Pectoralis major tendon tears

Pectoralis major is a large muscle across the front of the chest. It has a tendon which come across the front of the shoulder and attaches to the upper arm. The muscle, and then tendon, forms the front of the axilla (the armpit). Pec major tendon rupture (tear) is a rare injury, most commonly seen in weight-lifters doing a bench press. This injury is being seen more regularly due to the increased emphasis on healthy lifestyles and therefore gym attendance. It most commonly occurs during bench pressing and is felt as a painful snap at the front of the shoulder and chest. The muscle then 'bunches up' and deforms. This is most easily seen if the patient puts their hands on their hips and pushes in. Bruising and swelling are common.

The photograph shows a patient with a left pec major tear. There is loss of the anterior axillary fold.

You will be referred to a orthopaedic clinic where you will have the opportunity to discuss the injury with a specialist. Sometimes the diagnosis is unclear and you may need an MRI scan.  Once confirmed you have 2 options. You can either leave it or you can have it repaired.

Non-operative treatment

If you choose not to have the tendon repaired there is no need to rest the arm in a sling. You can resume physical work and even go to the gym once the initial discomfort settles (first 2 weeks). The asymmetry of the chest musculature will persist and will be longstanding. Some people feel that their strength is affected, for example, when doing a bench-press. You are unlikely to notice the strength loss of you aren’t the sort of person who is likely to be doing such an activity. If you dislike the asymmetry or are concerned about the loss of strength, surgical repair can be considered.

Operative treatment

The surgery is performed under general anaesthesia (asleep) and takes about an hour and a half. The procedure is done open (not key-hole) and through a horizontal cut across the top of the armpit. I reinforce the tendon with Polytape (Xiros, Leeds), and then use all-suture anchors into the humerus. I tend to find that most of these injuries present late (around 3 to 6 months) and by then there is no tendon to repair, there is just a ball of muscle. After the surgery, you must wear a polysling for 6 weeks, day and night, to protect the repair. The sling can be removed for washing and dressing and to do some gentle hand, wrist and elbow exercises. You can shower but you must keep the dressing dry. To do this, remove your sling but keep your arm in the position it would be if it were in a sling. Hold the shower head in your other hand and shower low down. Use a wet flannel around your dressing and under your arm.

At 2 weeks you will see a member of the team and have your wound checked. It is an awkward place to suture and to get to heal so sometimes the wound is a little leaky bu usually by 3 weeks it has settled to enable you to keep it uncovered and get it wet in the shower.

At 6 weeks you can discard the sling and start to use the arm more normally but you must resist the temptation to lift anything heavy or return to lifting in the gym (with this arm). The tendon probably takes 3 months to heal onto the bone, so I insist on no gym work for 3 months after surgical reconstruction.

Surgical repair / reconstruction of the pectoralis major tendon rupture has been shown to provide superior outcomes regarding strength return, when compared to nonoperative management. However, I consent my patients by explaining that strength return is somewhat unpredictable and isn’t guaranteed. The best advice I have is to follow the guidance of our physiotherapists. The fairly reliable thing that tendon repair does do is reconstruct the anterior fold of the axilla (the front of the armpit) and does stop the medial bunching of the muscle on contraction.

This patient is 3 months after a left pec major tendon reconstruction.

Polytape (by Xiros, Leeds, UK)

I use this synthetic (polyester), woven tape to reconstruct most of my pec majors tears. It comes as a roll (800 mm X 20mm) and I put limbs anterior and posterior to the muscle to achieve a good hold and to create a new tendon.

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