Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Pectoralis Major Tears

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Pectoralis Major Tears · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  All right, welcome to the deep dive. Today we're
• 0:02
  getting into an injury that, well, you might
• 0:04
  not hear about every day, but it can be a real
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  game changer if you're active. We're talking
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  about pectoralis major tendon tears. Yeah, the
• 0:13
  pec major. that big chest muscle. Exactly. And
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  if you're someone who pushes yourself, maybe
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  in the gym, understanding this one is pretty
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  important. Thinking about what could potentially
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  happen. Absolutely. It may be not as common as,
• 0:26
  say, a rotator cuff tear, but a pec major tear.
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  That can seriously impact your strength, your
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  daily function, not to mention sports. So our
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  mission today is really to break it down for
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  you. Right. What is it? How does it usually happen?
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  How would you know if you had one? And crucially,
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  what are the options to fix it? We're basing
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  this on medical studies out there. OK, let's
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  jump right in. What exactly is a pectoralis major
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  tendon tear? What's happening? So in simple terms,
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  it's when that strong tendon connecting your
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  main chest muscle, the pectoralis major, literally
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  pulls off the bone. Pulls right off. Yeah. And
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  avulsion. That's the medical term, a forceful
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  detachment. It's thankfully pretty rare, but
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  definitely a significant injury when it occurs.
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  Rare, but like you said, significant. Who tends
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  to get this injury? Is there a typical person?
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  There is, actually. It's rare overall, less than
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  one case per 100 ,000 people a year, something
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  like that. Wow, that is rare. It is. But what's
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  interesting is reports have been going up since
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  about 1990. It overwhelmingly hits men, usually
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  younger guys, say 20 to 40 years old. Okay. And
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  very often, it's weightlifters. The bench press
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  is, well, it's the classic activity associated
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  with this injury. The forces involved are just
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  immense. The bench press, yeah, I can picture
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  that heavy weight coming down. Where exactly
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  does it tend to tear? Like, what part gives way?
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  The most common place is right where the tendon
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  attaches to the upper arm bone. the humerus.
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  Specifically, it's usually the tendon from the
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  lower, larger part of the muscle. We call that
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  the sternocostal head that evulses, pulls away
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  from the bone. And it's also worth mentioning,
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  unfortunately, that anabolic steroid use is known
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  to be a risk factor. It can weaken the tendon.
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  OK, so let's talk about that moment of injury.
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  During something like a bench press, what's actually
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  going wrong mechanically? It typically happens
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  under what's called an eccentric load. That means
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  the muscle is contracting strongly, trying to
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  resist a force, but it's also being lengthened
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  at the same time. Like lowering the weight slowly.
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  Exactly. Think about that downward phase of the
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  bench press. Your pec is working hard to control
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  the weight, but it's stretching out. the tear
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  often happens right near the bottom of that movement,
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  particularly in sort of the last 30 degrees as
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  the bar gets close to your chest. That's when
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  the strain is highest on certain parts of the
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  tendon. So the muscles fighting the weight down
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  gets overstretched and pop? Pop is often what
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  people report feeling, yeah. And it seems there's
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  a sequence to it usually. The lower fibers of
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  that big sternocostal part tend to fail first.
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  Then the upper fibers of that same part, and
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  if the force is high enough, the clavicular head,
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  the part attached to the collarbone, can go too.
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  Why those lower fibers first? It's biomechanics.
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  In that specific bench press position, arms wide,
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  bar low, those inferior sternal fibers are stretched
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  the most. They're just at their limit. That makes
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  sense. It paints a clear picture. Let's maybe
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  zoom out a bit and talk about the muscle itself,
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  the pectoralis major. What's its structure? Sure.
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  So imagine this big fan -shaped muscle covering
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  your upper chest. It actually has two main parts,
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  or head. Two parts, okay. Yeah, there's the clavicular
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  head, the upper part, which starts on your collarbone,
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  the clavicle, and the top of your sternum. And
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  then there's the larger lower part, the sternocostal
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  head. Sternocostal, that's the bigger one. Much
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  bigger, yeah. Makes up over 80 % of the muscle
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  mass. It attaches all along your sternum, the
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  breastbone, down to the cartilage of ribs one
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  through six, and even connects a bit to the fascia
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  covering your abs. It's a broad origin. Okay,
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  two parts starting wide. Where do they come together?
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  Where do they attach to the arm? They both merge
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  to form a common tendon. And this tendon inserts
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  onto your upper arm bone, the humerus. It attaches
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  just on the outer edge of a groove where your
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  biceps tendon runs. So they join up near the
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  shoulder. Exactly. And there's neat anatomical
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  detail. As the fibers from the two heads come
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  together to form the tendon, they actually twist
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  about 90 degrees. They twist. Yeah. So the fibers
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  that started higher up on your chest actually
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  end up attaching a bit lower on the arm bone.
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  And the lower fibers attach higher up. Like twisting
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  a rope. Huh, interesting. So what are the main
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  jobs of this muscle then? What actions does it
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  power? Its main functions are bringing your arm
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  across your body, that's called adduction, and
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  turning your arm inward, which is internal rotation.
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  Think hugging or throwing a ball. The upper clavicular
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  part also helps lift your arm forward, that's
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  forward flexion. So yeah, it's involved in a
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  lot of powerful upper body movements. And how
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  is it controlled? What nerves make it work? It
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  gets signals from two main nerves branching off
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  the brachial plexus in your shoulder area. The
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  lateral pectoral nerve mostly handles the clavicular
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  head and upper sternal part. And the medial pectoral
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  nerve takes care of the lower sternal part. And
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  just for context, the pec major is one of four
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  muscles connecting your arm to your chest. There's
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  also the pec minor underneath it, the subclavius,
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  and the serratus anterior around the side. They
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  all work together. Right, a whole system. Okay,
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  we've got a good handle on the what and how.
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  Now let's switch to the patient perspective.
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  If someone tears this tendon, what would they
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  actually notice? What are the telltale signs?
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  Well, usually you'll remember the exact moment
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  it happened. People often describe feeling or
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  even hearing a sudden pop or a distinct tearing
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  sensation. A pop, yeah, you mentioned that. Right.
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  It often happens during a resisted movement,
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  like pushing something heavy or bringing the
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  arm forcefully across the chest or rotating it
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  inward. And immediately after, you'd expect pain,
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  usually quite significant, and weakness in the
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  shoulder and chest area. Okay, sudden pop, pain,
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  weakness. What would a doctor look for during
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  an examination? What visible clues might there
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  be? There are several classic signs. You'd likely
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  see swelling and bruising, which can be quite
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  extensive, spreading across the chest and down
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  the upper arm. Bruising down the arm. Yeah. And
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  sometimes if the bruising tracks further down
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  the arm, it might suggest the tear is closer
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  to where the tendon attaches to the humerus right
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  at the end. Interesting. What else? Another thing
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  is the drop nipple sign. Because the muscle retracts,
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  pulls back when it tears, the nipple on the injured
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  side might look lower than the uninjured side.
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  Might also be able to feel a gap, like a defect,
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  where the muscle should be. And the nice curve
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  you normally have at the front of your armpit,
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  the anterior axillary fold, can look flattened
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  or sort of disappear. This becomes more obvious
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  if you ask the person to put their hands together
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  in front of them. Right, trying to activate the
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  muscle shows the defect. Exactly. And then there's
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  the weakness. You'll find significant weakness
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  when testing their ability to adduct, bring the
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  arm across the body, and internally rotate it.
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  Forward flexion might be a bit weak too, but
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  usually less so. So it's a combination of the
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  story, the symptoms, and what the doctor finds
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  on exam. How do you confirm it for sure? What
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  about imaging? Good question. Standard x -rays
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  are often done first, mainly to rule out other
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  things, like a fracture. They don't usually show
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  the tendon tear itself. So x -rays are mostly
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  negative? Mostly, yeah. Sometimes, if a little
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  piece of bone got pulled off with a tendon that's
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  a bony avulsion, you might see that fragment
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  on the x -ray. But really, the gold standard
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  for diagnosing these is an MRI scan. MRI makes
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  sense for soft tissues. Definitely. MRI is excellent
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  at showing the tendon, differentiated between
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  a partial tear and a complete rupture. It can
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  pinpoint the location, is off the bone at the
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  muscle tendon junction, or within the muscle
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  belly. Does it require a special kind of MRI?
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  Often, yes. A dedicated MRI protocol focusing
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  on the pectoralis region is usually best. A standard
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  shoulder MRI might not capture the insertion
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  point clearly enough. Okay. The MRI shows the
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  severity, how far the tendon is retracted, if
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  it's pulled away completely. One small caveat
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  is that sometimes, if only the larger sternocostal
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  part is torn, but the clavicular part is okay,
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  the partial tear can be a bit masked or harder
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  to appreciate fully. Right, the intact part might
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  hide it a bit. Okay, so the MRI gives a clear
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  diagnosis. Once you know someone has a pec major
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  tear, what happens next? What are the treatment
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  paths? Broadly, there are two main paths. Non
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  -operative treatment, so no surgery, and operative
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  treatment, which means surgery. Let's start with
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  nonoperative. What does that involve? Nonoperative
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  usually means putting your arm in a sling for
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  a period, focusing on rest, using ice to manage
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  swelling, taking pain medication, and then eventually
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  starting physical therapy to regain motion and
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  strength. Who is that approach generally best
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  for? It's typically considered for maybe older,
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  less active individuals or for very minor tears,
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  perhaps tears within the muscle belly itself
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  rather than the tendon or low grade partial tendon
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  tears. But what about for younger, active people?
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  Say, that weightlifter we talked about. Yeah,
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  for younger, active patients who want to get
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  back to a high level of function, non -operative
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  treatment often leads to, well, less satisfactory
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  results. They often end up with a lasting cosmetic
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  deformity, a visible asymmetry in the chest because
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  the muscle stays retracted. More importantly,
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  they usually have significant permanent strength
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  loss, especially in adduction, bringing the arm
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  across. That sounds limiting. It is. Recovery
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  can also be delayed, patient satisfaction tends
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  to be lower, and getting back to sports or heavy
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  lifting at the previous level can be really difficult,
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  if not impossible. Okay, that makes a strong
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  case for considering surgery in those individuals.
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  When is surgery the preferred option? Surgery
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  is generally recommended for most acute tears,
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  meaning fresh injuries in athletes and younger,
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  active people. Especially if it's a complete
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  tear, or the tear right where the muscle joins
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  the tendon. The goal is to repair it. to reattach
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  the tendon back where it belongs. And what are
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  the outings like with surgery? Generally, much
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  better for that active group. Surgery tends to
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  provide reliable strength recovery. People have
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  a good chance of returning to their sports and
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  activities. And overall, patient satisfaction
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  is usually higher compared to non -op treatment.
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  Does it matter exactly where the terror was?
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  Good surgical results can often be achieved regardless
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  of the tear location, whether it's off the bone,
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  at the musculatendinous junction, or even sometimes
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  within the muscle belly if it's a significant
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  tear. What if someone has an older tear? Maybe
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  they didn't get it treated right away. Is surgery
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  still an option? Yes, absolutely. For chronic
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  tears, ones that are weeks or months old, surgical
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  reconstruction is often still a very viable option.
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  Reconstruction meaning not just a direct repair.
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  Right. If the tendon has retracted too much and
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  can't be pulled back to its original spot, or
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  if the tissue quality isn't great, the surgeon
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  might need to use a graft, like a donor tendon,
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  to bridge the gap. How do those reconstructions
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  do? Outcomes are generally good. Maybe not quite
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  as consistently excellent as an early primary
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  repair, but still significantly better than doing
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  nothing for an active person with a chronic tear
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  and ongoing weakness or functional problems.
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  Sometimes, even after several months, a direct
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  repair might still be possible if the tendon
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  hasn't retracted too far. Okay, so early repair
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  is ideal, but later options exist. You mentioned
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  different surgical techniques earlier. Can you
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  give us a quick rundown? Sure. So whether it's
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  non -op or pre -op, the initial phase is similar.
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  Sling, rest, ice, pain control. If surgery is
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  planned, Early gentle passive motion is often
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  encouraged once comfort allows. And the surgery
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  itself. For a standard open repair, the surgeon
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  usually makes an incision along the line between
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  your deltoid and pec muscles, the delta pectoral
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  approach. Then the main goal is anchoring that
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  torn tendon back to the humerus bone. How do
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  they anchor it? There are a few common ways.
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  They might drill small tunnels through the bone
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  and pass strong sutures through them to secure
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  the tendon. Or they might use suture anchors.
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  which are like small screws or plugs that go
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  into the bone and have sutures attached. Another
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  method uses buttons placed on the far side of
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  the bone for fixation. Is one method better than
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  others? You know, studies comparing them generally
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  show similar excellent results overall. There's
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  maybe some subtle biomechanical evidence suggesting
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  that the bone trough or button techniques might
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  be slightly stronger initially than anchors alone,
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  but clinically they all seem to work very well.
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  And if the tear is in the muscle itself? If it's
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  a tear within the muscle belly or right where
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  the muscle turns into tendon, sometimes a direct
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  repair, just stitching the torn muscle edges
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  together can be done. OK. And for those reconstructions
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  of older tears, what grafts are used? Right,
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  for reconstruction, the first step is often releasing
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  scar tissue to mobilize the retracted muscle.
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  Then to bridge that gap, an Achilles tendon allograft
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  that a donor tendon is a common choice. It's
• 13:02
  strong, readily available, and avoids taking
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  a graft from the patient's own body. An allograft,
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  so from a tissue bank. Exactly. Another option
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  sometimes used is a hamstring tendon, either
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  allograft or autograft, meaning taken from the
• 13:15
  patient's own hamstrings, which is then woven
• 13:17
  or folded to create a strong graft. These graphs
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  are then secured to the humerus, often using
• 13:22
  those bone tunnel techniques. Okay, that covers
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  the main approaches. Now, like any procedure,
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  there must be potential downsides or complications.
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  What should people be aware of? Yes, that's important.
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  Re -tear is probably the most significant surgical
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  complication, though thankfully not super common,
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  maybe around five to seven percent of cases.
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  It often happens where the sutures attach to
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  the tendon itself. That can be the weak point.
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  Okay, re -tear is one possibility. What else?
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  Persistent pain after surgery can sometimes be
• 13:50
  an issue for some individuals. It's probably
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  the most common longer -term complaint. There's
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  also a chance of some residual weakness or a
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  cosmetic difference compared to the other side,
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  even after a successful repair. And the usual
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  surgical risks. Right. Like with any surgery,
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  there are small risks of infection, nerve injury,
• 14:08
  or blood clots, but those are generally quite
• 14:11
  low for this type of procedure. All right. This
• 14:13
  has been incredibly informative. Let's try to
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  distill the main points for someone listening.
• 14:19
  What are the key takeaways? I think the main
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  things are, one, this is a specific injury, often
• 14:24
  tied to high -force activities like bench pressing.
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  Two, recognize the signs that sudden pop or tear,
• 14:31
  followed by pain, weakness, and bruising in the
• 14:33
  chest and arm. Right, be aware of those symptoms.
• 14:35
  Three, While nonoperative care exists for active
• 14:38
  people wanting full function back, surgery is
• 14:41
  usually the recommended route for acute tears,
• 14:44
  offering better strength and return to activity.
• 14:46
  And different surgical techniques work well.
• 14:48
  Exactly. And fourth, even if it's an older injury,
• 14:52
  don't assume nothing can be done. Reconstruction
• 14:54
  is often a good option for chronic tears with
• 14:57
  persistent problems. So the core message for
• 14:59
  listeners seems to be if you suspect this injury,
• 15:02
  especially after a specific event, get it checked
• 15:05
  out promptly. Definitely. Prompt diagnosis is
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  key. It allows for a proper discussion about
• 15:10
  your specific situation, your goals, and the
• 15:13
  best treatment plan to get you back to doing
• 15:15
  what you want to do. Don't just try to push through
• 15:18
  it. This has been a really valuable deep dive.
• 15:20
  It highlights just how powerful that pec muscle
• 15:23
  is and how crucial it is for so many movements
• 15:25
  we take for granted. It really does. It's a reminder
• 15:28
  of the incredible forces our bodies handle, but
• 15:31
  also their limits. Understanding how these injuries
• 15:34
  happen helps appreciate that balance. Thanks
• 15:36
  so much for breaking this down for us and for
• 15:39
  everyone listening.