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gicmechanism of injury is excessive tension on a maximallycontracted pectoralis major muscle. Weightlifting, specifi-calusu

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The Journal of Emergency Medicine, Vol. 38, No. 2, pp. 196200, 2010Copyright 2010 Elsevier Inc.

Printed in the USA. All rights reservedly bench pressing, is a common cause. The diagnosis canally be made based on a patients history and physicalmination, but shortly after injury, the diagnosis may be

scured by severe pain and swelling. Magnetic resonanceaging is the imaging modality of choice when the diag-sis remains unclear, and can avoid surgical delays. Earlygnosis and treatment within 3 to 8 weeks after theury has the advantage of avoiding adhesions and mus-atrophy, and can prevent a delayed return to normalivities. Given the trend toward improved results with

Patients who develop a pectoralis major rupture char-acteristically present complaining of pain and weaknessof the involved shoulder and chest; they are often young,active individuals with a potentially disabling injury.Due to the rarity of this condition, it may be missed atinitial presentationor misdiagnosed as a sprainandmanaged non-surgically (4). It is imperative to promptlyidentify the condition, because early treatment maxi-mizes the functional outcome of what can be a debilitat-ing injury.

Although the condition is well described by orthope-dic surgeons, it has not been well reported in the Emer-gency Medicine literature. We report a case of rupture ofthe pectoralis major in a 31-year-old man who presented

he views expressed in this article are those of the authorsdo not reflect the official policy or position of the Depart-

nt of the Navy, Department of Defense, or the United Statesvernment.doi:10.1016/j.jem

Selected Topics:Sports Medicine

RUPTURE OF THE PECTORALIS MA

Kohei Hasegawa, MD* an

*United States Naval Hospital Okinawa, Okinawa, Japan and DOkinawa, Ok

Reprint Address: Kohei Hasegawa, MD, Harvard AffiliatedHospital/Massachusetts General Hospital, 75 Francis

AbstractBackground: Rupture of the pectoralis majorscle is a rare clinical entity that is becoming more com-n due to the increasing popularity of weightlifting andreational sports. Due to the rarity of this condition, ity be missed at initial presentation and inappropriatelyated, potentially leading to increased disability. Objec-es: This case highlights the mechanism of injury, clinicaltures, diagnosis, and treatment of rupture of the pecto-is major. Case Report: The patient was a 31-year-oldle bodybuilder who presented to the Emergency Depart-nt with acute pain and swelling in the left axilla afterforming a bench press with a 400-pound barbell. Thegnosis of pectoralis major rupture was suspected andfirmed by magnetic resonance imaging, and early sur-

al repair was performed. Conclusion: The most commonCEIVED: 14 October 2007; FINAL SUBMISSION RECEIVED: 17 DeceCEPTED: 27 January 2008

196.2008.01.025

: A CASE REPORT AND REVIEW

el M. Schofer, MD

ent of Emergency Medicine, United States Naval HospitalJapanency Medicine Residency, Brigham and Womenseville House 236-A, Boston, MA 02115, USA

ly surgical repair of complete rupture, it is importantraise awareness about pectoralis major muscle injuryong Emergency Physicians to prevent missed or de-ed diagnosis and repair. 2010 Elsevier Inc.

Keywordsrupture of pectoralis major; weightlifting;abolic steroid; magnetic resonance imaging; surgicalrapy

INTRODUCTION

though ruptures of the pectoralis major muscle wereviously considered uncommon, the incidence has been

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Rupture of the Pectoralis Major 197the Emergency Department (ED) after bench pressingivity.

CASE REPORT

31-year-old male bodybuilder was in a bench pressmpetition. While eccentrically loading his pectoralisscles on a bench press and lowering a 400-pound

rbell, he heard a rip and immediately experienced paind swelling in the left axilla. He was brought to the ED.s examination revealed obvious ecchymosis and painthe left axillary fold, as well as abnormal contour ofanterior axillary fold. His shoulder range of motion

s limited by pain. He was neurovascularly intact in thet upper extremity with full motor strength throughoutcept for weakness in shoulder adduction and internalation.Radiographs of the left shoulder revealed no fracture,location, or other bony abnormality. The followingy the patient was sent for a magnetic resonance imag-

(MRI) study to confirm the diagnosis.The diagnosis of a left pectoralis major rupture was

nfirmed with MRI of the chest (Figures 1, 2), whichealed the detachment of the pectoralis major tendonm its insertion on the humerus (white arrow), a he-toma (dark arrows), and defect in the mid to inferiorect of the pectoralis major muscle, and medial retrac-

n of musculotendinous fibers. The patient underwentt pectoralis tendon repair 8 days after the injury.At 4-month follow-up, the patient had full, painlessge of motion and had begun a weight-training regimen.

ure 1. Coronal magnetic resonance image of the chest.rk arrows highlight the edema and hematoma present intorpectoralis major.DISCUSSION

story and Epidemiology

e rupture of the pectoralis major muscle is a rare injuryt reported by Patissier in 1822 (2). Approximately 200es have been described in the literature since Patissier. Whereas most pectoralis major ruptures seen in theeteenth century were related to horse riding accidents,

er the past 30 years, more than three-fourths have beenntified and are associated with increasing participa-n in competitive sports and weightlifting (3,5). Thest common activity associated with pectoralis majorture has been weightlifting, with bench pressing beingmost common inciting exercise, followed by water-

ing, football, wrestling, parallel bar dips, ice hockey,d windsurfing (611).The age range of patients with this injury is 15 to 91

ars, but it remains most common in athletes aged 20 toyears (2,12,13). The injury has been reported almostlusively in healthy males, however, three studies were

ne that observe these injuries in the elderly, includingrsing home patients (12,14,15). Several injuries haveolved use of anabolic steroids (6,13,1518).

rtinent Anatomy

e pectoralis major muscle is a powerful adductor,ernal rotator, and flexor of the humerus. Although

etimes considered unnecessary for normal shoulderction, it is important for carrying out strenuous activ-s because it is a main source of power of the upper

ure 2. Axial T2-weighted magnetic resonance image ofchest. White arrow highlights the pectoralis major ten-

n, which has detached from the humerus and retracteddially. Dark arrow demonstrates local hematoma.so in competitive athletes (19,20). It also forms the

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198 K. Hasegawa and J. M. Schoferterior axillary fold and is important cosmetically todybuilders.The pectoralis major arises as a broad sheet of muscle

d is often described as having two heads (Figure 3).e superior half, which forms the clavicular head, orig-tes from the medial clavicle and the upper portion ofsternum. The inferior half, which makes up the ster-

l head, arises from the distal end of the sternum, theternal oblique fascia, and the cartilages of the first sixs. These fibers converge and rotate 90 onto each otherfore uniting to form the tendinous insertion on themerus, lateral to the bicipital groove.The innervation of the pectoralis major muscle is bymedial and lateral pectoral nerves. The main bloodply is the pectoral branch of the thoracoacromial

ery.

thophysiology

tients with a rupture of the pectoralis major usuallysent after an acute injury. The typical injury occursen the patient is lifting weights or receives a directw to the upper torso.The most common mechanism of injury is indirect

d is related to excessive tension on a maximally con-cted muscle. Weightlifting, specifically bench pressivity, is an example of this mechanism (5,21). Duringbench press, the arms are abducted and externally

ure 3. Illustration demonstrating the anatomy of the pec-alis major muscle (reprinted from Shoulderdoc.co.uk,h permission from Dr. Lennard Funk).ated, and the pectoralis major muscle is under maxi- mel tension while contracting during the lift (22). Wolfeal., in a cadaver study with an experimental set-upmicking a bench press, showed that the short, inferiorers have a mechanical disadvantage in the final portionthe eccentric phase of the lift, making them suscepti-to injury (18).

Direct trauma to the muscle sustained during wres-g, rugby, football, and other contact sports may alsoduce the injury (5,7,23,24). A seat belt injury causingectoralis major rupture has also been reported (25).Steroid use also may make tendons more susceptibleinjury (2,18). In association with vigorous strengthining, the intake of anabolic steroids may increasescle strength disproportionate to the strength of thedon, of the musculo-tendinous junction, and of theertional site, leaving them at greater risk for injury.

analysis of the effects of anabolic steroids on ratdons showed that anabolic steroids produced stifferdons that absorbed less energy and failed with lesserngation (26). Those effects seemed to be reversible oncontinuation of steroids (26).

agnosis

story and physical examination. Due to the rarity ofs condition, rupture of the pectoralis major may bessed at initial presentation or misdiagnosed as a spraind managed non-surgically. Hanna et al. reported that 6their 12 patients with unrepaired tears were misdiag-sed or had a delay in their diagnosis (4).Most patients recall the specific incident related to the

ctoralis muscle injury. They detail a history of andible snap or even the sensation of tearing in theirilla, accompanied by immediate pain and weaknessth adduction, flexion, and internal rotation (11,13,,2729). After the initial swelling and ecchymosisolves, examination of the anterior axillary fold revealsasymmetric abnormal contour. Abnormal bulging ofanterior chest wall indicates that the pectoralis has

racted medially (Figure 4). There can be a palpablefect in the axillary fold, depending on the site of theture.In the acute setting, however, clinical diagnosis can beficult because ecchymosis, swelling, and severe pain

obscure the exact location and extent of injury.nsequently, it may be very difficult to distinguishtween complete and partial ruptures.

aging. Initial work-up of these injuries should includein radiographs to exclude comorbid bony abnormali-s. Cases of pectoralis major rupture with accompany-

anterior glenohumeral dislocation and proximal hu-

rus fracture have been reported in the literature

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Rupture of the Pectoralis Major 199,30). Additionally, in isolated pectoralis tendon avul-ns, the avulsed fragment may be visualized on plains (9,13). The characteristic finding of a pectoralis

jor muscle rupture is soft tissue swelling and absencethe pectoralis major shadow, but this finding is verytle and difficult to detect (5,7,8,19).MRI is the optimal imaging technique to visualize

normal conditions of the pectoralis major myotendi-us unit (9,23,31,32). Miller et al. proposed that MRIthin hours of injury can confirm a diagnosis of pectoralisjor tear when acute swelling, ecchymosis, and significantn may cloud physical examination findings (9).The increased sensitivity of MRI may enable imme-te diagnosis, thereby avoiding surgical delay and the

velopment of adhesions and atrophy, which can occurearly as 6 weeks after the injury (5,9,18). Early sur-al repair within 3 to 8 weeks of the injury has beenwn to result in better functional outcome, with early

urn to full strength and function of the muscle (2,17).When immediate MRI is not available in the ED,ly orthopedic consultation and an MRI should betained in a timely fashion so as to ensure that surgicalair can occur within 3 to 8 weeks of the initial injury.

eatment

tients presenting to the ED with pectoralis major tearsuld be treated with analgesia, ice application, and

ng immobilization and receive early orthopedic refer-. Because many of these injuries occur in athletes,st physicians now recommend acute surgical repair

ure 4. Clinical photograph shows retraction of the leftctoralis major, abnormal contour of the axillary fold, andhymosis over the medial arm in a patient with a completectoralis tendon rupture at the insertion site (reprintedm Shoulderdoc.co.uk, with permission from Dr. Lennardnk).all complete tears to restore full function and cos- strtic appearance of the pectoralis muscle (2,5,9,11,17,,21,24,27,28).In a meta-analysis of 112 cases of pectoralis majorture, Bak et al. demonstrated that patients who un-

rgo surgical repair have significantly decreased pain,well as a higher rate of pre-injury strength and returnactivities, than patients managed conservatively (2).tcome studies comparing conservative with surgicalatment have demonstrated that surgically repaired in-ies regained 97% of the strength of the uninjured arm,56% in non-operative patients (4).

Outcomes after acute primary repair have generallyen superior to those of delayed repair. Aarimaa et al.d Bak et al. reported better outcomes in their meta-alyses for patients treated 3 and 8 weeks, respec-ely, after injury (2,17). When surgery is delayed, thek of complications increases as a result of significantrring and retraction of the muscle.In general, conservative treatment is indicated ini-lly for partial tears or tears within the substance of thescle belly, which often do well without operativeervention (5,33,34). Additionally, conservative treat-nt might be satisfactory in elderly and inactive per-s in whom the risks associated with surgery may

tweigh any benefits to be gained from the surgicalair (18).

CONCLUSION

pture of the pectoralis major muscle is a rare clinicaltity that has become more common over the past 30ars with increasing participation in competitive sportsd weightlifting.The diagnosis can usually be made based on a pa-nts history and physical examination. However, clin-l diagnosis shortly after injury can be obscured be-se severe pain, swelling, and ecchymosis can makelocation and extent of injury difficult to ascertain.

MRI is the imaging modality of choice to confirm thegnosis, particularly in cases of acute rupture, wherenical examination may be limited by marked ecchy-sis, swelling, and tenderness. Immediate diagnosis

th MRI obtained from the ED can avoid surgical delay,t if immediate MRI is not available, then outpatienthopedic consultation and MRI should be obtained in aely fashion to ensure that a surgical repair could occur

thin 3 to 8 weeks of the injury.Non-surgical management is recommended only ofximal tears and in elderly, sedentary patients. For aller complete tears, surgical repair within the first 3 to 8eks after the injury is advocated to return patients to full

ength and function and to reduce cosmetic deformity.

Ruptures of the pectoralis major muscle likely willremain common. Proper understanding of the anatomy,mechanism of injury, clinical findings, and managementoptions is essential to minimize delays in diagnosis andmaximize the functional outcome of this often debilitat-ing injury.

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18. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pec-toralis major muscle. An anatomic and clinical analysis. Am JSports Med 1992;20:58793.

19. Marmor L, Hall CB. Pectoralis major muscle. Function of sternalportion and mechanism of rupture of normal muscle: Case reports.J Bone Joint Surg Am 1961;43:817.

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21. Kretzler HH Jr, Richardson AB. Rupture of the pectoralis majormuscle. Am J Sports Med 1989;17:4538.

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RUPTURE OF THE PECTORALIS MAJOR: A CASE REPORT AND REVIEWINTRODUCTIONCASE REPORTDISCUSSIONHistory and EpidemiologyPertinent AnatomyPathophysiologyDiagnosisHistory and physical examinationImaging

Treatment

CONCLUSIONREFERENCES