High Yield Overview

PECTORALIS MAJOR TENDON REPAIR - ACUTE AND CHRONIC RECONSTRUCTION

Deltopectoral approach, utilizing interval between deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves). Provides excellent access to pectoralis major insertion on lateral lip of bicipital groove of humerus. | intermediate

Critical Danger Structures - MUST PROTECT

Musculocutaneous Nerve

Location: Pierces coracobrachialis 5-8cm distal to coracoid tip (range 3-10cm)

Protection: Avoid inferior/deep dissection beyond conjoint tendon. Gentle retraction of conjoint only. No inferiorly-placed retractors

Lateral Pectoral Nerve

Location: Enters deep surface of pectoralis major from laterally, 2-4cm from clavicle (thoracoacromial artery branch)

Protection: Avoid aggressive superior retraction of pectoralis major. Identify during superior dissection if mobilizing clavicular head

Medial Pectoral Nerve

Location: Pierces pectoralis minor to enter deep surface of pectoralis major medially

Protection: Avoid deep medial dissection when mobilizing chronically retracted tendon. Stay superficial to pectoralis minor

Axillary Nerve

Location: Passes through quadrangular space approximately 5-7cm below acromion, along inferior border of subscapularis

Protection: Stay superior to surgical neck of humerus. No inferior retractors. Limit inferior exposure during chronic tendon retrieval

Anterior Humeral Circumflex Vessels

Location: Run along inferior border of subscapularis at surgical neck, medial to bicipital groove

Protection: Control bleeding if encountered during inferior humeral decortication. Cauterize or ligate if injured. Avoid aggressive inferior preparation

Mnemonic

SLABSPECTORALIS Insertion Anatomy

Mnemonic

MLMANERVES at Risk During Repair

Indications for Surgery

Absolute Indications

Complete pectoralis major tendon rupture (Grade III) in active patient
Acute complete rupture in athletes or high-demand workers
Bone avulsion fractures with displacement
Failed non-operative management of partial tears with persistent symptoms

Relative Indications

Symptomatic partial tears (Grade II) with weakness or pain
Chronic ruptures (>6 weeks) with cosmetic deformity and functional deficit in motivated patients
Revision of failed primary repair
High-demand occupation requiring strength (manual labor, military)

Contraindications

Medical comorbidities precluding surgery
Low-demand elderly patients with minimal symptoms
Complete muscle belly tears with severe retraction (poor tissue for repair)
Significant muscle atrophy in chronic tears (>6-12 months) - consider tendon transfer instead
Active infection

Pre-operative Assessment

History

Mechanism: Eccentric load to contracted muscle (bench press 80%, wrestling/tackling 15%, other 5%)
Sudden pop or tearing sensation with immediate pain
Rapid swelling and ecchymosis in anterior shoulder/chest
Weakness with adduction and internal rotation activities
Timing: acute (<6 weeks) vs chronic (>6 weeks) - affects surgical approach

Physical Examination

Inspection: Loss of anterior axillary fold (visible defect), asymmetric chest contour, ecchymosis
Palpation: Palpable gap at insertion (acute), retracted tendon mass medially (chronic)
Modified push-up test: Patient unable to perform push-up from floor, or pain/weakness during attempt
Strength testing: Weakness with resisted adduction, internal rotation. Compare to contralateral
Range of motion: Usually full passive ROM, limited active due to pain/weakness

Imaging

Plain radiographs: AP and axillary shoulder views. Usually normal, but may show bone avulsion fragment
Ultrasound: Dynamic, can show tendon retraction and gap. Operator-dependent
MRI (gold standard): Confirms diagnosis, shows rupture location (musculotendinous vs bone), degree of retraction, muscle atrophy (chronic), associated injuries. T2 shows fluid/edema at injury site
CT: Not routinely needed unless bone avulsion requires detailed assessment

Classification

Grade I: Muscle contusion/strain, fibers intact, full strength
Grade II: Partial tear, some function preserved, pain with activity
Grade III: Complete rupture, no function, visible deformity
Location: Muscle belly (10%, worst prognosis), musculotendinous junction (60%, most common), tendon avulsion from bone (30%, best prognosis)

Step-by-Step Surgical Technique

Step 1: Incision & Deltopectoral Interval

Technique:

Palpate coracoid process medially and deltopectoral groove
In acute ruptures, may palpate defect at anterior axillary fold
Make 8-12cm incision along deltopectoral groove from 2cm below clavicle extending toward axilla
Incise skin and subcutaneous tissue
Identify cephalic vein in deltopectoral groove
Preserve vein and retract laterally with deltoid (preferred), or ligate and divide if necessary

Exam Pearl

Examiner Question: "What is your surgical approach for pectoralis major repair?"

Model Answer: "I use the deltopectoral approach, starting 2cm below the clavicle at the coracoid level and extending 8-12cm distally toward the axilla. The cephalic vein marks the interval - I prefer to preserve and retract it laterally with the deltoid to avoid venous congestion, though ligation is acceptable. This is a true internervous plane between the axillary nerve supplying deltoid and the pectoral nerves supplying pectoralis major."

Critical Points

Incision must be centered on anticipated pectoralis insertion (lateral lip of bicipital groove)
Cephalic vein injury causes bleeding - have cautery ready
Avoid incision too medial (enters muscle belly) or too lateral (difficult deltoid retraction)

Step 2: Develop Deltopectoral Interval

Technique:

Identify interval between deltoid (lateral) and pectoralis major (medial)
In acute rupture, evacuate hematoma obscuring anatomy
Develop interval with blunt finger dissection
Retract deltoid laterally, pectoralis major medially with self-retaining retractor
Visualize deep structures: conjoint tendon, long head biceps in groove, pectoralis insertion site

Exam Pearl

Examiner Question: "What makes this a safe interval?"

Model Answer: "The deltopectoral interval is a true internervous plane. Deltoid is supplied by the axillary nerve from the posterior cord, while pectoralis major is supplied by the lateral and medial pectoral nerves. No motor nerves cross this plane, making it safe for dissection. The conjoint tendon is visible deep in the interval."

Nerve Protection

Musculocutaneous nerve in conjoint tendon 5-8cm distal to coracoid - avoid inferior dissection
Lateral pectoral nerve entering pectoralis superiorly - gentle retraction only
Axillary nerve inferiorly below subscapularis - stay above surgical neck

Step 3: Identify and Mobilize Ruptured Tendon

Technique:

Acute rupture (<6 weeks): Tendon retracted 3-5cm medially, surrounded by hematoma - palpate medially to find stump
Chronic rupture (>6 weeks): Tendon retracted 5-10cm, scarred to chest wall, significant muscle atrophy
Assess rupture location: musculotendinous junction (60%), bone avulsion (30%), muscle belly (10%)
Evaluate tissue quality: acute tears have good tissue, chronic may be friable
Mobilize tendon by releasing adhesions and scar tissue
May need to extend exposure medially/inferiorly to retrieve chronically retracted tendon
Assess both heads: typically sternal head tears, clavicular may be intact

Exam Pearl

Examiner Question: "How do acute and chronic tears differ intraoperatively?"

Model Answer: "Acute tears have minimal retraction, usually 3-5cm, with good tissue quality and minimal adhesions. The tendon is easily retrieved. Chronic tears have significant retraction, often 5-10cm, with muscle atrophy, scar tissue adherent to the chest wall, and friable tissue quality. Extensive mobilization is required, and I may need larger exposure. Despite this, repair is still worthwhile as outcomes show 70-80% good results compared to 85-95% for acute repairs."

Mobilization Risks

Excessive medial dissection risks medial pectoral nerve injury
Chronically retracted tendons may be difficult to find - extend exposure as needed
Friable tissue in chronic tears may not hold sutures well - use larger bites and consider augmentation

Step 4: Prepare Humeral Insertion Site

Technique:

Identify lateral lip of bicipital groove on proximal humerus (anatomic insertion)
Insertion starts approximately 5cm distal to greater tuberosity, extends 5-8cm distally
Use arm abduction and external rotation to visualize
Decorticate insertion site with rongeur/curette/rasp to bleeding bone
Create 2-3cm wide footprint area for tendon contact
Do NOT excessively decorticate - preserve bone stock for anchor purchase
Excise any remaining tendon fibers at insertion to create clean surface

Exam Pearl

Examiner Question: "Describe the pectoralis insertion anatomy"

Model Answer: "The pectoralis major inserts on the lateral lip of the bicipital groove of the humerus, creating a 5-8cm long footprint starting about 5cm distal to the greater tuberosity. The tendon twists 180 degrees, so the inferior sternal fibers insert most superiorly, and the superior clavicular fibers insert inferiorly. I prepare this site by decorticating to bleeding bone while preserving bone stock for solid anchor purchase."

Preparation Hazards

Aggressive decortication weakens bone and compromises anchor fixation
Inadequate preparation impairs tendon-bone healing
Long head biceps lies in groove medially - avoid injury
Anterior humeral circumflex vessels run inferiorly - control if encountered

Step 5: Place Suture Anchors

Technique:

Place 2-4 suture anchors (typically 3) along lateral lip of bicipital groove
Position anchors 1-1.5cm apart along humeral insertion footprint (5-8cm linear array)
Insert at 45° 'deadman' angle distally to resist proximal pull of tendon
Use 5.0-5.5mm metal or PEEK anchors, double-loaded with #2 high-strength suture
Ensure anchors fully seated in bone, not proud
Test suture purchase before passing through tendon
May use knotless anchors or suture bridge technique for increased footprint

Exam Pearl

Examiner Question: "Describe your anchor configuration"

Model Answer: "I place 3-4 double-loaded 5.5mm anchors along the lateral lip of the bicipital groove, spaced 1-1.5cm apart to recreate the normal footprint. Critical technique: anchors are inserted at 45 degrees distally - the 'deadman' angle - to resist the proximal pull of the tendon. This provides 6-8 sutures for secure fixation. I test each anchor's purchase before proceeding."

Anchor Complications

Anchors not fully seated will pull out during rehabilitation
Insufficient depth gives poor purchase and early failure
Divergent anchors reduce overall construct strength
Fracture through weak bone is rare but possible

Step 6: Prepare Tendon with Whipstitch

Technique:

Mobilize tendon to reach insertion without excessive tension
Release adhesions between pectoralis and chest wall (chronic tears)
Gently stretch contracted tendon and muscle (chronic cases)
Whipstitch end of pectoralis tendon with #2 high-strength suture using Krackow or locking running technique
Ensure locked sutures pass through robust tissue
If tendon quality poor (chronic, friable), incorporate more proximal muscle-tendon junction
Test mobilization: tendon should reach insertion with arm in neutral without excessive tension

Exam Pearl

Examiner Question: "How do you ensure adequate mobilization?"

Model Answer: "Adequate mobilization is critical for repair success. I release all adhesions and scar tissue, particularly in chronic tears where the tendon may be adherent to the chest wall. I whipstitch the tendon end with heavy locking sutures using a Krackow technique for strong purchase. I then test that the tendon reaches the insertion site with the arm in neutral position without excessive tension. Inadequate mobilization leads to excessive tension on the repair and early failure."

Mobilization Risks

Inadequate mobilization creates excessive repair tension and predisposes to failure
Whipstitch through poor quality tissue will cut through - use healthy proximal tissue
Overtensioning during testing can damage tissue before repair is complete

Step 7: Pass Sutures Through Tendon

Technique:

Pass sutures from bone anchors through tendon in mattress configuration
Create horizontal mattress sutures approximately 1cm from tendon edge
Space sutures along tendon width to distribute load evenly
Ensure good tissue bites (at least 1cm of tendon substance)
Keep sutures organized with clamps - multiple sutures can be confusing
Alternative: tie anchor sutures to whipstitch sutures (less secure than mattress)

Exam Pearl

Examiner Question: "Describe your suture technique through the tendon"

Model Answer: "I pass the sutures from the bone anchors through the tendon in horizontal mattress configuration, approximately 1cm from the edge. This is superior to simple sutures as it distributes forces and resists cut-through. I space the mattress sutures along the width of the tendon to create even load distribution. Good tissue bites of at least 1cm are essential. I keep all sutures organized with clamps to avoid confusion with multiple suture limbs."

Suture Passage Errors

Sutures too close to edge will cut through tendon
Inadequate tissue bites create weak points and repair failure
Uneven tension distribution causes gap formation
Poor organization of multiple sutures leads to technical errors

Step 8: Reduce Tendon and Tie Knots

Technique:

Position arm in 30-45° abduction and neutral rotation (functional position)
Reduce tendon to bone footprint
Sequentially tie knots from proximal to distal anchor
Use sliding-locking knot technique (SMC, surgeon's sixth)
Tighten with appropriate tension - snug contact without overtightening
Verify all knots secure with additional half-hitches
Check repair: tendon flat against bone with even contact, no gaps
Test with gentle passive ROM - repair should remain secure without gapping

Exam Pearl

Examiner Question: "What arm position do you use for tensioning the repair?"

Model Answer: "I reduce the tendon to bone with the arm in 30-45 degrees of abduction and neutral rotation. This is a functional position that allows healing at appropriate length. Excessive adduction would overtension the repair and risk failure, while excessive abduction would undertension it and allow lengthening. I tie the knots sequentially, creating snug tendon-bone contact without strangulating the tissue. I then test the repair with gentle passive motion to ensure no gapping occurs."

Tensioning Complications

Overtensioning strangulates tissue and causes repair failure
Undertensioning creates gaps and poor healing
Knots not secure lead to early failure
Testing too aggressively can cause intraoperative failure

Step 9: Augmentation (Chronic or High-Demand Cases)

Technique:

Consider in chronic tears (>6 weeks), poor tissue quality, revision, high-demand athletes
Graft augmentation: Use semitendinosus autograft, allograft, or dermal graft to bridge tendon to bone
- Weave through tendon substance
- Secure to bone with additional anchors or tie to existing anchor sutures
- Creates load-sharing during healing phase
Internal brace: High-strength suture tape from tendon to bone parallel to repair
- Acts as internal splint
- Shares load during early healing
Additional anchors: Extra fixation points for increased security
Not always necessary: acute tears with good tissue may not need augmentation

Exam Pearl

Examiner Question: "When would you augment a pectoralis repair?"

Model Answer: "I consider augmentation in high-risk scenarios: chronic tears beyond 6 weeks where tissue quality is poor and retraction is significant, revision surgery where the primary repair failed, and high-demand athletes who will return to maximal loading activities like powerlifting. Options include tendon graft augmentation with allograft or autograft to bridge the gap and share load, or internal bracing with suture tape. Evidence suggests augmentation may reduce re-rupture rates from 15-20% to under 10% in these high-risk cases. However, acute tears with good tissue don't routinely need augmentation."

Augmentation Considerations

Autograft harvest creates donor site morbidity
Overtightening augmentation excessively constrains the shoulder
Added cost and operative time - use judiciously
Allograft carries theoretical disease transmission risk

Step 10: Final Assessment and Closure

Technique:

Final checks:
- Repair secure without gapping with gentle passive ROM
- Full passive ROM (elevation, rotation) achieved without excessive tension
- Hemostasis adequate - cauterize all bleeding vessels
- No tethered structures or injured neurovascular elements
Copious irrigation of wound
Consider closed suction drain if significant dead space (remove POD 1-2)
Repair deltopectoral fascia if divided
Close subcutaneous tissue in layers with 2-0 Vicryl
Skin closure with staples or subcuticular 3-0 Monocryl
Sterile dressing and sling in neutral position
Counsel patient: strict protection protocol, NO active pectoralis contraction for 6 weeks minimum

Exam Pearl

Examiner Question: "What do you tell the patient about post-operative precautions?"

Model Answer: "This is critical counseling. I emphasize that the tendon repair requires 6 weeks of strict protection to heal to bone. During this time, absolutely no active pectoralis muscle contraction - no pushing, pressing, lifting, or reaching activities. Violations of this protocol are the leading cause of repair failure and re-rupture. The patient can perform gentle passive range of motion with a therapist, but no active motion. I explain that rushing the rehabilitation is the primary cause of failure, and adherence to this protocol is essential for successful healing."

Closure Complications

Inadequate hemostasis leads to hematoma formation
Early active motion causes re-rupture (most common cause of failure)
Patient non-compliance with rehabilitation protocol increases failure rate from 5% to 20%
Infection risk is 1-2% - prophylactic antibiotics and sterile technique essential

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 35-year-old powerlifter presents 3 days after acute pectoralis major rupture during bench press. Walk me through your assessment and surgical decision-making."

EXCEPTIONAL ANSWER

I will take a focused history, perform a physical examination, obtain imaging, and discuss surgical indications with this patient. HISTORY: I ask about the mechanism - typically eccentric load to maximally contracted muscle during bench press, the patient feels a sudden pop or tearing sensation with immediate pain. I confirm timing (3 days is acute, optimal window), hand dominance, occupation (powerlifting suggests high-demand), previous injuries, and functional deficits (weakness with pushing, adduction, internal rotation activities). PHYSICAL EXAMINATION: On inspection, I look for loss of the anterior axillary fold creating asymmetry compared to the contralateral side, visible deformity or defect, and ecchymosis along the anterior chest and arm. On palpation, I expect to feel a gap at the insertion site and a retracted tendon mass medially. I assess strength - typically marked weakness with resisted adduction and internal rotation. I check passive ROM which should be full, and perform a modified push-up test which will demonstrate inability or significant weakness. IMAGING: Plain radiographs (AP and axillary views) are usually normal but may show bone avulsion. MRI is the gold standard - it confirms complete rupture, shows the rupture location (musculotendinous junction in 60%, bone avulsion in 30%, muscle belly in 10%), quantifies retraction distance, and identifies any associated injuries. SURGICAL INDICATIONS: This patient has absolute indications for surgery: (1) Complete pectoralis major rupture confirmed on imaging, (2) Acute presentation within optimal repair window (3 days, ideally <2 weeks), (3) High-demand athlete (powerlifter) who requires maximal strength, (4) Young and motivated patient. I counsel the patient that acute repair gives 85-95% good to excellent results with near-normal strength recovery (90-95% of contralateral), whereas non-operative treatment results in 40-60% persistent weakness, cosmetic deformity, and inability to return to powerlifting. The re-rupture rate with surgery is 5-10% if protocol followed, but violations cause 20% failure rate. SURGICAL PLAN: I plan deltopectoral approach, identification and mobilization of the ruptured sternal head, preparation of the lateral lip of the bicipital groove insertion site, suture anchor fixation (3-4 anchors at 45-degree deadman angle), and secure tendon-to-bone repair with mattress sutures. Given high-demand athlete status, I would consider augmentation with internal brace or graft. Post-operatively, strict 6-week protection is mandatory - no active pectoralis contraction. Return to powerlifting expected at 9-12 months.

VIVA SCENARIOStandard

EXAMINER

"During pectoralis major repair via deltopectoral approach, you encounter significant bleeding from the inferomedial aspect of your dissection while mobilizing a chronically retracted tendon. What has happened and how do you manage it?"

EXCEPTIONAL ANSWER

This bleeding is most likely from injury to the anterior humeral circumflex vessels or branches of the thoracoacromial artery during deep inferomedial dissection. ANATOMIC LOCATION: The anterior humeral circumflex artery runs along the surgical neck of the humerus, inferior to the subscapularis and medial to the bicipital groove where I am working. The thoracoacromial artery branches include the pectoral branch that runs along the deep surface of pectoralis major medially. During mobilization of a chronically retracted pectoralis tendon, I am extending my dissection medially and inferiorly to retrieve the retracted stump, which puts these vessels at risk. IMMEDIATE MANAGEMENT: First, I obtain proximal and distal control with pressure using a lap sponge while maintaining visualization. I ask the assistant to hold pressure while I improve my exposure. I may need to extend the skin incision inferiorly and medially to better visualize the bleeding source. I identify the specific bleeding vessel - if it is a small branch, I can cauterize it with bipolar electrocautery. If it is the main anterior humeral circumflex artery, I will need to ligate it with suture ties or clips. I ensure hemostasis is complete before proceeding. PREVENTION: This complication is preventable through careful surgical technique. When mobilizing a chronically retracted pectoralis tendon, I should stay on the superficial surface of the pectoralis muscle belly and avoid deep dissection toward the humerus inferiorly. I identify anatomic landmarks - the conjoint tendon medially and the long head biceps in the groove laterally - and work in the plane superficial to these structures. I use gentle retraction and blunt dissection rather than sharp dissection when mobilizing scar tissue. If I need to extend exposure to retrieve a chronically retracted tendon, I do so under direct vision rather than blind dissection. NEUROVASCULAR STRUCTURES AT RISK: In addition to the anterior humeral circumflex vessels, other structures at risk with inferior-medial dissection include: (1) Musculocutaneous nerve, which pierces the coracobrachialis 5-8cm distal to the coracoid - I must avoid inferior dissection beyond this point, (2) Axillary nerve, which runs inferior to subscapularis - I stay superior to the surgical neck, (3) Brachial plexus cords medially - I avoid aggressive medial retraction. ONGOING PROCEDURE: Once hemostasis is achieved and I have confirmed no neurologic injury, I continue with the repair. I reassess my mobilization - if the tendon still cannot reach the insertion without excessive tension despite adequate release, I consider graft augmentation to bridge the gap rather than risk overtensioning the repair. At case completion, I place a drain due to the dead space and bleeding, and monitor post-operatively for hematoma formation.

VIVA SCENARIOStandard

EXAMINER

"Your patient had an excellent pectoralis major repair 4 weeks ago but now presents with sudden pop and pain after pushing a heavy door. Examination shows return of the anterior axillary fold defect and MRI confirms re-rupture at the tendon-bone interface. How do you manage this?"

EXCEPTIONAL ANSWER

This is a re-rupture at 4 weeks post-operatively, almost certainly due to early active pectoralis contraction violating the strict protection protocol. This is the most common cause of pectoralis repair failure. ASSESSMENT: I first confirm the diagnosis - examination shows return of the anterior axillary fold defect, weakness with adduction and internal rotation, and palpable gap at the repair site. MRI confirms re-rupture at the tendon-bone interface, which is the most common site of failure. I assess whether any anchors have pulled out (radiographs or MRI) and evaluate tissue quality. I document clearly in the medical record that the patient violated the post-operative protocol by actively pushing a heavy door at 4 weeks, which is prohibited until 6 weeks minimum. COUNSELING: This is a difficult conversation but must be handled professionally. I explain to the patient that the tendon-bone interface requires 6 weeks minimum to heal, and active pectoralis contraction before this time places excessive force on the healing repair, causing failure. The strict protection protocol exists specifically to prevent this complication. I emphasize that while this is frustrating, revision surgery can be performed but has lower success rates than primary repair (60-70% good results compared to 85-95% for primary acute repair). I discuss the importance of absolute adherence to the protocol after revision surgery. MANAGEMENT OPTIONS: **Non-operative**: Generally not appropriate for this young, active patient. Would result in same functional deficits and cosmetic deformity as the initial untreated rupture. Only consider in low-demand elderly patients. **Revision surgical repair**: This is the appropriate management for most patients. However, timing is important: - If patient presents immediately (within days of re-rupture): I proceed with early revision within 1-2 weeks while tissue is still relatively fresh - If delayed presentation: May wait 6-8 weeks for inflammation to settle before revision - I counsel that revision has lower success rates (60-70% vs 85-95% primary repair) due to scar tissue, potentially compromised tissue quality, and bone stock issues from prior anchors REVISION SURGICAL TECHNIQUE: - Use previous deltopectoral incision, expect more scar tissue and adhesions - Identify the re-ruptured tendon (likely retracted again medially) - Assess prior anchor sites - if anchors pulled out, may need to place new anchors in different locations or use larger/stronger anchors - Prepare humeral insertion site, removing scar tissue but preserving bone stock - Mobilize tendon aggressively to ensure adequate excursion without tension - Consider augmentation (high indication in this revision case) with allograft or internal brace to load-share during healing and reduce risk of second re-rupture - Secure fixation with mattress sutures through healthy tissue - Meticulous repair technique POST-OPERATIVE PROTOCOL: I emphasize even more strictly the 6-week protection, potentially extending to 8 weeks given revision status. I may use a shoulder immobilizer rather than simple sling to ensure better compliance. I involve physical therapy team in reinforcing protocol. I see patient more frequently (weekly for first 6 weeks) to reinforce education and monitor compliance. I document extensively the discussion about protocol violation and consequences. EXPECTED OUTCOMES: Counsel patient that revision repair provides 60-70% good to excellent outcomes (lower than primary 85-95%), may have more persistent weakness (20-30% deficit common), and has higher re-rupture risk (15-20% vs 5-10% primary). However, this is still superior to non-operative treatment and worth attempting in motivated patient. ALTERNATIVE: If patient demonstrates inability to comply with restrictions, or if second re-rupture occurs, may need to consider non-operative treatment or tendon transfer procedures, though the latter are not well-established for pectoralis reconstruction.

Pectoralis Major Tendon Repair - Exam Day Summary

High-Yield Exam Summary

References

Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc. 2000;8(2):113-119. doi:10.1007/s001670050197. Evidence: Meta-analysis demonstrating 26% loss of peak torque and 44% loss of total work with non-operative treatment vs near-normal strength with surgical repair.
ElMaraghy AW, Devereaux MW. A systematic review and comprehensive classification of pectoralis major tears. J Shoulder Elbow Surg. 2012;21(3):412-422. doi:10.1016/j.jse.2011.04.035. Evidence: Comprehensive classification system - Grade I (strain), Grade II (partial tear), Grade III (complete rupture). Location: muscle belly (10%), musculotendinous junction (60%), tendon avulsion (30%).
Schepsis AA, Grafe MW, Jones HP, Lemos MJ. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med. 2000;28(1):9-15. doi:10.1177/03635465000280011401. Evidence: Acute repair <6 weeks: 91% good/excellent results, 94% strength vs contralateral. Chronic repair >6 weeks: 76% good/excellent, 84% strength. Surgery superior to non-operative.
Aarimaa V, Rantanen J, Heikkilä J, Helttula I, Orava S. Rupture of the pectoralis major muscle. Am J Sports Med. 2004;32(5):1256-1262. doi:10.1177/0363546503261137. Evidence: Surgical repair resulted in significantly better strength (Cybex testing) and patient satisfaction compared to conservative treatment. 91% patients satisfied with surgery vs 27% with non-operative.
Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle. An anatomic and clinical analysis. Am J Sports Med. 1992;20(5):587-593. doi:10.1177/036354659202000517. Evidence: Classic anatomic study describing pectoralis insertion anatomy, tendon twist (inferior sternal fibers insert superiorly), and surgical technique for repair with suture anchors.
Hanna CM, Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med. 2001;35(3):202-206. doi:10.1136/bjsm.35.3.202. Evidence: Systematic review of 112 pectoralis major ruptures. Surgical repair resulted in 78% excellent outcomes vs 27% with conservative treatment. Surgery recommended for complete ruptures in active patients.
de Castro Pochini A, Ejnisman B, Andreoli CV, et al. Pectoralis major muscle rupture in athletes: a prospective study. Am J Sports Med. 2010;38(1):92-98. doi:10.1177/0363546509347995. Evidence: Prospective study of 46 athletes. Surgical repair within 6 weeks resulted in 95% return to sport at same level at mean 6 months. Isokinetic testing showed 8% deficit vs contralateral at 12 months.
Butt U, Mehta S, Funk L, Monga P. Pectoralis major ruptures: a review of current management. J Shoulder Elbow Surg. 2015;24(4):655-662. doi:10.1016/j.jse.2014.10.024. Evidence: Comprehensive review of surgical techniques. Recommends 2-4 suture anchors at lateral lip of bicipital groove, mattress sutures through tendon, consideration of augmentation for chronic tears. Emphasizes strict 6-week protection protocol.
Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92(3):542-549. doi:10.2106/JBJS.I.00450. Evidence: Epidemiologic data on shoulder injuries. Pectoralis major ruptures represent 1% of all shoulder soft tissue injuries, occurring predominantly in males (>95%), peak age 20-40 years, most common in weightlifters and contact athletes.
Provencher MT, Handfield K, Boniquit NT, Reiff SN, Sekiya JK, Romeo AA. Injuries to the pectoralis major muscle: diagnosis and management. Am J Sports Med. 2010;38(8):1693-1705. doi:10.1177/0363546509348051. Evidence: Comprehensive review including surgical indications, techniques, and outcomes. Discusses augmentation techniques with allograft or internal bracing for chronic tears and high-demand athletes. Reports re-rupture rates of 5-10% for acute repairs, 15-20% for chronic, reduced to <10% with augmentation.

Pectoralis Major Tendon Repair - Acute and Chronic Reconstruction