Pectoralis Major Tendon Repair

Abstract & Commentary

Synopsis: Pectoralis major tendon repair for both acute and chronic injuries shows significantly better outcomes than nonoperative treatment.

Source: Schepsis AA, et al. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.

Schepsis and colleagues retrospectively reviewed 17 cases of pectoralis major muscle rupture in order to compare nonoperative vs. operative treatment of acute and chronic injuries. They define an acute injury as less than two weeks from injury to surgical repair. There were six acute repairs, seven chronic repairs, and four patients with no repair. Subjective and objective outcome questionnaires showed patient satisfaction to be 96%, 93%, and 51%, respectively. Isokinetic adduction strength testing was performed, which also showed improved results with surgical repair (102%, 94%, and 71%, respectively). Patient satisfaction with cosmetic results was recorded as an average of 84% in both operative groups and 56% in the nonoperative group. All of the surgeries were performed by Schepsis using an identical technique of suture repair through a bony trough in the humerus tied over a bone tunnel. Schepsis et al conclude that, although their sample numbers were small, all patients treated surgically fared significantly better subjectively and objectively than those treated nonoperatively. "Furthermore, delayed repair does not significantly compromise the subjective or objective results of surgery," according to Schepsis et al.

Comment by Stephen B. Gunther, MD

This retrospective review of pectoralis major tendon rupture does shed some light on this rare type of injury. There are many reports in the literature with small numbers of subjects, but it is difficult to collect a large series of patients by any one surgeon with such a rare injury. This case series, however, reports a significant improvement in patient satisfaction and adduction strength. It is also interesting to note that there was no significant difference in results between the acute and chronic repair groups. It also would be interesting to evaluate patients with a treatment delay of more than 12 months.

Schepsis et al also elucidate an increasing trend in pectoralis major tendon ruptures due to weightlifting activities. The majority of these injuries (8/10) occurred during use of the bench press. The biomechanics of the bench press exercise have been well studied by Elliott et al, but the prevalence of pectoralis tendon ruptures in weightlifters has not been specifically studied.1 A review of the literature demonstrates that most pectoralis major tendon ruptures occur in males involved in heavy lifting activities in either the work environment or sports.2,3

In summary, this paper sheds light on a rare injury. Patient outcomes were improved by surgical reconstruction of the pectoralis major musculotendinous unit for both acute and relatively chronic tears. It would be beneficial to perform a collaborative collation of data from multiple surgeons in order to increase the number of patients with chronic tendon repairs with more than a one-year delay in surgery.

References

1. Elliott BC, et al. A biomechanical analysis of the sticking region in the bench press. Med Sci Sports Exerc 1989;21:450-462.

2. Park JY, Espiniella JL. Rupture of pectoralis major muscle. A case report and review of literature. J Bone Joint Surg Am 1970;52:577-581.

3. McEntire JE, et al. Rupture of the pectoralis major muscle. A report of eleven injuries and review of fifty-six. J Bone Joint Surg Am 1972;54:1040-1046.

Patients with a pectoralis major tendon repair may expect to improve all of the following except:

a. adduction weakness.

b. cosmetic defect.

c. external rotation lag.

d. subjective outcome.

e. function even with a late repair of a chronic rupture.