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AbstractPectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50% of these injuries occur in athletes, classically in weight-lifters during the ‘bench press’ maneuver.

We wish to emphasize the importance of accurate clinical diagnosis, appropriate investigations, early surgical repair and an accelerated rehabilitation protocol for the distal rupture of the pectoralis major muscle as this allows complete functional recovery and restoration of full strength of the muscle, which is essential for the active athle

Fig.1

Rupture of the pectoralis major is a rare injury that was first described by Patissier in 1822 in Paris

AnatomyThe pectoralis major muscle is a powerful adductor, internal rotator and flexor of the shoulder

It arises as a broad sheet with two heads of origin: the upper clavicular head and the lower sterno-costal headand insert on the lateral lip of the bicepital groove over an area of 5 cm

. Although most cases are undoubtedly partial, most reported injuries have been complete ruptures predominantly affecting the distal musculo-tendinous junction or insertion of the tendon

MechanismThe mechanism of injury of a pectoralis major rupture is either due to direct injury or indirect trauma due to extreme muscle tension or a combination of both.. Most injuries occur as the weight is lowered down to the chest.

There also appears to be a correlation between the mechanism of injury and the site of rupture. Direct trauma causes tears of the muscle belly, whereas excessive tension or indirect trauma causes avulsion of the humeral insertion or disruption at the musculo-tendinous junction.

Diagnosis of injury

The patients presented with the classic history of a tearing sensation in the axilla and on examination revealed local tenderness, bruising and loss of contour of the pectoralis major muscle (Fig. 1). Significant weakness of adduction and internal rotation of the arm were also noted.

Plain radiology generally showed a loss of the pectoralis major shadow and loss of the normal anterior axillary fold.

MRI; magnetic resonance imaging, which confirms the site and extent of the rupture precisely

Fig.2

Axial oblique magnetic resonance image showing a complete rupture of the pectoralis major tendon

Management

). The tear was approached via a delto-pectoral crease-line incision. The underlying hematoma was evacuated and the torn tendon carefully identified (Fig. 3). The lateral lip of the bicipital groove was exposed and cleared of soft tissue. The distal end of the tendon was reattached using ‘Twinfix’ anchors. The repair was tested intraoperatively and the ‘safe arc’ of the external rotation was determined and documented. All patients were immobilized postoperatively in a shoulder immobilizer for 2 weeks.

Fig.   3

Intraoperative photograph demonstrating complete distal rupture of the pectoralis major

RehabilitationThe accelerated rehabilitation protocol involved: (1) elbow exercises from day 1. (2) Isometric rotator cuff and pectoralis major strengthening was permitted with the shoulder in neutral rotation at 2 weeks along with passive external rotation within the documented ‘safe arc’. (3) Progressive physiotherapy included range of motion, strengthening and endurance exercises. Regular follow-ups

Discussion

Rupture of the pectoralis major muscle can occur from infancy to old age, but sports-related injuries tend to occur from the 2nd to the 4th decades. The majority of cases occurs in athletes involved in weight-lifting, wrestling,

football, rugby and wind surfing. By far the most common method of injury is the ‘bench press’ as was noted in the cases in our study.

The cause of rupture of the pectoralis major is multifactorial. Kannus and Jozsa.in 1991 stated that for a tendon to fail, it must have a focal area of degeneration. We postulate that although asymptomatic prior to the injury, these patients have some degeneration of their tendons resulting from the repetitive stress involved with regular weight training, thus contributing to the injury.Distal ruptures of the pectoralis major are usually complete . MR imaging has been shown to be valuable in determining the extent and site of tendon injuries]. The most important images appear to be the axial oblique and coronal views.

Conservatively treated individuals demonstrated a marked deficit in the peak torque and work/repetition using the Cybex isokinetic testing .Zeman et al. have reported that four out of five injured athletes who did not undergo surgical repair failed to return to their previous level of athletic functional ability .Aarimaa et al. in a large series of 33 anatomically repaired cases of rupture of the pectoralis major have reported the best outcomes in ruptures repaired acutely, compared to those who underwent a delayed repair .In an extensive meta-analysis of Bak et al., surgical treatment had significantly better outcomes compared with conservative or delayed repair .We agree with other authors that acute surgical repair ensures good to excellent results in up to 90% of the cases as compared to 70% when treated non-operatively. Although both methods restore a full range of motion and pain relief, surgery is essential for restoration of normal strength and greater recovery of peak torques and work performed, especially for the athlete.The technique for surgical repair varies from suturing the tendon to the periosteum.to the remaining tendon or clavi-pectoral fascia .Osseous fixation can be achieved through drill holes barbed and anchors .

Our study;

5 cases – 2 soldier -2 wieght lifter-I business

All was athletics

Time of presentation to clinic 2-4 weeks

Age 28-42

All were males and dominat side.

3 was right and 2 left