Surgical Repair of Pectoralis Muscle Rupture Following Sport/Exercise Injuries: Case Series

Introduction

Rupture of the Pectoralis muscle tendon is usually rare. And when it does happen, Sports or exercises are most often the culprit. An abducted, extended and externally rotated shoulder is weak and adding tension to it, as happens during a bench press or throwing a ball, is the most likely mechanism to tear off the Pectoral tendon. Sites recognised are: At tendon attachment, Musculo- tendinous junction and Muscle belly 2012, El Maraghy A [1]. Patients often present with pain, bruising over medial arm and chest deformity with restricted range of shoulder movement. Surgical repair for tear is a very effective method of treatment, especially in cases of complete rupture.

Background

The powerful Pectoralis muscle is responsible for the adduction, external rotation and flexion of the shoulder joint. Anatomically, it is known to have an upper, Clavicular head and a lower sternal head. Fibers emerge towards the Lateral lip of Bicipital groove of Humerus in a rather unusual pattern, as the Clavicular and upper sternal fibers insert distally and the lower sternal and abdominal fibers cross the former and insert proximally.

Currently, ruptures of the Pectoralis muscle tendon are on the rise. This frequently happens in sports like weight lifting, Rugby, American football and Cricket. The patient presents with a history of severe sharp pain, with or without a ‘snap’ at the time of injury, followed by painful and reduced range of movement, localized swelling and ecchymosis over the shoulder. When examined, there is a classic ‘bunched-up’ deformity over this muscle region as the muscle becomes retracted, and leaves a thin anterior axillary fold or sulcus at the Delto-pectoral groove. Specific muscular tests show weakness on adduction and internal rotation of the arm. It was first described by Patissierin 1822, followed by Letenneur in 1861. Between 1822 and 2010, 365 cases of PM injury were published (75% occurred in the last 20 years). The vast majority resulted from an indirect trauma [2]. Various authors have attempted to grade these injuries in order to aid in the diagnosis, treatment and rehabilitation. In 2012, El Maraghy A [1] came forth with a new classification system based on a) time of injury, (acute or chronic), b) the anatomic location (at the muscleorigin or muscle belly, at or between the musculo- tendinous junction and the tendinous insertion, or bony avulsion). Most commonly the Pectoralis major muscle tendon ruptures off the Humerus bone. Then management technique we describe is the “Fiber- tape and Pec Button repair technique” [6]. Firstly, exposure of the tendons via an incision over anterior axillary fold is done followed by fiber tape suturing of the medial end. Then, on the Humeral surface pilot holes are drilled with a 3.7 mm drill bit and Pec Buttons are threaded with fiber tape and docked into the Humerus. With tension-slide technique the tendon is re-attached. Here we discuss three cases of Pectoralis muscle rupture and the subsequent management.

Comparative Results

Discussion

These cases are in early post-operative phase (3 months), and under regular follow-up. Two of the cases show very good recovery with progressive physiotherapy - minimal pain for normal activities. Although the third patient is struggling with soreness, it has shown a decreasing trend. This evidence is consistent with separate studies done by Aarima et al. [2] and Bak et al. [3]. Hanna CM_,_ in 2002 [10], reported 21 patients with complete Pectoralis muscle tear, of which ten surgically treated patients showed 41-43% greater recovery of work performed and peak torque when tested with a Kin- com Isokinetic Dynamometer, than conservative management. Furthermore, no complications such as - Post op bleeding, infection or joint stiffness has been found in any of the cases. We cannot help but mention that, amongst the three, MRI failed to demonstrate ruptures in two cases. This contradicts the finding of Connell et al. [4] who published an article in 1998, based on a case series of 15 patients similar injuries and concluded that MRI is “the” imaging technique for evaluation of such injuries. Additionally, according to Ohashi et al. [5] the imaging modality had very good surgical correlations. Despite such strong evidences however, the disparity between the correct clinical findings and incorrect MRI findings in two of our cases cannot be overlooked.

Conclusion

Early surgical repair followed by physiotherapy can allow 80-90 % of functionality and return to normality, compared to 60- 70% from conservative management [2]. Even in partial tears, surgery seems worthwhile, particularly to restore contour. MRI appears to have poor specificity in delineating the exact site of rupture & occasionally can be unhelpful. It serves as an excellent adjunct, but cannot substitute Clinical examination.