of power for the upper torso in compet- itive athletes. 14 It also forms the an- terior axillary fold and is important cosmetically to bodybuilders. Pathogenesis Rupture of the pectoralis major mus- cle is most commonly caused by an indirect mechanism, such as forced abduction against resistance, involun- Figure 2 The pectoralis major muscle cord is evident on the right chest wall in this patient with 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 origin and 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 traction on the arm. 1,8,11,15 In weight lifting, the injury occurs during the eccentric phase 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 maximal eccentric contraction to concentric contraction. In their cadaveric stud- ies mimicking the bench press mo- tion, Wolfe et al 8 reported that the in- ferior fibers of the muscle respond disproportionately during the final 30° of humeral extension and are at a mechanical disadvantage when placed under external load, thereby making them more vulnerable to in- jury. Further observations indicate that the injury tends to occur at low speeds with the arms abducted and externally rotated, placing the inferi- or fibers at maximal stretch. 1 There- fore, during the bench press, the low- er sternal head fibers are subjected to an inordinate amount of stress and are 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 avulsion of the tendon at the site of insertion. Of 86 surgically verified cases, 78 wer e described as complete. In all, ther e wer e 56 tendon avulsions, 21 ruptures at the myotendinous junction, 4 bony avulsions, 3 r uptures in the tendon sub- stance, and 2 muscle belly tears. This analysis contradicted earlier reports that the muscle belly or myotendinous junction was most commonly affect- ed. 8,10 Muscle belly tears, unlike dis- tal tears, usually are associated with direct 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 may increase muscle strength at a rate to which the tendon cannot adapt, leav- ing it at greater risk for injury. Anal- ysis of the effects of steroids on rat tendons demonstrated that the ten- dons became stiffer, could not absorb as much energy, and failed with less- er elongation. 17 Those effects seemed to be reversible with discontinuation of steroid use. Diagnosis History and Physical Examination Most patients recall the specific in- cident related to the pectoralis mus- cle injury. They often report a tearing sensation with or without a pop, pain- ful limitation of motion, localized swell- ing, ecchymosis, and weakness. It is not uncommon for patients to initially treat the injury as they would a sprain or strain, with rest and ice. However, persistent weakness and asymmetry once the swelling and bruising have resolved usually suggest the presence of a more severe injury. Figure 3 A, Intraoperative view demonstrating the cord connecting the medial brachial and antebrachial septum to the torn pectoralis major tendon. B, Line drawing of the intraoperative view. Pec tendon = pectoralis major tendon. Figure 4 The anterior laminaoriginates from the clavicular head and the posterior lamina, from the sternal head. Julio Petilon, MD, et al Vol 13, No 1, January/February 2005 61 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 chest wall; those with the more common distal tears present acutely with ec- chymosis and swelling over the arm or axilla.Apalpable defect may be ob- scured by swelling, an intact fascial covering, or the overlying (uninjured) clavicular head. However, the classic webbed 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 any asymmetry. Chest wall deformity can be enhanced by contraction of the muscle or by resisted adduction as the muscle is retracted medially. In chron- ic cases, retracting the muscle medi- ally may pull adherent overlying soft tissue (Fig. 5). Shoulder motion also may be limited by pain. Weakness in adduction and internal rotation of the arm ar e usually clinically evident. Iso- kinetic testing with a dynamometer can help assess the patient’s strength deficits and assist in surgical selec- tion. 18 Nevertheless, this condition still is primarily diagnosed clinically. When all of the findings are present, the assumption is that a complete rupture 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 and internal rotation. 19 Imaging Conventional radiographs are rec- ommended during the initial eval- uation to rule out bony avulsions, fractures, or dislocations. Humeral fractures may give evidence of an as- sociated pectoralis major muscle rup- ture when the distal fragment of a two-part proximal humeral fracture is displaced posterolateral because such displacement is in the opposite direction of the natural deforming pull of this muscle. 20 The character- istic finding of a pectoralis major muscle ruptur e is soft-tissue swelling and absence of the pectoralis major shadow. 9,10,13,15,21,22 Radiographs can- not accurately determine the extent of the injury, however. Ultrasound also has been used suc- cessfully, with good correlation at sur- gery. 1,23 Tears are identified by uneven echogenicity and muscle thinning in comparison with the opposite side. Although computed tomography may detect a pectoralis major mus- cle tear, it is limited by its inferior soft- tissue contrast quality. Magnetic res- onance imaging (MRI) is widely accepted as the modality of choice when attempting to confirm or eval- uate possible tears of the pectoralis major muscle. The use of MRI to accurately as- sess the grade of injury, site, and, in some cases, amount of retraction correlates very well with surgical findings. 24-27 MRI may be helpful in the acute setting when clinical diag- nosis is difficult. In addition, the in- creased sensitivity of MRI may enable efficient diagnosis, thereby avoiding surgical delay and the accompanying possibility of subsequent develop- ment of adhesions, muscle retraction, and atrophy. 26 Diagnosing and surgi- cally treating this injury earlier may allow athletes a timely return to com- petition. MRI can help dif fer entiate between complete, partial, and intramuscular tears in both acute and chronic cases. It also can help identify patients who would benefit most from surgical re- pair (Fig. 6). The exact location of a pectoralis major injury can be seen on MRI scans. MRI also may be used to monitor interval healing, muscle quality, and hematoma resolution be- fore returning a patient to competi- tive sports. Ohashi et al 27 reported that T2-weighted axial images were the most useful for acute and sub- acute tears because on T1-weighted images, a fresh hematoma or hemor- rhage may be indistinguishable from Figure 5 Deformity and ecchymosis are evident in this right acute pectoralis major muscle injury. Note the significant deformity and loss of contour of the right anterior chest wall (ar- row) compared with the left side. Pectoralis Major Muscle Injuries 62 Journal of the American Academy of Orthopaedic Surgeons adjacent muscle, thereby making the diagnosis of injury more difficult. In contrast, chronic injuries, which tend to produce more fibrous tissue and scarring, are best evaluated on T1- weighted axial images. Connell et al 24 recommended using coronal im- ages to determine the grade of par- tial tearing. Classification Tietjen 15 proposed a classification system to assist in the diagnosis and management of pectoralis major mus- cle injuries based on the extent and site of injury. Type I injuries consist of muscle contusions and sprains and type II injuries, of partial tears. Type III injuries, which consist of complete tears, are further subdivided accord- ing to location: A, muscle origin; B, muscle belly; C, myotendinous junction; and D, tendon. According to Tietjen, patients with type IIID injury are the best candidates for surgical repair; all others likely can be initially managed nonsurgically. This classification system provides a guideline for evaluating ruptures of the pectoralis major muscle, but the rupture can be more simply defined as partial or complete with involve- ment of only the sternal or of both heads, and as proximal or distal. Management Nonsurgical Management Nonsurgical management is rec- ommended for proximal tears (tears at the sternoclavicular origin) and some partial tears. In older or seden- tary individuals, nonsurgical man- agement may be sufficient, even for complete tears, because repair of this muscle 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 leave the individual with a cosmetically disfiguring bulge or defect and a sig- nificant strength deficit. 4,6,7,10,11,18,29 Furthermore, healing and return of functional strength may be slow. Pa- tient age, activity level, and cosmetic desires, as well as the type of tear, are vital to determine the proper meth- od of care. Although some partial tears can be managed nonsurgically, ecchymosis, swelling, and tenderness make it difficult to determine the ex- tent of the injury in the acute setting. MRI or repeated clinical examinations may be needed as the acute inflam- mation resolves. The patient is initially placed in a sling for comfort and is directed to rest and take analgesics as necessary. The patient is begun on early shoul- der mobilization and unresisted stretching exercises, then advanced to resisted strengthening exer cises when mobility is normal and pain has im- proved, usually at 6 to 8 weeks after injury. Patients should be instructed on proper weight lifting techniques to decrease the risk of rupture or re- injury. One technique involves low- ering the weight to no more than 4 to 6 cm above the anterior chest wall, which minimizes eccentric stresses placed on the pectoralis major mus- cle. 30 In addition, a narrower grip on the bench press no wider than 1.5 times the biacromial width also can reduce stress on the muscle. 31 Surgical Management Surgical 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 Any complete tear (including isolated ster- nal head tears) involving either the myotendinous junction or the tendon insertion site should be repaired. A meta-analysis of the literature on pec- toralis major muscle injuries revealed that patients repaired surgically had 88% excellent or good results com- pared with 27% for patients treated nonsurgically. 1 Hanna et al 5 per- formed a retrospective analysis on 21 patients with 22 complete tears and reported objective results based on isokinetic testing. Peak torque re- turned to 99% of that of the uninjured side in patients treated surgically ver- sus only 56% in patients treated non- surgically. Some authors recommend acute diagnosis and repair within 8 weeks of injury for optimal results, assert- ing that delayed surgery is more dif- ficult and less predictable. 1,10,22,29 However, repairs delayed from 3 months 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 al 4 on 17 patients demonstrated no significant subjective or objective difference be- tween acute and delayed repairs, both of which did markedly better than nonsurgical treatment. Subjective re- sults were calculated based on a pa- tient questionnair e that assessed post- operative strength, pain, motion, cosmesis, and overall satisfaction. The acute repair group scored 96%; the delayed group, 93%; and the nonsur- gical group, 51%. On isokinetic ad- duction strength testing, results were given as strength percentages of the uninjured arm. The surgical group Figure 6 T2-weighted coronal MRI scan of a pectoralis major intramuscular tear (ar- row). Julio Petilon, MD, et al Vol 13, No 1, January/February 2005 63 demonstrated greater success, with acute repairs averaging 102%; de- layed repairs, 94%; and the nonsur- gical group, 71%. Some authors at- tribute the success of delayed surgical repair only to those torn muscles whose retraction was limited by ei- ther adhesion or an intact portion of the tendon. 23,33-35 Surgical Options Most types of surgical repair have provided good results. In almost all cases, the deltopectoral approach is used, with the patient in a modified beach-chair position. Most techniques recommend some form of suturing through drill holes. 4,6,10,11,18,35,36 Schep- sis et al 4 described a technique in which a 5-cm trough is made lateral to the bicipital groove and medial to any remaining distal tendinous at- tachment. Using no. 5 nonabsorbable sutures, two sets of horizontal and vertical modified Kessler sutures are used to grasp the muscle and fascia. The sutures are then passed and tied through four drill holes made 1 cm lateral to the trough. Any remaining distal tendon is oversewn into the muscle. Schepsis et al 4 performed this technique on six acute and seven de- layed repairs. This trough–and–drill- hole technique also has been used successfully in a 13-year-delayed re- pair 35 and in a rupture associated with an anterior shoulder dislocation. 37 In another series of 16 cases, two rows of drill holes were used at the site of insertion, and sutures were passed through the holes with a cro- chet hook. 11 The sutures then were passed into the torn tendon and tied with the arm in adduction and inter- nal rotation. In the one case in which only a partial tear with good tendon attachment was noted, a primary re- pair of the muscle to the tendon was performed. Greater mobilization was required in the chronic cases because of adhesions, but this did not seem to incr ease the dif ficulty of repair. Pain was relieved in all cases. All but one patient experienced full return of mo- tion. Deformity was corrected in all but the two patients who underwent delayed r epairs 5 years after initial in- jury and who did not have a com- pletely normal contour. Strength was fully restored in 13 of the patients; the others 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 from 60% to 84%. Similar techniques have provided good results in other series, including one case of rerupture that initially was fixed with periosteal su- tures. 9,36 Good outcomes have been achieved in nine cases repaired by at- taching the ruptured end of the pec- toralis major tendon to the humerus with periosteal sutures. 10,22 Excellent results were reported in two patients with delayed repairs who were treated by petaling the in- sertion site with an osteotome and then fixing the tendon with two 4.5- mm cancellous screws and spiked plastic soft-tissue washers. 2 An acute repair of a complete tendinous tear was managed by reattaching the ten- don to the humerus using three bone anchors and r einforcing the repair by oversewing the remaining distal tis- sue. 26 The 19-year-old patient re- turned to collegiate football. There was concern about using this device because 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 used as fixators. 38 Rijnberg and Van Linge 29 used di- rect suture approximation of the rup- tured ends of the pectoralis major mus- cle to repair an acute myotendinous junction tear in a bodybuilder. The pa- tient returned to his training program in 6 months. Liu et al 23 achieved ex- cellent results in one patient by su- turing the avulsed tendon to the clavi- pectoral fascia using nonabsorbable, interrupted heavy sutur es. Muscle bel- ly tears, although not often tr eated sur - gically, also have been repaired dir ect- 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 free to allow range of motion (ROM) dur - ing the procedur e. A general a nesthet- ic is preferred to achieve muscle re- laxation and to facilitate mobilization of the torn muscle, particularly in chronic tears.Astandard deltopectoral incision is used. The proximal extent is 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 to the pectoralis major insertion. The an- terior laminar fibers from the clavicu- lar head usually are intact. Addition- ally, the anterior fascia of the pectoralis major tendon, which is continuous with the brachial fascia and the me- dial antebrachial septum, is also usu- ally intact, giving the false appearance of an intact tendon. Blunt dissection is performed inferior and medial to the clavicular insertion. Occasional- ly, the anterior fascia and cord to the medial antebrachial septum ar e incised to allow better access to the ruptured sternal portion of the pectoralis ma- jor tendon, which lies posterior and usually is retracted medial to the cla- vicular insertion. The ruptured ten- don end is identified and freshened with a scalpel. The tendon is mobi- lized, and stay sutures are placed for improved traction and tensioning. The insertion of the pectoralis ma- jor tendon is identified just lateral to the long head of the biceps at the in- ferior portion of the incision. The long head of the biceps can be palpated in the bicipital groove. If the clavicular head is intact, the insertion will be posterior to the tendinous insertion of the anterior lamina, just lateral to the bicipital groove (Fig. 7). If the cla- vicular insertion also is ruptured, lo- cating the commonly present resid- ual fibers lateral to the biceps helps identify the tendinous insertion of the pectoralis major muscle. Pectoralis Major Muscle Injuries 64 Journal of the American Academy of Orthopaedic Surgeons Fixation of the torn pectoralis ma- jor muscle and tendon to the humer- al insertion can be done with either a suture anchor or a bone trough. When using a suture anchor, the in- sertion site, which is lateral to the long head of the biceps (in the tendon foot- print), is prepared with a burr to cre- ate a 3-cm × 1-cm area of bleeding bone. Care is taken not to decorticate the ar ea, which would weaken the su- ture anchor strength. A suture anchor with a strong no. 2 or no. 5 braided nonabsorbable suture is preferred. Three to five anchors are placed, and a grasping stitch (eg, Krackow, mod- ified Kessler) (Fig. 8) is sutured through the tendon with a single limb of the suture. 39 The second limb of the suture is then brought through the tendon with a single throw and used as the post to tension and advance the tendon as the suture slides through the anchor. The arm is then held in neutral r otation, and the suture i s tied. The remaining sutures are evenly spaced along the ruptured tendon and then tensioned and tied. Suture anchors 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 burr is used to create a 3-cm bony trough at 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. The forceps points to the acutely torn and retracted sternal head of the pectoralis major muscle. Note the intact clavicular head. B, Drawing of the 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 placed through 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 placed in 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: Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.) Julio Petilon, MD, et al Vol 13, No 1, January/February 2005 65 cut with the burr. A 2-mm drill bit is used to create three to five equally spaced drill holes 1 cm distal to the trough edge. A strong no. 2 braided nonabsorbable suture is woven through the tendon, similar to the su- ture anchor technique. Three or four of these sutures ar e placed and passed through the drill holes using a suture passer. The arm is held in neutral ro- tation, and the sutures are tied over the bone bridge (Fig. 9). The bone trough technique is preferable in chronic ruptures, in ruptures that are repaired under some tension, and in patients with poor bone quality. Chronic Rupture (>6 Weeks) For chronic ruptures, a larger in- cision extends both proximally and distally to facilitate soft-tissue dissec- tion and tendon mobilization. A large amount of scar tissue is usually en- countered, and it may give the im- pression of an intact tendon. The scar tissue is carefully excised, and the dis- section is performed to delineate the injury pattern. Blunt dissection is used to car efully separate the scarred and retracted ruptured tendon end. With chronic ruptures, adhesions to the overlying subdermal layers, as well as to the chest wall, typically are present. A combination of blunt and sharp dissection is performed to re- lease these adhesions and to mobilize the retracted tendon. Care must be taken when mobilizing deep to the muscle because the medial and lat- eral pectoral nerves enter the muscle on its deep surface medially, and overzealous dissection may injure them. The tendon is repaired once the pectoralis major muscle tendon is ad- equately mobilized (Fig. 10). Usually it is not necessary to augment the re- pair with autograft or allograft tissue, even with repairs done as late as 18 months after injury. Intramuscular Ruptures Intramuscular ruptur es of the pec- toralis major muscle, although rare, present a unique challenge. If surgery is indicated, the injured muscle belly can be repaired by using a modified Kessler technique. Multiple no. 2 braided nonabsorbable sutures are placed in three layers beginning in the posterior fascia, followed by a mid- dle layer, and finally by placing a third layer through the anterior fas- cia and muscle 39,40 (Fig. 8, B). These three layers of interlocking grasping sutures evenly distribute the load among the sutures. The sutures are then repaired to the remaining mus- cle or tendon on the insertion side of the injury. Unfortunately, depending on the chronicity of the case, there is often little or no remaining sternal head muscle or tendon medially to which to sew. In such cases, the mus- cle belly is sutured to the remaining clavicular head tendon to provide ad- ditional length and to prevent over- tightening the repair, which could lead to failure. Postoperative Rehabilitation The patient is kept in a sling for 4 to 6 weeks, depending on the type of repair and the tear pattern. The reha- bilitation pr otocol is the same for both acute and chronic repairs. Repairs that require mobilization of the mus- cle or that are repaired under some tension are usually protected in a sling for 6 weeks. Passive pendulum exercises are begun immediately, and passive forward elevation with the arm adducted is allowed to 130°. The patient is instructed to avoid active abduction, forward elevation, and ex- ternal rotation. At 6 weeks, gentle passive ROM is gradually progressed to full ROM over the ensuing 6 weeks. A gentle periscapular strengthening program is also added at 6 weeks. Additionally, isometric strengthening exercises are begun, although the patient should avoid shoulder adduc- tion, internal rotation, and horizon- Figure 9 The bone trough technique. The trough is placed in the footprint of the tendon rupture (inset) just lateral to the long head of the biceps tendon. A, The sutures are passed through the bone trough out four separate drill holes. B, The sutures are tied, pulling the ruptured tendon into the bone trough. (Adapted with permission from Kretzler HH Jr, Richardson AB: Rupture of the pectoralis major muscle. Am J Sports Med 1989;17: 453-458.) Pectoralis Major Muscle Injuries 66 Journal of the American Academy of Orthopaedic Surgeons tal adduction. At 3 months postoper- atively, ROM should be full or nearly full, with an emphasis placed on re- gaining strength. Pectoralis major muscle strengthening is begun with single arm pulleys and bands and in- cludes horizontal adduction, internal rotation, forward elevation, and shoulder adduction exercises. Rota- tor cuff and periscapular strengthen- ing exercises also are included in the strengthening program. At 6 months postoperatively, the patient may be- gin push-ups and dumbbell bench presses with light weight and high repetition. The patient is returned to full activities between 9 and 12 months, although high-weight, low- repetition barbell bench pressing is discouraged 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 mechanism of injury is commonly indirect, sec- ondary to a sudden forceful overload of a maximally contracted muscle. In most patients, the site of the tear is at either the myotendinous junction or the tendinous insertion. The pa- tient usually is able to recall the spe- cific time of injury and presents with ecchymosis and swelling about the shoulder and with pain and weakness in adduction and internal rotation of the arm. Diagnosis of pectoralis major mus- cle ruptur e is often made clinically, but further imaging or examination is occasionally required. MRI is the im- aging modality of choice because it can be used to accurately assess the site and extent of ruptur e in both acute and chronic cases. Nonsurgical man- agement is recommended only for proximal tears and elderly, sedentary patients. For all other complete tears, surgery is advocated to return the pa- tient to full strength and function and to reduce cosmetic deformity. References 1. Bak K, Cameron EA, Henderson IJ: Rup- ture of the pectoralis major: A meta- analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-119. 2. Quinlan JF, Molloy M, Hurson BJ: Pec- toralis major tendon ruptures: When to operate. Br J Sports Med 2002;36: 226-228. 3. Beloosesky Y, Hendel D, Weiss A, Rosen- berg PH, Grinblat J: Rupture of the pec- toralis major muscle in nursing home residents. Am J Med 2001;111:233-235. 4. Schepsis AA, Grafe MW, Jones HP, Lemos MJ: Rupture of the pectoralis major muscle: Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15. 5. Hanna CM, Glenny AB, Stanley SN, Caughey MA: Pectoralis major tears: Comparison of surgical and conserva- tive treatment. Br J Sports Med 2001;35: 202-206. 6. Park JY, Espiniella JL: Rupture of pec- toralis major muscle: A case report and review of literature. J Bone Joint Surg Am 1970;52:577-581. 7. Zeman SC, Rosenfeld RT, Lipscomb PR: Tears of the pectoralis major mus- cle. Am J Sports Med 1979;7:343-347. 8. Wolfe SW, Wickiewicz TL, Cavanaugh JT: Rupture of the pectoralis major muscle: An anatomic and clinical anal- ysis. Am J Sports Med 1992;20:587-593. 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 pectoralis major muscle have been repaired back to the anatomic insertion. Arm = direction of the involved arm, Axilla = direction of the involved axilla, 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. Julio Petilon, MD, et al Vol 13, No 1, January/February 2005 67 9. Dunkelman NR, Collier F, Rook JL, Nagler W, Brennan MJ: Pectoralis ma- jor muscle rupture in windsurfing. Arch Phys Med Rehabil 1994;75:819-821. 10. McEntire JE, Hess WE, Coleman SS: Rupture of the pectoralis major muscle: A report of eleven injuries and review of fifty-six. J Bone Joint Surg Am 1972;54: 1040-1046. 11. Kretzler HH Jr, Richardson AB: Rup- ture of the pectoralis major muscle. Am J Sports Med 1989;17:453-458. 12. Moore KL (ed): Clinically Oriented Anat- omy, ed 2. Baltimore, MD: Williams & Wilkins, 1985, pp 642-643. 13. Marmor L, Bechtol CO, Hall CB: Pecto- ralis major muscle: Function of sternal portion and mechanism of rupture of normal muscle: Case reports. J Bone Joint Surg Am 1961;43:81-87. 14. Haupt HA: Overuse injuries in the up- per extremity: Upper extremity injuries associated with strength training. Clin Sports Med 2001;20:481-490. 15. Tietjen R: Closed injuries of the pecto- ralis major muscle. J Trauma 1980;20: 262-264. 16. Garrett WE Jr: Muscle strain injuries: Clinical and basic aspects. Med Sci Sports Exerc 1990;22:436-443. 17. Inhofe PD, Grana WA, Egle D, et al: The effects of anabolic steroids on rat ten- don: An ultrastructural, biomechanical, and biochemical analysis. Am J Sports Med 1995;23:227-232. 18. Scott BW, Wallace WA, Barton MA: Di- agnosis and assessment of pectoralis major rupture by dynamometry. J Bone Joint Surg Br 1992;74:111-113. 19. Dietz FR, Morcuende JA: Chapter 1, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics,ed4. Philadelphia, PA: Lippincott, 1996, vol 1, p 54. 20. Kono M, Johnson EE: Pectoralis major tendon avulsion in association with a proximal humerus fracture. J Orthop Trauma 1996;10:508-510. 21. Delport HP, Piper MS: Pectoralis major rupture in athletes. Arch Orthop Trauma Surg 1982;100:135-137. 22. Berson BL: Surgical repair of pectoralis major rupture in an athlete: Case report of an unusual injury in a wrestler. Am J Sports Med 1979;7:348-351. 23. Liu J, Wu JJ, Chang CY, Chou YH, Lo WH: Avulsion of the pectoralis major ten- don. Am J Sports Med 1992;20:366-368. 24. Connell DA, Potter HG, Sherman MF, Wickiewicz TL: Injuries of the pectora- lis major muscle: Evaluation with MR imaging. Radiology 1999;210:785-791. 25. Carrino JA, Chandnanni VP, Mitchell DB, Choi-Chinn K, DeBerardino TM, Miller MD: Pectoralis major muscle and tendon tears: Diagnosis and grading using magnetic resonance imaging. Skeletal Radiol 2000;29:305-313. 26. Miller MD, Johnson DL, Fu FH, Thaete FL, Blanc RO: Rupture of the pectoralis major muscle in a collegiate football player: Use of magnetic resonance im- aging in early diagnosis. Am J Sports Med 1993;21:475-477. 27. Ohashi K, El-Khoury GY, Albright JP, Tearse DS: MRI of complete rupture of the pectoralis major muscle. Skeletal Radiol 1996;25:625-628. 28. Goriganti MR, Bodack MP, Nagler W: Pectoralis major rupture during gait training: Case report. Arch Phys Med Rehabil 1999;80:115-117. 29. Rijnberg WJ, Van Linge B: Rupture of the pectoralis major muscle in body- builders. Arch Orthop Trauma Surg 1993; 112:104-105. 30. Keeves RK, Laskowski ER, Smith J: Let- ter: Upper extremity weight-training modifications for the injured athlete. A clinical perspective. Am J Sports Med 1999;27:545-546. 31. Fees M, Decker T, Snyder-Mackler L, Axe MJ: Upper extremity weight- training modifications for the injured athlete: A clinical perspective. Am J Sports Med 1998;26:732-742. 32. Pavlik A, Csepai D, Berkes I: Surgical treatment of pectoralis major rupture in athletes. Knee Surg Sports Traumatol Ar- throsc 1998;6:129-133. 33. Roi GS, Respizzi S, Dworzak F: Partial rupture of the pectoralis major muscle in athletes. Int J Sports Med 1990;11: 85-87. 34. Lindenbaum BL: Delayed repair of a ruptured pectoralis major muscle. Clin Orthop 1975;109:120-121. 35. Anbari A, Kelly JD IV, Moyer RA: De- layed repair of a ruptured pectoralis major muscle: A case report. Am J Sports Med 2000;28:254-256. 36. Orava S, Sorasto A, Aalto K, Kvist H: To- tal r upture of pectoralis major muscle in athletes. Int J Sports Med 1984;5:272-274. 37. Arciero RA, Cruser DL: Pectoralis ma- jor rupture with simultaneous anterior dislocation of the shoulder. J Shoulder Elbow Surg 1997;6:318-320. 38. Egan TM, Hall H: Avulsion of the pec- toralis major tendon in a weight lifter: Repair using a barbed staple. Can J Surg 1987;30:434-435. 39. Kragh JF Jr, Basamania CJ: Surgical re- pair of acute traumatic closed transac- tion of the biceps brachii. J Bone Joint Surg Am 2002;84:992-998. 40. Menetrey J, Kasemkijwattana C, Fu FH, Moreland MS, Huard J: Suturing versus immobilization of a muscle laceration: A morphological and functional study in a mouse model. Am J Sports Med 1999;27:222-229. Pectoralis Major Muscle Injuries 68 Journal of the American Academy of Orthopaedic Surgeons