Pectoralis Major Repair
DEFINITION
Pectoralis major ruptures are injuries to the one of the largest and strongest muscles of the shoulder girdle. Injuries can be categorized based on the location and size of the rupture.
Location: Tears most commonly occur at the tendon-bone junction but can also occur anywhere along the muscle-tendon-bone unit (including intramuscular, muscle-tendon junction, intratendinous, or as an avulsion with a fleck of the proximal humerus attached).
Size: Partial-thickness tears can affect either head. Fullthickness tears frequently involve the sternocostal head but can be a complete tear, with rupture of both the sternocostal and clavicular heads.
ANATOMY
The pectoralis major is a broad triangular muscle made up of two heads. The clavicular head originates from the medial clavicle, and the sternocostal head originates from the anterior sternum, costal cartilages to the sixth rib, and external obliques.
The tendon inserts into the proximal humerus over an approximately 5-cm strip on the lateral edge of the bicipital groove.
The pectoralis major tendon has two distinct laminae, corresponding to the two heads. The tendon from the clavicular head inserts anteriorly and distally and is about 1 cm long, and the sternocostal head inserts
posteriorly with a 2.5 cm long tendon.6
The sternocostal head spirals 180 degrees on itself, inserting posteriorly and superiorly to the clavicular head, creating a rolled inferior surface that is the axillary fold (FIG 1).
The function of the pectoralis major varies depending on the division. Its primary function is to adduct the humerus and its secondary role is to forward flex and internally rotate. The clavicular head primarily forward flexes and horizontally adducts. The sternocostal head internally rotates and adducts.
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FIG 1 • A. Anatomy of the pectoralis major. Two distinct heads are clearly demonstrated. B. The clavicular portion of the tendon inserts anteriorly and distally. The sternocostal lamina inserts posteriorly and proximally.
PATHOGENESIS
Pectoralis major ruptures typically occur during a powerful eccentric or concentric contraction during a forceful forward flexion or adduction motion of the humerus (frequently heavy bench pressing). The final 30 degrees of humeral extension disproportionally stretches the inferior fibers of the sternocostal head, putting it at a mechanical disadvantage and predisposing it to injury. The inferior fibers fail first, followed by progression toward the clavicular head.
Ruptures may also occur when a traction injury such as rapid extension, abduction, or external rotation force is applied to the extremity (such as catching oneself during a fall or during a football tackle).
Injuries to the muscle belly can also be caused by a direct blow, which can result in hematoma formation.
Patients often hear or feel a rip or tear in the shoulder region, feel a burning pain, and occasionally hear a pop.
Younger patients (younger than 30 years old) tear at the tendon-bone insertion, whereas patients older than 30 years old tend to tear at the musculotendinous junction.
Swelling and ecchymosis occur from several hours to days after the injury in the lateral chest wall, upper arm, or axilla.
Medial muscle retraction along with loss of the axillary fold may not be evident for several days until the swelling subsides.
Anabolic steroids enhance the muscle's ability to generate force but weaken the muscle-tendon unit, making patients more susceptible to tears.4
NATURAL HISTORY
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Weakness of the affected shoulder in adduction, forward flexion, and internal rotation can be expected with nonoperative treatment of full-thickness tears.
Isokinetic strength testing has demonstrated 25% to 50% deficits of strength in adduction and internal rotation in preoperative patients and people treated nonoperatively.6,7,11
Cosmetic deformity occurs secondary to the loss of the tendon in the axillary fold as well as from the medial retraction that occurs during contraction of the muscle.
Partial tears will elicit a variable degree of weakness and deformity, depending on the amount and location of tendon torn.
The initial pain and cramping that occurs during contraction of the pectoralis major usually subsides in 2 to 3 months.
Patients treated nonoperatively for full-thickness tears may complain of a cosmetic deformity as well as weakness and fatigue with vigorous recreational and occupational activities.
PATIENT HISTORY AND PHYSICAL FINDINGS
A previous history of pain is not typical.
The patient's handedness, occupation, and involvement in sports and weight-lifting activities are important in decision making regarding treatment.
Use of anabolic steroids is common in this population.
Physical examination initially will yield painful range of motion of the shoulder and arm. When the swelling subsides, patients typically have full range of motion of the glenohumeral joint.
Swelling and ecchymosis are variable depending on the chronicity and the degree of the tear.
Isometric or resisted adduction and forward flexion may show the loss of the tendon contour along the anterior axillary fold and medial retraction of the pectoralis muscle. However, initial swelling can falsely make the axillary fold appear intact and obscure any defects in the contour of the pectoralis major muscle.
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FIG 2 • A. Resisted forward flexion demonstrates the intact clavicular head and the defect from the ruptured sternocostal head. The retracted sternocostal head is evident. B. Isometric adduction demonstrating the normal contour of the right pectoralis major compared with the medially retracted left sternocostal head.
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FIG 3 • Axial and coronal T2-weighted MRIs.
The examiner should instruct the patient to hold the arm at 90 degrees of abduction, and the anterior head of the deltoid will be accentuated. If the arm is held in forward flexion, the clavicular head will be accentuated (FIG 2A).
Directing the patient to press their hands together in front of their abdomen for isometric adduction accentuates the contour of the sternocostal head and anterior axillary fold— allowing simultaneous inspection and palpation of both sides (FIG 2B).
Manual strength testing will demonstrate weakness in adduction and forward flexion.
IMAGING AND OTHER DIAGNOSTIC STUDIES
A standard shoulder radiographic series is obtained to rule out fractures, avulsions, or signs of instability.
A magnetic resonance imaging (MRI) of the chest, protocoled with a field of view large enough to include the pectoralis major, may be obtained to evaluate the location of the tear or assist in making the diagnosis.8,13 It has been shown to be beneficial in differentiating musculotendinous junction ruptures from tendinous avulsions and
may change the treatment strategy (FIG 3).13
Ultrasound may be used to identify the location and severity of the tear. Results, however, are user-dependent.
DIFFERENTIAL DIAGNOSIS
Rotator cuff tears Proximal biceps tear Proximal humerus fracture
Anterior shoulder instability
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Deltoid rupture Latissimus dorsi tear Brachial plexus injury
NONOPERATIVE MANAGEMENT
Nonoperative treatment is indicated for intramuscular tears or tears at the musculotendinous junction in some people. Also, nonoperative treatment should be considered in lowdemand patients with distal tendon ruptures.
Nonoperative treatment begins with a sling for the first 7 to 10 days. Ice should be applied intermittently for the first 72 hours.
Gentle active-assisted range of motion is then begun, avoiding aggressive external rotation, abduction, or extension stretching in the initial phases.
Strength training is typically initiated gradually at 6 to 8 weeks. Depending on the level of occupational or sporting demands, patients may return between 8 and 12 weeks.
Strength deficits of 25% and 50% can be expected with nonoperative treatment.6,7,11
SURGICAL MANAGEMENT
Pectoralis major repair is recommended for complete tears of both heads, distal to the musculotendinous junction (intratendinous, tendon-bone junction, or bony avulsion). In highdemand patients, surgery is also recommended for isolated sternocostal head tears distal to the musculotendinous junction and musculotendinous junction tears with large defects.
A direct tendon-to-bone repair with heavy, nonabsorbable sutures is performed for complete distal tears and sternocostal tears.
A side-to-side repair, with or without Achilles allograft reinforcement, is used for musculotendinous junction tears.
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FIG 4 • Operative setup. The patient is placed in the beach-chair position with the arm draped free.
Preoperative Planning
A standard examination under anesthesia of the glenohumeral joint is performed to evaluate for instability.
Positioning
The patient is placed in the 30-degree modified beach-chair position. The shoulder and arm are prepared free. A shoulder positioning device is helpful, but not necessary, to position the arm during surgery (FIG 4).
Approach
An anterior approach to the shoulder and proximal humerus is used—the internervous plane is between the
axillary nerve of the deltoid and the medial and lateral pectoral nerves of the pectoralis major.
TECHNIQUES
Pectoralis Major Repair using Drill Holes
Our preferred technique for direct primary repair of the pectoralis major tendon is to attach the tendon directly to the humeral cortex using drill holes.
A limited 4- to 5-cm deltopectoral incision is made (TECH FIG 1A). The cephalic vein is identified and retracted laterally with the deltoid.
Given the sternocostal head tendon insertion posterior to the clavicular head, the pectoralis major tendon may initially appear intact in cases of isolated sternocostal head ruptures.
The biceps tendon is identified, gaining access to the insertion of the pectoralis major just lateral to the
biceps tendon on the proximal humerus. In cases of musculotendinous junction tears or partial tears, the entire tendon or a portion of it will be intact.
A small, sharp Hohmann retractor placed laterally to the long head of the biceps tendon and around the cortex of the medial humerus will subluxate the biceps medially, out of its groove, for protection.
Medial dissection is then performed to identify the retracted tendon. The sternocostal and clavicular heads are identified as well as the location of the tendon or musculotendinous junction tear.
The tendon is typically retracted medially and folded on itself and is identifiable by palpation.
A traction suture is placed in the tendon, and stepwise gentle blunt mobilization of the muscle and tendon is performed.
The excursion of the tendon is then tested. Even in cases of chronic tears, the tendon can typically be mobilized to reach the humerus without difficulty.
The tendon edge is freshened with a scalpel. A no. 5 braided, nonabsorbable suture is used in a Bunnell or modified Mason-Allen locking stitch in the end of the tendon (TECH FIG 1B). Two or three sutures are used, spaced about 1 cm apart, depending on the width of the tendon.
The insertion site lateral to the biceps tendon is partially decorticated with a burr.
A medial and lateral set of holes is drilled through the humerus. A bridge of 8 to 10 mm is adequate secondary to the thickness of the humerus.
The humeral cortex is extremely strong and thick at this location, so holes generally need to be 2 mm in diameter, possibly even enlarged with a 3-0 angled curette.
A commercially available curved drill can be used.
A needle with a matching radius of curvature is then used to pass a 2-0 Vicryl passing suture (TECH FIG 1C). Each corresponding suture is passed from medial to lateral using the 2-0 Vicryl passing suture.
In cases of isolated sternocostal head rupture, the ruptured tendon should be brought posteriorly and slightly superior
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to the clavicular head to recreate normal anatomy and the rolled shape of the anterior axillary fold.
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TECH FIG 1 • Drill hole technique. A. Limited deltopectoral incision. B. Modified Mason-Allen stitch in tendon edge. C. Drill hole placement with 2-0 Vicryl sutures placed. D. Bunnell technique with sutures passed and ready to tie. The central holes are shared by two sutures. E. Suture passage when modified Mason-Allen stitch is used. The deep suture is passed through the drill holes. F. Bunnell technique after suture tying.
In cases of complete ruptures, the tendon may need to be twisted to provide the proper orientation of the spiraling laminae.
The central drill holes are shared by the upper and lower respective sutures in a horizontal mattress configuration for the Bunnell technique (TECH FIG 1D).
If a modified Mason-Allen stitch was used, the deep suture is passed through the drill hole and the knot tied on the upper surface of the tendon (TECH FIG 1E).
The sutures are then tied with the arm in adduction and internal rotation to ensure apposition of the tendon to the humerus (TECH FIG 1F).
In cases of isolated sternocostal head tendon ruptures, additional sutures can be placed to sew the ruptured head into the back of the intact clavicular head.
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Pectoralis Major Repair using an Endosteal Button
The musculotendinous unit is mobilized in the same way as described for drill hole repair. The humeral cortex is partially decorticated with a burr.
Two or three cortical buttons are then placed in the humeral insertion, spaced 1 cm apart. One limb of each suture is passed in a Kessler mattress stitch through the distal pectoralis tendon (TECH FIG 2).
The second limb of each suture is passed in a simple fashion. This is used as the post during tying so the knot slides and apposes the tendon to the humerus without the knot lying in the repair site.
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TECH FIG 2 • Endosteal button technique. A. Limited deltopectoral incision with the long head biceps tendon (asterisk) subluxated medially from its groove and two drill holes in the lateral side of the groove. B. Inserting a cortical button with sutures attached. C. The sutures are tensioned, reducing the tendon to the bone. D. Final repair with sutures tied. E. Postoperative internal rotation x-ray showing the buttons on the endosteal cortex. (Image courtesy of Scott Buckel, DO.)
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Pectoralis Major Repair using Suture Anchors
The musculotendinous unit is mobilized in the same way as described for drill hole repair. The humeral cortex is partially decorticated with a burr.
Two or three suture anchors are then placed in the humeral insertion, spaced 1 cm apart. One limb of each suture is passed in a Kessler mattress stitch through the distal pectoralis tendon (TECH FIG 3).
The second limb of each suture is passed in a simple fashion. This is used as the post during tying so the knot slides and apposes the tendon to the humerus without the knot lying in the repair site.
Metallic anchors loaded with braided, nonabsorbable no. 5 sutures are used, as the humeral cortex in this region may be too thick to accept an absorbable anchor.
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TECH FIG 3 • Suture anchor technique: placement of sutures and passage through the tendon edge.
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Musculotendinous Junction Repairs
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Multiple figure-8 or modified Kessler sutures of a no. 2 braided, nonabsorbable suture are used on both the superficial and deep layers.
The quality of the repair depends on the strength and the amount of tendon left on the muscular side as the muscle itself is poor at holding suture.
The broad, flat portion of an Achilles tendon allograft may be used to reinforce the repair.
PEARLS AND PITFALLS
Indications
for repair
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A discussion and risk-benefit analysis is necessary in patients with partial and
musculotendinous junction ruptures.
Tendon ▪ Medial dissection is required to free the perimuscular adhesions in chronic ruptures.
mobilization Although elevating adherent subcutaneous tissue can provide mobilization, knowing the location of the neurovascular bundle helps avoid risk if mobilization on the deep side is required.
Suture
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Using a commercially available matched drill and needle facilitates suture passage
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passing through the humerus (CurvTek). Because of the thickness of the humerus, overdrilling the holes makes needle passage easier.
Chronic ▪ Repair of pectoralis major ruptures is feasible up to 5 years after the injury. The tears outcome of chronic repairs is not as good as that of acute repairs, with residual weakness as the most common complaint. |
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POSTOPERATIVE CARE
The arm is kept in a sling for 6 weeks postoperatively. The sling is removed two times daily for motion of the elbow, wrist, and hand. Stiffness is not generally an issue, but if the patient begins to become stiff, gentle passive motion of the shoulder can be instituted.
The extremes of abduction and external rotation are avoided for the first 6 weeks. At this time, the sling is removed and unrestricted movement is allowed. In addition, light, progressive strengthening is begun.
Return to full activities, including bench press, is generally achieved between 3 and 5 months.
OUTCOMES
Results are universally good with acute repairs (within 3 to 4 weeks).
De Castro Pochini et al2 in 2010 published the only prospective, randomized trial of 10 operative and 10 nonoperatively treated patients. The operative group had a better functional result.
Park and Espiniella9 in 1970 evaluated 30 patients with pectoralis major ruptures. The results were 90% good to excellent results with operative repair versus 75% with nonoperative treatment.
Zeman and coworkers12 in 1979 reviewed nine athletes with pectoralis major ruptures. Four patients were treated with surgical repair and had excellent results. All five of the patients treated nonoperatively had residual weakness, and two were dissatisfied with their outcome.
Kretzler and Richardson6 in 1989 reported on their results after repair of 16 distal tendon tears. Eighty-one percent regained full motion and strength. Two repairs that occurred 5 years after the injury had persistent weakness.
Wolfe and colleagues11 in 1992 evaluated 14 patients with pectoralis major ruptures, half of whom were treated with operative repair. Cybex strength testing demonstrated normal strength in the repaired patients, with persistent weakness in the unrepaired group.
Jones and Matthews5 in 1988 reviewed the literature and concluded that acute repair within 7 days has 57% excellent and 30% good results. Repair in the setting of a chronic tear yielded 0% excellent and 60% good results. They concluded that although chronic repair is possible even up to 5 years after the injury, the outcome is not as good as an acute repair, with a high likelihood of persistent weakness and cosmetic deformity.
Schepsis and colleagues10 in 2000 found that operatively repaired patients (both acute and chronic) had significantly better outcomes than conservatively treated patients.
Aärimaa and colleagues1 in 2004 evaluated 33 of their own cases and performed a meta-analysis of the 73 cases published in the English-speaking literature. They found predictably excellent result when the ruptured pectoralis major was repaired within 3 weeks. The results were less predictable with a delay to
repair of over 3 weeks. Nonoperatively treated patients had the worst results of all groups, with poor
strength and cosmesis.
Garrigues and colleagues3 in 2012 reported on a large single-surgeon cohort of pectoralis major tendon ruptures.
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Operative treatment yielded good to excellent functional results in all but one patient. Cosmesis and return of bench press strength was also acceptable.
To the best of our knowledge, pectoralis major rupture has not been reported in a female patient.
COMPLICATIONS
Complications are relatively infrequent after pectoralis major repair. Rerupture is uncommon but can occur if allograft is used. Chronic cases are at risk for an asymmetric cosmetic result and incomplete return of strength.10 Loss of abduction and paresthesias are rare.8,10
There have been several reports of complications in the elderly after rupture and nonsurgical management. The muscle injury and hematoma that forms can lead to acute anemia requiring blood transfusion, sepsis from an infected hematoma, or myositis ossificans.
REFERENCES
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Aärimaa V, Rantanen J, Heikkilä J, et al. Rupture of the pectoralis major muscle. Am J Sports Med 2004;32(5):1256-1262.
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de Castro Pochini A, Ejnisman B, Andreoli CV, et al. Pectoralis major muscle rupture in athletes: a prospective study. Am J Sports Med 2010;38(1):92-98.
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Garrigues GE, Kraeutler MJ, Gillespie RJ, et al. Repair of pectoralis major ruptures: single-surgeon case series. Orthopedics 2012;35(8):e1184-e1190.
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Hunter MB, Shybut GT, Nuber G. The effect of anabolic steroid hormones on the mechanical properties of tendons and ligaments. Trans Orthop Res Soc 1986;11:240.
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Jones MW, Matthews JP. Rupture of the pectoralis major in weightlifters: a case report and review of the literature. Injury 1988;19:219.
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Kretzler HH Jr, Richardson AB. Rupture of the pectoralis major muscle. Am J Sports Med 1989;17:453-458.
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Liu J, Wu JJ, Chang CY, et al. Avulsion of the pectoralis major tendon. Am J Sports Med 1992;20:366-368.
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Miller MD, Johnson DL, Fu FH, et al. Rupture of the pectoralis major muscle in a collegiate football player. Use of magnetic resonance imaging in early diagnosis. Am J Sports Med 1993;21:475-477.
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Park JY, Espiniella LJ. Rupture of the pectoralis major muscle. A case report and review of the literature. J Bone Joint Surg Am 1970;52(3):577-581.
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Schepsis AA, Grafe MW, Jones HP, et al. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.
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Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle: an anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.
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Zeman SC, Rosenfeld RT, Lipscomb PR. Tears of the pectoralis major muscle. Am J Sports Med 1979;7:343-347.
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Zvijac JE, Schurhoff MR, Hechtman KS, et al. Pectoralis major tears: correlation of magnetic resonance imaging and treatment strategies. Am J Sports Med 2006;34:289-294.