Working Diagnosis:
Pectoralis major tendon rupture.

Treatment:
Patient had successful left pectoralis major tendon primary open repair 2.5 weeks after the injury. Case Photo #3

Outcome:
The patient was discharged in a sling to be worn until surgery. Patient had an uncomplicated repair and post-op course. He started physical therapy, following a pectoralis major repair protocol starting with scapular exercises and pendulums. Initial passive ROM was limited to 90 degrees flexion, 40 degrees abduction and 30 degrees external rotation. Range of motion was progressed at 6 weeks postop and strengthening began at 12 weeks. Patient refrained from bench press until 5 to 6 months postop. Case Photo #4

Author's Comments:
Pectoralis major rupture is relatively rare and is most commonly seen in weightlifters, particularly while bench pressing. The mechanism involves excessive tension on a maximally eccentrically contracted muscle. This typically occurs during the downward portion of bench press with arm in final 30 degrees of humeral extension while pushing against heavy resistance. This case is a unique circumstance in which a pectoralis major rupture occurred playing recreational football. While rare compared to other injuries on an outstretched hand, it is critical not to miss this diagnosis, as prompt surgical repair within 3 to 8 weeks can significantly improve clinical outcomes. This case also highlights the use of POCUS to confirm the diagnosis when MRI was inconclusive.

Editor's Comments:
The epidemiology of pectorals major rupture is broadening. While commonly associated with anabolic steroid use, this injury is also being diagnosed in elderly, nursing home bound women and is thought to be due to muscle/tendon injury sustained during transfer. There has been one case report of this injury in a 34-year-old female rugby player and another in a woman who had previous breast surgery.

The pectoralis major index can be used in the diagnostic evaluation. This is calculated by measuring the pectoralis major distance (PMD) and comparing the injured side parameters to the uninjured extremity. The PMD should be calculated by placing the patient in the military press position. The contour of the pectoralis major should be marked along the axillary fold and the most prominent lateral aspect of the pectoralis should be noted. The PMD is the length of the line from the nipple to the lateral prominence. A PMI < 0.9 has been found to be 79% sensitive and 98% specific for a pectoralis major injury. This measurement provides an objective means by which a pectoralis major tear can be diagnosed. This parameter can be used to rapidly identify pectoralis muscle tears when MRI is unavailable or is likely to be delayed. Lastly, the PMI is particularly useful immediately following the injury as the drop nipple sign may not be present until a hematoma has accumulated.

There is an increased focus on chronic pectorals major tears. These long-term injuries typically require reconstruction (both allograft and autograft techniques have been used). Functional outcomes following delayed repair are approaching those of immediate repair and are significantly better than those treated non-operatively.

References:
Kowalczuk M and Elmaraghy A. Pectoralis Major Rupture: Evaluation and Management. J Am Acad Orthop Sur. 2022 Apr 1;30(I'm 7):e617-e627.

Stringer MA, Cockfield AN and Sharpe TR. Pectoralis Major Rupture in an Active Female. J Am Acad Orthop Surg Glob Res Rev. 2019 Oct; 3(10):e19.00030.

Franks N, Gross J and Joseph R. Point-of-care Ultrasound for Suspected Pectoralis Major Rupture: A Case Report. Clin Pract Cases Emerg Med. 2021 Feb;5(1):93-6.

ElMaraghy A, Rehsia SS and Pennings AL. Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears. Orthop J Sports Med. 2013 Dec 16;1(7):2325967.

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