A systematic review and comprehensive classification of pectoralis major tears

doi:10.1016/j.jse.2011.04.035

Journal of Shoulder and Elbow Surgery

Volume 21, Issue 3, March 2012, Pages 412-422

https://doi.org/10.1016/j.jse.2011.04.035 Get rights and content

Background

Reported descriptions of pectoralis major (PM) injury are often inconsistent with the actual musculotendinous morphology. The literature lacks an injury classification system that is consistently applied and accurately reflects surgically relevant anatomic injury patterns, making meaningful comparison of treatment techniques and outcomes difficult.

Materials and methods

Published cases of PM injury between 1822 and 2010 were analyzed to identify incidence and injury patterns and the extent to which these injuries fit into a classification category. Recent work outlining the 3-dimensional anatomy of the PM muscle and tendon, as well as biomechanical studies of PM muscle segments, were reviewed to identify the aspects of musculotendinous anatomy that are clinically and surgically relevant to injury classification.

Results

We identified 365 cases of PM injury, with 75% occurring in the last 20 years; of these, 83% were a result of indirect trauma, with 48% occurring during weight-training activities. Injury patterns were not classified in any consistent way in timing, location, or tear extent, particularly with regard to affected muscle segments contributing to the PM’s bilaminar tendon.

Conclusions

A contemporary injury classification system is proposed that includes (1) injury timing (acute vs chronic), (2) injury location (at the muscle origin or muscle belly, at or between the musculotendinous junction and the tendinous insertion, or bony avulsion), and (3) standardized terminology addressing tear extent (anterior-to-posterior thickness and complete vs incomplete width) to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research.

Section snippets

Material and methods

To identify the incidence and injury patterns of the PM to date, the available literature was reviewed by accessing 3 scientific databases: Medline, Excerpta Medica Database (EMBASE), and Allied and Complimentary Medicine Database (AMED). The final search was completed in October 2010. The search was performed by combining the term pectoralis major with each of the following terms: rupture, injuries, tears, surgical repair, operative technique, partial tear, partial rupture, complete tear,

Results

The final literature review produced 67 articles that met the inclusion criteria.^† This resulted in 365 reported cases of PM injury between 1822 and 2010. Only 86 cases (24%) were reported between 1822 and 1990. These were

Anatomy

The broad, multipennate PM muscle is primarily responsible for adduction, internal rotation, and flexion of the humerus, as well as dynamic stabilization of the shoulder.2, 49, 62 It is a significant contributor to the aesthetic appearance of the chest wall and the contour of the anterior axillary fold. We identified 4 cadaveric studies before 2009 that examined the PM anatomy in detail.6, 43, 44, 77 A comparison of the authors’ findings revealed inconsistencies in the number of muscle segments

Conclusions

To date, there has been little consensus on the normal musculotendinous architecture nor has there been a comprehensive classification system with consistent terminology that accurately describes the timing, location, and extent of tears of the PM muscle and tendon. A contemporary, comprehensive, and standardized classification system for PM injuries has been proposed that takes into account injury timing, location, and extent based on recent anatomic studies and a systematic review of injuries

Acknowledgment

The authors thank Valerie Oxorn for her illustrative contributions to this article.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Optimizing pectoralis major tendon repair: a modified knotless suture anchor technique using high-strength suture and tape
2024, JSES Reviews, Reports, and Techniques
Rupture of the pectoralis major (PM) tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined.
We present a modified surgical technique utilizing knotless suture anchors for PM tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture.
The utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques.
Our modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful PM tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care.
Imaging of musculotendinous lesions of the pectoralis major in athletes: Interpretation bases
2024, Journal d'imagerie diagnostique et interventionnelle
L’exploration du muscle grand pectoral et de son tendon comporte des particularités à connaître aux niveaux anatomique et technique afin de détecter et de décrire précisément les lésions. Le radiologue possède un rôle central pour réaliser un diagnostic précoce et un bilan lésionnel complet.
Le muscle grand pectoral est composé d’une portion claviculaire et d’une portion sternale qui est prédominante. Le tendon conjoint distal s’insère sur le bord latéral de la gouttière intertubérositaire de l’humérus. Les lésions touchent principalement la jonction myotendineuse et le tendon distal chez l’homme de 20 à 40 ans lors d’efforts de contraction excentrique en abduction et rotation externe du bras. Le bilan en imagerie se fait dans un premier temps par échographie pour dépister précocement les lésions et orienter le patient vers un spécialiste. Celle-ci permet de visualiser la lésion sous la forme d’une infiltration liquidienne et/ou d’un hématome en regard du site de rupture. L’IRM doit être réalisée dès qu’une prise en charge chirurgicale est envisagée. Elle permet de préciser la topographie de la lésion sous la forme d’une plage œdémateuse en hypersignal T2 ou d’un hématome en regard du site de rupture, ainsi que la localisation et l’aspect du moignon tendineux. La prise en charge est volontiers chirurgicale pour les lésions de la jonction myotendineuse ou du tendon distal chez le patient jeune et actif. Son efficacité est conditionnée par la rapidité de la prise en charge.
Le diagnostic et la caractérisation des lésions du grand pectoral reposent principalement sur l’IRM avec un protocole complet permettant de localiser la zone de rupture, caractériser la lésion comme complète ou incomplète et orienter la prise en charge thérapeutique.
Exploring the pectoralis major muscle and its tendon involves several anatomical and technical specificities that need to be understood in order to detect and describe the lesions accurately. The radiologist has a key role to fulfil in making an early diagnosis and providing a complete lesion assessment.
The pectoralis major muscle is made up of a clavicular head and a predominant sternal head. The distal conjoint tendon inserts on the lateral margin of the inter-tuberosity groove of the humerus. Lesions mainly affect the myotendinous junction and the distal tendon, in men aged between 20 and 40, during eccentric contraction efforts in abduction and external rotation. Imaging is initially performed using ultrasound to detect lesions at an early stage and refer the patient to a specialist. This will reveal the lesion in the appearance of a hypoechoic patch and/or haematoma adjacent to the site of rupture. MRI should be carried out if surgery is being considered. This will identify the topography of the lesion in the form of an edematous T2 hypersignal area or a haematoma at the site of rupture, and specify the location and appearance of the tendon stump. Management is usually surgical for injuries involving the myotendinous junction or the distal tendon in young, active patients. Its effectiveness depends on the speed with which the treatment is carried out.
Diagnosis and characterization of pectoralis major lesions rely mainly on MRI, with a complete protocol for locating the zone of rupture, characterizing the lesion as complete or partial, and guiding therapeutic management.
Myotendinous junction tears of the pectoralis major are occurring more frequently and discrepancies exist between intraoperative and radiographic assessments
2023, JSES International
Pectoralis major (PM) tears have been shown to occur most frequently at the tendinous humeral insertion. However, no substantial updates on tear location have been published in 20 years or are based on relatively small sample sizes. The primary purpose of this study was to evaluate PM tear location based on magnetic resonance imaging (MRI). A secondary purpose was to evaluate agreement between MRI and intraoperative assessments of tear characteristics. We hypothesized that PM tears at the myotendinous junction (MTJ) occur at a higher rate than previously reported and that intraoperative and MRI assessments would demonstrate agreement in at least 80% of cases.
An observational study of consecutive patients evaluated for a PM tear at a single institution between 2010 and 2022 was conducted. Patient demographics as well as MRI and intraoperative assessments of tear location, extent of tear, and muscle head involvement were collected from the electronic medical record. Agreement was calculated by comparing radiographic and intraoperative assessments per variable and reported as percentages. Data and statistical analysis were performed with SPSS software with a significance level set to P < .05.
A total of 102 patients were included for analysis. Mean age was 35.8 ± 10.5 years and mean body mass index was 29.4 ± 4.8 kg/m². 60.4% of the study population had tears of the MTJ, 34.9% of the tendinous humeral insertion, and 4.7% within the muscle belly, as determined intraoperatively. Complete tears had significantly higher agreement between MRI and intraoperative assessments relative to partial tears (83.9% and 62.5%, respectively; P ≤ .01).
The majority of PM tears occurred at the MTJ. Preoperative MRI and intraoperative assessments agreed in 80% of cases, a value that was significantly higher for complete over partial tears. These findings demonstrate that tears of the MTJ are increasingly more common and support the use of MRI in preoperative planning for complete PM tears.
Reconstruction of Chronic, Retracted Pectoralis Major Tendon Tear With Achilles Tendon Allograft
2023, Arthroscopy Techniques
Rupture of pectoralis major tendon (PMT) is an uncommon injury, but its incidence has been increasing in the past 2 decades. Although open repair of the torn tendon is the preferred choice of treatment in acute and chronic cases, this often is not possible for chronic retracted tendon injuries. While several techniques have been described for PMT reconstruction, these allografts and autografts are often smaller and less thick than the native PMT. In this study, we describe the use of the Achilles tendon allograft with unicortical suture buttons for the reconstruction of a chronic and retracted PMT. Furthermore, the advantages and disadvantages of this technique are discussed.
Pectoralis Major Tendon Rupture While Bouldering
2023, Wilderness and Environmental Medicine
Citation Excerpt :
The tendon of the pectoralis major inserts on the humerus at the lateral lip of the bicipital groove.4 The pectoralis major is vital to adequate adduction, flexion, internal rotation of the humerus, and general dynamic stabilization of the shoulder.5 To enable power production through a range of muscle shortening velocities, the pectoralis major demonstrates considerable variation across muscle segment lengths.
Pectoralis major tendon ruptures are rare injuries. We present a case of a pectoralis major tendon rupture incurred while bouldering that required surgical repair. The diagnosis of pectoralis major tendon rupture relies predominantly on clinical examination. Among athletes, outcomes after surgical repair are superior to those after nonoperative therapy in most cases of complete tendon rupture. Although infrequent, pectoralis major tendon ruptures can occur while climbing, and early recognition and expedited surgical treatment are paramount to maximize functional recovery.
Non-uniform excitation of pectoralis major induced by changes in bench press inclination leads to uneven variations in the cross-sectional area measured by panoramic ultrasonography
2022, Journal of Electromyography and Kinesiology
This study combined surface electromyography with panoramic ultrasound imaging to investigate whether non-uniform excitation could lead to acute localized variations in cross-sectional area and muscle thickness of the clavicular and sternocostal heads of pectoralis major (PM). Bipolar surface electromyograms (EMGs) were acquired from both PM heads, while 13 men performed four sets of the flat and 45° inclined bench press exercises. Before and immediately after exercise, panoramic ultrasound images were collected transversely to the fibers. Normalized root mean square (RMS) amplitude and variations in the cross-sectional area and muscle thickness were calculated separately for each PM head. For all sets of the inclined bench press, the normalized RMS amplitude was greater for the clavicular head than the sternocostal head (P < 0.001), and the opposite was observed during the flat bench press (P < 0.001). Similarly, while greater increases in cross-sectional area were observed in the clavicular than in the sternocostal head after the inclined bench press (P < 0.001), greater increases were quantified in the sternocostal than in the clavicular head after the flat bench press exercise (P = 0.046). Therefore, our results suggest that the PM regional excitation induced by changes in bench press inclination leads to acute, uneven responses of muscle architecture following the exercise.

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: Institutional Review Board (IRB) approval was not required because this study was a systematic review of the literature.

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Review articleA systematic review and comprehensive classification of pectoralis major tears

Background

Materials and methods

Results

Conclusions

Section snippets

Material and methods

Results

Anatomy

Conclusions

Acknowledgment

Disclaimer

J Shoulder Elbow Surg

Am J Med

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Shoulder Elbow Surg

J Emerg Med

Injury

J Shoulder Elbow Surg

Oper Tech Sports Med

Injury

Injury

Rupture of the pectoralis major muscle

Am J Sports Med

Moment arms of the muscles crossing the anatomical shoulder

J Anat

Ruptured pectoralis major tendon, a case report on delayed repair with muscle advancement

Acta Orthop Scand

Delayed repair of a ruptured pectoralis major muscle: a case report

Am J Sports Med

The manner of insertion of the pectoralis major muscle in man

Anat Rec

Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg

Sports Traumatol Arthrosc

Rupture of the pectoralis major muscle, a case report

Acta Orthop Scand

Pectoralis major tendon ruptures: diagnosis and treatment

Tech Shoulder Elbow Surg

Pectoralis major rupture in elderly patients, a clinical study of 13 patients

Clin Orthop

Surgical repair of pectoralis major rupture in an athlete: case report of an unusual injury in a wrestler

Am J Sports Med

Traumatic rupture of the pectoralis major

Br Med J

Rupture of pectoralis major during parallel bar dips: case report and review

Med Sci Sports Exerc

Pectoralis major muscle and tendon tears: diagnosis and grading using magnetic resonance imaging

Skeletal Radiol

Traumatic abscess of pectoralis major

Arch Orthop Trauma Surg

Injuries of the pectoralis major muscle: evaluation with MR imaging

Radiology

Pectoralis major muscle rupture in athletes, a prospective study

Am J Sports Med

Pectoralis major rupture in athletes

Arch Orthop Traumat Surg

Injuries to the pectoralis major

Sports Med

Diagnosis and treatment of incomplete rotator cuff tears

Clin Orthop Relat Res

Three-dimensional study of pectoralis major muscle and tendon architecture

Clin Anat

A case of agenesis and a case of rupture of the pectoralis major muscle

Acta Orthop Scand

Pectoralis major tears: comparison of surgical and conservative treatment

Br J Sports Med

Seat belt trauma: pectoralis muscle rupture and delayed mesh repair

J Trauma

Rupture of the pectoralis major muscle, review of the literature and report of two cases

J Intl Coll Surg

Twelve cases of the pectoralis major muscle tendon rupture with surgical treatment – an average of 6.7 year follow-up

Chin Med J

Rupture of the pectoralis major muscle: surgical treatment in athletes

Intl Orthop

Rupture of the pectoralis major, report of 2 cases

Clin Orthop

Epidemiology of weight training-related injuries presenting to United States emergency departments, 1990 to 2007

Am J Sports Med

Review article
A systematic review and comprehensive classification of pectoralis major tears