Pectoralis Major Ruptures

Abstract

Ruptures of the pectoralis major tendon have traditionally been considered a rare injury, but there has been a rise in the number of reported cases over the last decade. The majority of cases occur in young adult males engaging in strenuous sporting activities such as weight training, and there is an association with the use of anabolic steroids. A thorough understanding of the mechanisms and presenting features with an early referral for specialist assessment and treatment can improve long-term outcomes. Early surgical treatment is the preferred management option in the majority of cases with non-operative management considered for late presentation, partial tears, muscle belly tears, and those occurring in the frail and low-demand subgroup of patients.

Q&A

• (1) Which groups of patients commonly sustain ruptures of the pectoralis major tendon?

  The injury most-commonly occurs in young muscular adult males between the age of 20 and 40. It has also been described in elderly frail patients.

• (2) How do ruptures of the pectoralis major tendon occur?

  In the young and high demand patient, it typically occurs when the shoulder is extended and eccentrically loaded as in the depth of the bench press manoeuvre, but it can occur in any sporting activity.

• (3) What are the examination findings?

  Key findings are the presence of bruising over the chest wall and upper arm; a medially retracted muscle belly; a “dropped nipple” sign and loss of the anterior axillary fold. These features are best appreciated by comparing to the contralateral side and can be accentuated by passively abducting the arm or by resisted adduction. Partial tears may not demonstrate all of these features, and likewise swelling in the acute setting may obscure some of the findings. It is therefore important to consider the history carefully and maintain a high index of suspicion.

• (4) What is the preferred method of treatment?

  Initial management involves rest in a sling with analgesia and cryotherapy. Definitive management in the majority of cases involves surgical repair, which is best undertaken within the first few weeks of the injury. However, surgery can still be considered in selected cases where the diagnosis has been delayed or even in longstanding chronic cases.

• (5) Who should manage this condition

  These are uncommon injuries and as such tend to be managed by surgeons with a specialist interest in sports injuries. Initial and early referral to the most appropriate clinician will result in timely management.