Orthopedics

Materials and Methods

After institutional review board approval, 24 consecutive patients who underwent pectoralis major repair by the senior author (M.D.L.) between May 2005 and March 2011 were retrospectively identified. Patients with tendon avulsions, tendon tears, and muscle–tendon junction tears were included. Patients with intramuscular tears were excluded. All tears were diagnosed by physical examination and confirmed by magnetic resonance imaging.

Surgical Technique

All patients were treated by the senior author. The patients were positioned in the semi-Fowler’s position. An S-shaped incision was made using the distal portion of the deltopectoral interval, curving from the medial aspect of the deltoid insertion, along the anterior axillary fold, and then back along the deltopectoral interval. The cephalic vein was protected, and, after irrigating away any hematoma, the pectoralis major muscle insertion was visualized. In all cases, the clavicular head remained intact. Dissecting medially, the torn sternocostal head was identified, and 2 heavy, braided (#5 FiberWire; Arthrex, Naples, Florida) running Krakow stitches were threaded through the tendon (Figure 1A). The insertion site lateral to the bicipital groove was identified, and a pine-cone burr was used to remove any adherent soft tissue and provide a freshened surface for tendon-to-bone healing.

Figure 1: Intraoperative photograph of the mobilized pectoralis major tendon (asterisk) with sutures in place (A). Intraoperative photograph showing passing of sutures through bone tunnels (black arrows) in the lateral aspect of the biceps groove (white arrow). The metal Homan retractor at the inferior aspect of the image holds the biceps tendon safely, medially dislocated from its groove (B). Intraoperative photograph of final repair after sewing the pectoralis major tendon (asterisk) back to the humerus through the bone tunnels (C).

Then, with care to protect the biceps tendon, 3 holes were made with a wire-passer burr (Figure 1B). A trough was not made because the lateral ridge of the biceps groove is hard bone and removing it sacrifices quality bone for the suture repair and creates a potential stress riser. The sternocostal head was passed anatomically deep to the clavicular tendon, and the sutures were pulled through the bone tunnels and tied over a bone bridge (Figure 1C). In 2 cases of a retracted musculotendinous junction rupture, an Achilles allograft was used to reattach the tendon to the bone. Suture anchors were used only in extremely muscular patients where using bone tunnels would be technically difficult.

Results

All 24 patients undergoing pectoralis major repair were men (Table 1). Average patient age at the time of surgery was 34 years (range, 18–48 years). Dominant arm side was known for all 24 patients, of whom 9 (39%) injured their dominant shoulder. Fourteen (58%) patients ruptured their pectoralis major muscle during a flat bench press. Of the remaining 10 patients, 2 were performing an incline bench press, 2 were firefighters who ruptured their pectoralis major muscle coming out of a window, 1 was lifting a garbage can, 1 was an emergency medical technician who was lifting a patient, 1 was wrestling, 1 was a police officer who was breaking up a riot, 1 was in a car accident, and 1 was sliding into base during a softball game.

Table 1: Demographics and Operative Details of the 24 Patients Undergoing Pectoralis Major Repair

Mean time to surgery was 44 days (range, 7–387), but excluding 3 patients who waited several months before seeking evaluation, mean time to surgery was 19 days (range, 7–40). Of the 3 patients who waited, 1 did not have health insurance immediately following his injury. When he did have insurance a year later, he sought medical assistance due to pain and weakness. Another patient was involved in a head-on car accident and did not seek medical attention until his other injuries had subsided. He sought treatment solely because of weakness. The third patient initially tried physical therapy but sought orthopedic treatment when he did not regain ROM in his arm. He also sought further help due to excessive pain.

Blood loss was minimal (less than 50 cc) in all cases, and only 2 cases required Achilles tendon allograft for a muscle–tendon junction rupture. One superficial infection resolved with oral antibiotics and 1 keloid scar. Three cases of clinically diagnosed medial cord brachial plexopathy existed: 1 that presented as numbness in the ulnar nerve distribution that resolved, 1 with ulnar nerve numbness and weakness that resolved, and 1 with persistant medial arm radiating pain that did not recover.

Nineteen (79%) patients were successfully contacted for follow-up (Table 2). Mean time to follow-up was 33 months (range, 7–70 months). Average SANE score for these patients was 93% (range, 50%–100%). Using the outcome criteria developed by Bak et al⁹ to grade pectoralis major muscle ruptures, 14 patients were rated as excellent. An excellent outcome is defined as no pain, normal ROM, no cosmetic modifications, subjectively normal adduction strength, and return to sport. Of the remaining patients, 4 were rated as good, and 1 workers’ compensation patient—a policeman with no pain with activities of daily living but severe pain with strenuous activity as required by his job, weakness, and inability to return to work—was rated as fair/bad. All other patients had returned to their normal job and/or sport by follow-up. Average preoperative Penn Shoulder Score was 60.0 (range, 22–77), which improved postoperatively to 94.2 (range, 64–100) (P=.011). During follow-up, 2 (10.5%) patients reported anabolic steroid use prior to their injury.

Table 2: Outcome Scores for 19 Patients Contacted for Follow-up

Eighteen patients performed routine bench press exercising prior to their injury, with 15 patients having returned to bench pressing at follow-up. As indicated by Schepsis et al,¹⁵ patient-reported pre- and postoperative bench press maximum is a useful objective measure of pectoralis major strength. Maximum bench press weight for these 15 patients decreased from 325 lb (range, 145–525 lb) to 264 lb (range, 100–500 lb) postoperatively (22% decrease) (P<.001). The 3 patients who had not yet returned to bench pressing stated that they were worried about potential reinjury but believed they could bench press at some level if attempted.

The survey of Schepsis et al¹⁵ is designed for pectoralis major muscle ruptures and has been used to evaluate their outcome in several domains. Mean scores as a percent of 100 were pain relief (94%), ROM (96%), return of strength (89%), satisfaction with cosmesis (92%), and overall satisfaction with treatment (96%).

In addition, 6 patients with pectoralis major tears were evaluated by the senior author during the same time period but did not undergo surgical repair. Five of these 6 patients injured their shoulders during a bench press, and 1 patient injured his shoulder while playing baseball. Two of the patients were advised not to undergo surgery due to the chronic nature of the injury. These patients waited 2 and 9 years, respectively, following their injury prior to initial evaluation. The other 4 patients were candidates for pectoralis major repair but decided not to undergo surgery.

Five (83%) of the 6 patients were contacted for follow-up at an average of 20.8 months (range, 12–26 months) after their initial evaluation. According to the Bak rating, 4 of these patients were rated as good and 1 as fair. Compared with patients who underwent pectoralis major repair, nonoperative patients had a greater decline in bench press and lower SANE; Penn Shoulder Score; SF-12 Physical and Mental; and Schepsis strength, cosmesis, and satisfaction subscores (Table 3). The difference in SANE scores (93 vs 84) was the only significant difference in outcome between operative and nonoperative groups, although this study was not powered to detect equivalence.

Table 3: Comparison of Outcome Scores Between Surgical and Nonsurgical Patients

Discussion

Pectoralis major ruptures are rare but increasingly recognized injuries. Although multiple small case series exist, to the authors’ knowledge, the current consecutive, single-surgeon series of operative repair is the largest to date.

The first case of pectoralis major muscle rupture was documented by Patissier in 1822 in a Parisian butcher boy attempting to lift a heavy side of beef off a hook.¹⁸ Most cases were rare traumatic or work-related events until heavy weight training and bodybuilding with use of anabolic steroids became popular in the second half of the 20th century.^5,18 Park and Espiniella²⁵ reviewed the literature in 1970 and found 29 reported cases. Since then, more than 200 cases have been reported, but nearly all have been isolated case reports.⁵

Kretzler and Richardson⁴ published one of the first series of pectoralis major muscle ruptures with more than a handful of patients, and it remains one of the largest series in the literature. They compared the results of 16 patients with operative repair to 3 treated nonoperatively. Their operative treatment involved repair through bone tunnels with 4 drill holes. As in the current study, they also noted the preponderance of injuries in men during bench press. The surgery corrected the cosmetic deformity and returned subjectively full strength in 16 of 19 patients, with a significant strength improvement in the remaining 3.⁴

Wolfe et al¹ reported a restoration of objectively measured strength after operative repair. Their repair added a 4-cm trough in addition to fixation with suture pulled through drill holes. They repaired 7 ruptures and showed that surgically treated patients had comparable torque and work measurements by isokinetic testing, whereas nonoperatively treated patients had a marked deficit in these strength domains. Their study was a cadaveric study of simulated bench press activity, which showed that the inferior fibers of the sternal head were lengthened disproportionately during the final 30° of humeral extension.¹ In addition, they are at a mechanical disadvantage during this eccentric phase of a bench press lift, elucidating the mechanism for rupture of the sternal head during bench press.

Schepsis et al¹⁵ reported 13 cases of operative treatment of pectoralis major ruptures. As with the current study, all patients were young men, and the majority of injuries were due to weight lifting. The authors used a technique with a Kessler grasping stitch in the tendon to repair the tendon into a 5-cm trough with the sutures tied over a bone bridge. Some operative cases were acute and some were chronic. These were compared with a nonoperative arm. Schepsis et al¹⁵ developed their own survey to rate the outcome of pectoralis major muscle by incorporating domains of pain, ROM, subjective strength, cosmesis, and overall satisfaction. They also introduced the idea of measuring strength pre- and postoperatively by comparing the patient’s stated bench press maximums.¹⁵ The current authors found this to be helpful because the majority of these patients are serious about weight lifting and can recall their maximum bench press to the pound. This provides an objective measure of preinjury strength that would otherwise not be available. Similar to the current operative results in the 90th percentile, Schepsis et al’s¹⁵ results showed a 96% Schepsis scale rating for acute operative treatment: 93% in the chronic group and 51% in the nonoperative group. Isokinetic adduction strength testing again showed a strength deficit (71%) relative to the uninjured side with nonoperative treatment, but none existed with operative treatment (102%).¹⁵

The superior results of operative compared with nonoperative treatment are evident in meta-analyses grouping multiple single case reports.^1,5,15,25,26 In a prospective, randomized trial of operative vs nonoperative treatment for pectoralis major muscle in athletes, operative treatment used suture anchors and screws with interference washers.⁵ Each study group comprised 10 patients, and the results showed the superiority of operative treatment, with 70% excellent outcomes in the operative group and no excellent outcomes in the nonoperative group. In addition, isokinetic testing to compare the peak torque in the uninjured pectoralis major muscle showed a 14% deficit in the operative group and a 41% deficit in the nonoperative group.⁵

The retrospective nature of the current study was a limitation. However, given the rarity of this injury and the fact that this is the largest single-surgeon series the authors are aware of, this study may be helpful to practitioners because some biases inherent in meta-analyses with data pooled from multiple surgeons across multiple centers are eliminated. In addition, the rate of follow-up was 79%. This could introduce bias but is likely the result of a young, geographically mobile patient population. However, with a mean 2.8-year follow-up, no long-term data are available. It is possible the patients’ clinical condition may improve or deteriorate over longer follow-up, but all patients had reached a plateau of recovery before discharge.

Although studies have established that operative treatment leads to measurable, consistent improvements in strength and cosmetic deformity,^1,5,15,25 functional outcome after operative repair has not been well studied. The current authors had access to a large cohort of patients with this rare injury. Their results showed that functional outcome across a variety of validated measures is fairly predictable after operative repair of pectoralis major muscle ruptures. These data can be used by practicing surgeons to counsel patients.

Conclusion

Pectoralis major injuries are rare, and various treatment techniques are proposed in individual case reports. The current study reports fairly predictable results using a repair with bone tunnels and heavy suture. Validated outcome scores are provided to assist in counseling patients and as a baseline for future research. This operative intervention is recommended for any patient who desires full upper-extremity strength for work or sport.