Dr. Anthony A. Schepsis

Coastal Orthopedics
Beverly, MA
Professor of Orthopedic Surgery
Boston University School of Medicine

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Pec Major publication

Rupture of the Pectoralis Major Muscle

Outcome After Repair of Acute and Chronic Injuries*

Anthony A. Schepsis,† MD, Michael W. Grafe, MD, Hugh P. Jones, MB, and

Mark J. Lemos, MD

From the Department of Orthopaedic Surgery, Boston Medical Center,

Boston, Massachusetts

ABSTRACT

We retrospectively studied 17 cases of distal pectoralis

major muscle rupture to compare the results of repair

in acute and chronic injuries and to compare operative

and nonoperative treatment. Thirteen patients underwent

surgery (six acute injuries [less than 2 weeks after

injury] and seven chronic injuries) and four had nonoperative

management. The mean age of the patients

at injury was 29, and 10 of the 17 injuries were the

result of weight lifting. Follow-up ranged from 18

months to 6 years (mean, 28 months). All patients

subjectively rated strength, pain, motion, function with

strenuous sporting activities, cosmesis, and overall

satisfaction. Objectively, patients were examined for

range of motion, deformity, atrophy, and strength. Isokinetic

strength testing was performed in eight patients:

six treated operatively (three acute and three chronic)

and two treated nonoperatively. Overall subjective ratings

were 96% in the acute group, 93% in the chronic

group, and only 51% in the nonoperative group. Isokinetic

testing showed that patients operated on for

acute injuries had the highest adduction strength

(102% of the opposite side) compared with patients

with chronic injuries (94%) or nonoperative treatment

(71%). There were no statistically significant subjective

or objective differences in outcome between the patients

treated operatively for acute or chronic injuries,

but these patients fared significantly better than patients

treated nonoperatively.

Rupture of the pectoralis major muscle was regarded as

uncommon until the late 1970s. However, in the last 20

years there has been a significant increase in the number

of reported ruptures of the pectoralis major muscle. This

injury is almost exclusively associated with participation

in athletic endeavors, in particular the bench press exercise.

1, 21, 29, 46, 47, 55, 56, 60,68 Many authors have disagreed

about how this injury should be treated.1–14,16–30,32–69

Some authors have claimed that this injury does not need

to be treated surgically.11, 17, 32, 50, 58,68 Others have argued

that surgical repair must be done in the acute stage

of injury because results in chronic injuries are

inferior.1–3,7, 12, 20, 41,55

We retrospectively reviewed all patients with pectoralis

major muscle ruptures treated by one surgeon (AAS). We

compared the treatment choices of operative versus nonoperative

and compared outcome after operative repair of

acute and chronic injuries. We evaluated treatment choices

by using a subjective questionnaire, objective examination,

and measurements on a strength resistance machine.

MATERIALS AND METHODS

Twenty-three patients with pectoralis major muscle ruptures

were seen by the senior author between 1983 and

1996. Three patients were lost to follow-up and three had

only partial muscle tears and were not included in the

study. Seventeen patients with complete or nearly complete

distal ruptures were seen between 1985 and 1996

and were available for follow-up. All of the patients were

men and their ages at injury ranged from 19 to 37 years,

with a mean age of 29. All patients were athletic, and all

reported some type of trauma or participation in an athletic

event as the cause of injury. The mechanisms of

injury are listed in Table 1. Ten of the 17 injuries were the

result of weight lifting and, specifically, eight of these

cases involved the bench press. All patients described a

traumatic injury involving the anterior chest wall or

shoulder area. The dominant arm was involved in 5 patients

and the nondominant arm was involved in 12 patients.

Eight patients had acute injuries, and six of these

elected to have surgery, which was performed within 2

weeks of injury (average, 9 days). Nine patients were seen

with chronic injuries, and seven of these patients under-

* Presented at the 24th annual meeting of the AOSSM, Vancouver, British

Columbia, Canada, July 1998.

† Address correspondence and reprint requests to Anthony A. Schepsis,

MD, Department of Orthopaedic Surgery, Boston University Medical Center

Hospital, Doctors Building, Suite 808, 720 Harrison Avenue, Boston, MA

02118.

No author or related institution has received any financial benefit from

research in this study.

0363-5465/100/2828-0009$02.00/0

THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 28, No. 1

© 2000 American Orthopaedic Society for Sports Medicine

9

went operative repair between 10 weeks and 14 months

after injury (average, 7 months).

In patients with acute tears, physical examination revealed

swelling and ecchymosis of the anterior axilla,

chest wall, and upper arm area. Some objective weakness

of adduction or internal rotation was usually evident. Deformity

with medial retraction of the muscle belly was not

always evident in patients with acute injuries, particularly

in well-muscled patients. In patients with injuries

older than 2 weeks, abduction of the arm created a

“webbed” appearance at the anterior axilla as the torn

distal portion of the muscle retracted into the chest wall;

this was less apparent with the arm at the side. With

contraction of the pectoralis muscle, the deformity was

made obvious as the muscle retracted medially and sometimes

pulled the adherent anterior axillary subcutis medially

(Fig. 1). A presumptive diagnosis of distal rupture of

the pectoralis muscle was made and, in some cases, was

confirmed by MRI.

Surgical Technique

The patient was placed in a beach-chair position with the

affected arm and chest wall draped free. An anterior axillary

approach was made extending distally along the

proximal humerus. The deltopectoral interval was easily

found and the deltoid muscle was retracted laterally. In

cases of chronic injuries, the torn muscle had formed adhesions

to the skin, subcutaneous tissue, and sometimes

the conjoint tendon. Fibrous tissue often filled the gap,

giving the appearance of an intact tendon. The muscle

belly could be easily freed from the anterior chest wall

medially and mobilized on all sides, allowing it to be

pulled back laterally to its anatomic attachment.

A 5-cm trough was made in the proximal humerus just

lateral to the biceps tendon at the anatomic insertion of

the pectoralis major muscle. In most cases the rupture

was complete, occurring either directly at the insertion on

the humerus or at the musculotendinous junction, leaving

a 0.5- to 2-cm cuff of tissue. In these latter cases, the

trough was made just medial to this remaining tendinous

attachment, which was oversewn into the muscle after the

repair was completed. Our repair involved two sets of

horizontal and vertical modified Kessler sutures using No.

5 nonabsorbable sutures as shown in Figure 2. We prefer

to use No. 5 suture in such a configuration to adequately

grasp the muscle fascia and also because the repair is

often placed under considerable tension initially, particularly

in the cases of chronic injury. Four drill holes were

made 1 cm lateral to the trough for passage and tying of

the sutures (Figs. 3 and 4). In several cases, the proximalanterior

insertion was still intact, but the distal twothirds

was ruptured in all cases.

Postoperatively, the arm was immobilized in a sling and

swathe for 4 weeks and then range of motion exercises

were begun except for abduction and external rotation

movements, which were deferred for 6 weeks. Isometric

exercises were allowed at 2 months, and light resistive

exercises were started at 3 months. Heavy resistive

strengthening was allowed at 4 months, and contact

sports were allowed at 5 to 6 months.

Follow-up ranged from 18 months to 6 years, with a

mean of 28 months. Each patient was evaluated with a

subjective questionnaire and an objective examination.

The subjective questionnaire consisted of 23 questions, 17

of which used visual analog scales (Fig. 5). The visual

Figure 1. Medial retraction of the pectoralis muscle belly

with active contraction is quite evident in this patient with a

chronic rupture.

Figure 2. Configuration of the two sets of horizontal and

vertical modified Kessler sutures used to capture the whole

muscle and its surrounding fascia.

TABLE 1

Mechanism of Injury for Pectoralis Major Rupture Patients

Mechanism of Injury Number of

patients

Weight lifting 10

Bench press (8)

Dumbell flies (1)

Incline bench press (1)

Football 2

Hockey 1

Car door flew back 1

Large weight fell on shoulder 1

Altercation 1

Fall from height 1

10 Schepsis et al. American Journal of Sports Medicine

analog scale questions were based on the style introduced

by Labib et al.31 and analyzed by Flandry et al.15 These

questions assessed function with daily activities, strenuous

activities, and sports, as well as strength, pain, range

of motion, cosmesis, and overall satisfaction.

The operating surgeon performed objective examinations

on all patients. Patients were carefully assessed for

strength, with special attention to strength in adduction

and internal rotation. Range of motion and cosmesis were

also assessed.

We were able to perform isokinetic testing in eight patients:

six treated operatively (three acute and three

chronic) and two treated nonoperatively. Testing was performed

with the patient supine on the bench with the arm

elevated 90°. The plane of motion tested was straight

horizontal adduction performed at 60, 180, and 240 deg/

sec. Peak torque production, work per repetition, and fatigue

index were measured as a percentage of the values

obtained for the uninjured side. Internal rotation testing

was not performed uniformly and in all cases, and therefore

results were not included in the data.

RESULTS

All diagnoses of distal rupture of the pectoralis major

muscle were confirmed at the time of surgery. All ruptures

involved the distal portion of the pectoralis major tendon,

either at the humeral insertion or at the musculotendinous

junction. All ruptures involved the inferior portion of

the muscle and the sternocostal head. In several cases the

tendon to the clavicular head was preserved.

Subjective Results

Subjective results were determined by patient questionnaires

as measured on a 10-cm visual analog scale and

given a percentage value (Fig. 5). The patients treated

operatively for acute ruptures (acute group) reported that

their strength had returned to 85% to 100% of preinjury

levels, with an average of 94%. The patients treated operatively

for chronic ruptures (chronic group) reported that

their strength had returned to 80% to 100% of preinjury

levels, with an average of 90%. The patients treated nonoperatively

(nonoperative group) reported that their

strength had returned to 55% to 85% of preinjury levels,

with an average of 67.5%.

The acute group had an average level of pain relief or

“comfort level” of 95%, with a range of 85% to 100%. The

chronic group had an average level of pain relief of 89%,

with a range from 75% to 100%. The nonoperative group

had an average level of pain relief of 65%, with a range of

50% to 80%.

In terms of cosmesis, the acute group reported average

satisfaction of 84%, with a range of 75% to 95%. The

chronic group reported an average satisfaction with cosmesis

of 84%, with a range of 70% to 95%. The nonoperative

group reported an average satisfaction with cosmesis

of 56%, with a range of 40% to 70%.

Subjective overall satisfaction with treatment outcome

was also evaluated. The acute group reported that they

were 90% to 100% satisfied with their treatment outcome,

Figure 4. The final repair.

Figure 3. The sequence of suture passage through the four

drill holes.

Vol. 28, No. 1, 2000 Pectoralis Major Muscle Rupture 11

with an average of 96%. The chronic group reported that

they were 85% to 100% satisfied with their treatment

outcome, with an average of 93%. The nonoperative group

reported that they were 40% to 70% satisfied with their

treatment outcome, with an average of 51%.

Patients reported that their range of motion had returned

to preinjury levels in all directions of motion. Thus,

all three groups reported that they had regained full range

of motion. The average results of each area of the questionnaire

are listed in Table 2.

Objective Results

An objective examination of each patient was performed

after surgery. When the patients were examined, all demonstrated

full range of motion of the affected shoulder

girdle. When the patients were manually tested for

strength by the examiner, all patients with operative repair

demonstrated 5/5 strength on adduction (horizontal

and vertical) and internal rotation in the affected shoulder.

Three of the four patients in the nonoperative group

demonstrated 4/5 strength for horizontal adduction, and

one had 5/5 strength for horizontal adduction. Two patients

demonstrated 4/5 strength for internal rotation, and

Figure 5. The subjective questionnaire using a visual analog scale employed in this study.

TABLE 2

Average Answers from Subjective Questionnaire

(Percentages based on 100%)

Question

Acute

ruptures

(N 5 6)

Chronic

ruptures

(N 5 7)

Nonoperative

therapy

(N 5 4)

Pain relief 95 89 65

Range of motion 100 100 100

Return of strength 94 90 67.5

Satisfaction with cosmesis 84 84 56

Satisfaction with treatment 96 93 51

12 Schepsis et al. American Journal of Sports Medicine

the other two had 5/5 strength for internal rotation. In

terms of cosmesis, one patient in the chronic group still

had some mild deformity with retraction of the distal 25%

of the muscle. All four of the nonoperatively treated patients

had obvious deformity.

Isokinetic Testing

Isokinetic strength testing was performed in eight patients,

three from the acute group, three from the chronic

group, and two from the nonoperative group. The patients

were tested at an average of 26.9 months after surgery or

injury, with a range of 18 to 42 months. Results of the

peak torque testing demonstrated that patients in the

acute and chronic groups were able to achieve similar

peak torque levels. Furthermore, peak torque values in

these patients more closely matched those of the noninjured

side than did those in the nonoperative group.

These results were reproduced at all three angular velocities:

60, 180, and 240 deg/sec. Patients in the acute and

chronic groups had peak torques between 74% and 110%

for the three velocities measured. Patients in the nonoperative

group averaged between 63% and 75% (Table 3).

When work per repetition was evaluated for each treatment

group, the acute and chronic groups again obtained

similar results, with values between 82% and 108% obtained

for each angular velocity level evaluated. These

results were also closer to those of the noninjured side

when compared with those of the nonoperative group. The

results of the nonoperative group were between 58% and

82% (Table 4).

The fatigue index results revealed that three of the

operatively treated patients (two acute and one chronic)

were able to consistently achieve results that were between

102% and 121% of the fatigue index of the noninjured

side. When the acute and chronic groups were evaluated

together, their results ranged from 86% to 121%.

The results from the two nonoperatively treated patients

ranged between 52% and 78% (Table 5).

Statistical Analysis

Subjective results from the questionnaire and isokinetic

testing were statistically analyzed using the Student’s

t-test with a two-tailed distribution and unequal variance

with the threshold of significance set at P , 0.05. There

were no significant differences in subjective pain scores

(P 5 0.288), strength scores (P 5 0.301), and satisfaction

(P 5 0.981) in the acute and chronic groups.

Conversely, there were statistically significant differences

in all categories of pain (P 5 0.013), strength (P 5

0.037), satisfaction (P 5 0.004), and cosmesis (P 5 0.013)

between patients treated operatively and those treated

nonoperatively. Similar findings were apparent with comparison

of the chronic and nonoperative groups with re-

TABLE 3

Results of Peak Torque from Isokinetic Testinga

Torque

(deg/sec)

Acute Chronic Nonoperative

1 2 3 Average 1 2 3 Average 1 2 Average

60 92 88 86 88.7 74 82 84 80 62 64 63

180 100 98 110 102.7 100 90 88 92.7 72 70 71

240 100 103 98 100.3 103 92 92 95.7 74 76 75

a Results are a percentage of the value obtained from the noninjured side. Individual and average values for three patients in the acute

group, three in the chronic group, and two in the nonoperative group.

TABLE 4

Results of Work/Repetition with Three Different Torquesa

Torque

(deg/sec)

Acute Chronic Nonoperative

1 2 3 Average 1 2 3 Average 1 2 Average

60 96 90 90 92 94 84 82 86.7 70 58 64

180 92 104 98 98 105 90 88 94.3 74 78 76

240 94 108 104 102 103 92 90 95 78 82 80

a Results are a percentage of the value obtained from the noninjured side. Individual and average values for three patients in the acute

group, three in the chronic group, and two in the nonoperative group.

TABLE 5

Results of Fatigue Index at Three Different Torquesa

Torque

(deg/sec)

Acute Chronic Nonoperative

1 2 3 Average 1 2 3 Average 1 2 Average

60 88 110 110 102.7 121 94 90 101.7 60 52 56

180 92 102 120 104.7 111 90 90 97 70 72 71

240 96 108 104 102.7 104 86 92 94 78 78 78

a Results are a percentage of the value obtained from the noninjured side. Individual and average values for three patients in the acute

group, three in the chronic group, and two in the nonoperative group.

Vol. 28, No. 1, 2000 Pectoralis Major Muscle Rupture 13

gard to pain (P 5 0.0183), satisfaction (P 5 0.0046), and

cosmesis (P 5 0.011). Subjective strength was not significantly

different (P 5 0.066) between the two groups;

however, the P value was small. Full subjective range of

motion was obtained in all groups.

Because of the small sample numbers, analysis of objective

data from isokinetic testing was performed on pooled

data. Statistically significant differences were found between

the acute group and the nonoperative group in all

parameters (peak torque, P 5 0.0001; work per repetition,

P 5 0.0003; and fatigue index, P 5 0.0001). Similar significant

differences were found between the chronic group

and the nonoperative group (P 5 0.0001, P 5 0.0015, and

P 5 0.0003, respectively). There were no significant differences

between the acute and chronic groups (peak

torque, P 5 0.08; work per repetition, P 5 0.137; fatigue

index, P 5 0.281).

DISCUSSION

Rupture of the pectoralis major muscle is an entity that

has been discussed for more than 170 years. Within

the published literature more than 141 cases have been

cited.1–14,16–19,21–30,32–69 Eighty-nine cases have been reported

in the last 20 years,1, 3,9–14,21,23,25,26,29,30,35,36,39,

43,46–48,55,56,58–60,62,63,65,67–69 and these cases account for

approximately 63% of the total cases reported in the literature.

As one looks back on the literature, it is interesting

to note how the activities associated with this injury

have changed. Initially, it was reported that most patients

were injured from falls or direct blows to the anterior

chest wall.4, 24, 32, 33, 37, 41, 49, 52, 54, 57,61 However, within the

last 20 years, this injury has increasingly been related to

the participation in athletic endeavors.1, 3, 10, 12, 14, 21, 23, 26,

29, 35, 36, 39, 43, 46, 47, 55, 56, 59, 62, 65, 67,68 Forty-six percent (41

of 89) of reported patients with a rupture of pectoralis

major muscle since 1978 were involved in some type

of “weight lifting activity.”1, 12, 14, 21, 23, 29, 35, 39, 46, 47, 55, 56,

59, 67,68 The single most common cause of rupture of the

pectoralis major muscle has been the bench press exercise,

with 29% (26 of 89) of the reported cases citing it as the

cause.1, 21, 23, 29, 35, 39, 46, 47, 55, 56, 59,68 Our study agrees with

this trend, with 47% of our subjects being injured while

bench pressing. Even though 28 different activities have

been associated with the rupture of the pectoralis major

muscle, the mechanism of injury has been similar in most

cases: the shoulder is in full extension and external rotation

while trying to resist a force directed in an anteriorto-

posterior direction.67 It may be possible that although

the majority of this force is directed in an anterior-toposterior

direction, smaller components of the force may

be acting on multiple axes at the time of injury. This

postulate has resulted from the observation that many

injuries occur during the bench press when the athlete

attempts to prevent the weights from “going over.”47,55

We attempted to address two fundamental questions:

First, is it necessary to repair a distal rupture of the

pectoralis major muscle, and, second, is there a difference

between repairing this rupture in the acute stage or in the

chronic stage? The results from this study clearly demonstrate

that repair of a ruptured pectoralis major muscle is

advantageous for the patient. Patients who had had their

pectoralis major muscle repaired had fewer problems with

pain, had subjective and objective improvement in

strength, and were happier with their outcome when compared

with patients who had not had their pectoralis

major muscle repaired. These results are in agreement

with the literature, which shows that the highest percentage

of excellent results occurs with surgical repair.

We do agree with Tietjen,63 who has chosen to classify

certain types of muscle ruptures in relationship to modality

of therapy, but our classification system is simpler.

Those patients who have partial ruptures of the muscle

belly probably do not need surgical repair and can be

treated nonoperatively in most cases. However, in our

experience, and in our series, most ruptures are distal, at

the musculotendinous junction or at the humeral insertion,

and are usually complete or involve at least the distal

two-thirds of the attachment. These ruptures should be

repaired in most cases.

We addressed the second question by demonstrating

that there was no improvement in outcome between ruptures

repaired in the acute stage and those repaired in the

chronic stage. This is also in agreement with previous

papers that have shown that surgical repair of a chronic

rupture (up to 5 years)29 will result in good or excellent

results.29, 57, 65,67 Thus, our study has shown that it is

advantageous to repair a torn pectoralis major muscle,

and there seems to be no difference if the rupture is

repaired immediately or several months after the injury.

It should be noted, however, that this is a retrospective

study, and it was difficult to ascertain whether the time to

full recovery was different in the two patient groups.

The timing of this article is important because the incidence

of this injury is increasing. This increase in incidence

is likely due to an increase in the population that

uses weight lifting as a form of exercise, as well as better

recognition by physicians. Until now, this injury has been

reported only in men. There have been no reports in the

literature of a woman suffering this injury. It is also

interesting to note that several patients in our study admitted

to anabolic steroid use.

In 1992, Wolfe et al.67 demonstrated with cadaveric

dissection and histologic examination that the weakest

portion of the pectoralis major muscle was at the inferior

portion of the sternocostal head because the muscle fiber

length there was inadequate for the excessive eccentric

stresses placed on it. Therefore, it makes sense that these

distal ruptures always involve the inferior portion of the

muscle. In those cases where the superior fibers are still in

continuity, the examiner may be given the false impression

that the whole attachment is still in continuity. The

fibers of the smaller, less functionally important, clavicular

head attach anteriorly to the more important manubrial

portion of the sternal head, which, because of the

normal 90° twist of the fibers of insertion, attaches posteriorly

as well as inferiorly. When the anterior lamina is

intact, it may appear that the majority or all of the attachment

is still in continuity when, in fact, the bulk and most

important functional portion of the muscle is not.

14 Schepsis et al. American Journal of Sports Medicine

In conclusion, although our sample numbers were

small, analysis of our results suggests that all patients

treated operatively fared significantly better subjectively

and objectively than those treated nonoperatively. Furthermore,

delayed repair does not significantly compromise

the subjective or objective results of surgery.

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Vol. 28, No. 1, 2000 Pectoralis Major Muscle Rupture 15

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