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