Working Diagnosis:
Complex partial tear of pectoralis major muscle belly extending into the tendon

Treatment:
The patient underwent an ultrasound guided injection of 6cc of leukocyte rich platelet rich plasma Case Photo #2 into the area of demonstrated pathology in the pectoralis muscle. He began osteopathic manipulation for somatic dysfunction and took Tylenol as needed for pain.

Outcome:
One week following the injection the patient reported improvement in pain, range of motion, and ability to perform activities of daily living. He continued rehabilitation with his personal trainer and reported weekly improvement in his upper extremity functional index from an initial score of 29 out of 80 at the time of injury to 79 out of 80 at 8 week follow-up. He was back to wrestling by week 4 and had full pain free range of motion by 8 week follow-up.

Author's Comments:
Delays in treatment of pectoralis major injuries can lead to muscular atrophy, adhesions, tendon retraction, and worsened functional outcomes. The decision for surgical versus non-operative management has typically been dictated by the extent of the tear. The literature reveals that non-operative treatment of complete tears results in significant strength deficits while non-operative treatment of partial tears leads to full functional recovery. However, a 1990 study revealed that this complete return of strength and ROM took 4-7 years post-injury. The literature on nonsurgical treatment options is limited, however there is a consistent emphasis on a strong physical therapy program.
In hopes of finding a middle ground option many physicians have turned to a regenerative technique known as Platelet-Rich Plasma, or PRP. Research reveals mixed results for acute muscle injuries but suggests improved pain and functional outcomes for tendon and ligament injuries.
In this case, our goal was to enhance healing, reduce recovery time and return to play, which is why we elected to proceed with PRP.

Editor's Comments:
This case is a good illustration of the typical mechanism of injury for the internal rotators of the shoulder, ie pectoralis major, latissimus dorsi, and subscapularis. All are injured with forced external rotation of the shoulder but the positioning of the shoulder differentiates the most likely muscle to be injured. The subscapularis is most likely injured with the shoulder fully adducted, the latissimus dorsi is most likely injured with the shoulder in abduction with forward flexion, and the pectoralis major is most likely injured with the shoulder in abduction with extension. Of the the three internal rotators, only the latissimus dorsi and pectoralis major originate on the axial skeleton and insert on the appendicular skeleton thus increasing their injury potential with significant differences in truncal positioning relative to the associated upper extremity.

It is imperative to discriminate a full rupture or high grade partial tear from a low grade partial tear or strain due to the potential functional recovery deficit associated with non-operative treatment of a high-grade injury. For active individuals, surgical repair is recommended for high grade partial tears and complete ruptures due to a low rate of return to sport and functional performance without surgical repair. After ruling out bony injury with plain film radiography, MRI is the study of choice to evaluate the extent of the injury.

This patient was treated successfully without surgery but with the addition of LR-PRP which acts to induce an increased inflammatory and healing response where it is injected. This patient had an excellent outcome which demonstrates the strong potential for benefit for this type of therapy in acute tendon and muscle injuries.

References:
1. Wilk KE, Reinold MM, Andrews JR. Soft Tissue Injuries of the Shoulder. In: The Athlete's Shoulder. Philadelphia, PA: Churchill Livingstone; 2009: 287-289.
2. Chiavaras MM, Jacobson JA, Smith J, Dahm DL. Pectoralis major tears: anatomy, classification, and diagnosis with ultrasound and MR imaging. Skeletal Radiology. 2015; 44:157-164
3. Lee YK, Skalski MR, White EA, Tomasian A, Phan DD, Patel DB, Matuck GR, Schein AF. US and MR Imaging of Pectoralis Major Injuries. RadioGraphics. 2017; 37: 176-189.
4. Reid DC. Injuries to the Thorax, Abdominopelvic Viscera, and Genitourinary System. In: Sports Injury Assessment and Rehabilitation. Edinburgh: Churchill Livingstone; 2002: 683-684.
5. Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada. 2001: 53(4):259-267.
6. Nicolette GW, Farrell K. Case Report: Platelet Rich Plasma Injection Used as Treatment of High-Grade Partial Pectoralis Muscle Tear in Division 1 Football Player. Annals of Case Reports. 2017; Issue 5.
7. Cruciani M, Franchini M, Mengoli C, Marano G, Pati I, Masiello F, et al. Platelet-rich plasma for sports-related muscle, tendon and ligament injuries: an umbrella review. Blood Transfus. 2019; 17: 465-478.

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