Pectoralis Major Tendon Repair - Acute and Chronic Reconstruction

Indication. A pectoralis major tendon rupture in an active patient - sudden pain and a pop during an eccentric load, loss of the anterior axillary fold, weakness of adduction and internal rotation, and a complete (Grade III) tear confirmed on MRI - that will benefit from restoration of strength and contour. The strong driver is a high-demand patient (athlete, manual worker, military) with a complete acute rupture, where surgery gives 85-95 percent good to excellent results versus 40-60 percent persistent weakness without surgery. Absolute indications

• Complete pectoralis major tendon rupture (Grade III) in an active patient
• Acute complete rupture in athletes or high-demand workers
• Displaced bone avulsion fractures
• Failed non-operative management of partial tears with persistent symptoms Relative indications
• Symptomatic partial tears (Grade II) with weakness or pain
• Chronic ruptures (greater than 6 weeks) with cosmetic deformity and functional deficit in a motivated patient
• Revision of a failed primary repair
• High-demand occupation requiring strength (manual labour, 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 (greater than 6-12 months) - consider tendon transfer instead
• Active infection Workup. Confirm the diagnosis and plan the repair. The mechanism is classically an eccentric load to a maximally contracted muscle (bench press about 80 percent, wrestling/tackling 15 percent, other 5 percent), with a sudden pop or tearing sensation and immediate pain, rapid swelling and ecchymosis over the anterior chest and arm. On examination look for loss of the anterior axillary fold with an asymmetric chest contour, a palpable gap at the insertion (acute) or a retracted tendon mass medially (chronic), weakness of resisted adduction and internal rotation, and a positive modified push-up test; passive ROM is usually full. Plain radiographs (AP and axillary) are usually normal but may show a bone avulsion fragment. Ultrasound can dynamically show retraction and a gap but is operator-dependent. MRI is the gold standard - it confirms rupture, shows the location (musculotendinous versus bone), quantifies retraction, and in chronic tears demonstrates muscle atrophy. Consent specifically for re-rupture (5-10 percent acute, 15-20 percent chronic), a 5-10 percent persistent strength deficit even after a successful acute repair, residual cosmetic deformity (especially chronic repairs), infection (1-2 percent), nerve injury - most often a musculocutaneous neuropraxia (1-2 percent) - and the absolute need for 6 weeks of strict protection. Setup. Beach chair (60-70 degrees elevation) or supine with a bump under the ipsilateral scapula. The arm is draped free on a mobile arm board so it can be moved through full ROM for tensioning and testing. Prophylactic antibiotics (e.g. Cefazolin 2g IV within 60 minutes) and standard shoulder prep.

The goal: expose the insertion through the deltopectoral approach, retrieve and mobilise the retracted tendon, prepare the lateral lip of the bicipital groove, re-attach the tendon under correct tension with suture anchors at the 45-degree deadman angle, and protect the musculocutaneous, pectoral and axillary nerves throughout. The exposure is laid out in full below (and in depth on the deltopectoral approach to the shoulder page).

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Rehabilitation | Phase | Timing | Immobilisation | Activity | |-------|--------|----------------|----------| | 1 Protection | 0-6 weeks | Sling at all times (except hygiene/therapy) | CRITICAL: no active pectoralis contraction (no pushing, pressing, lifting, reaching). Passive ROM only - pendulums, passive elevation to 90 degrees, passive ER to neutral. Elbow/wrist/hand active ROM and grip | | 2 Early active motion | 6-12 weeks | Sling weaned | Active-assisted ROM (week 6-8), light active ROM (week 8-10). No resisted adduction or internal rotation until week 12 | | 3 Strengthening | 12-16 weeks | None | Progressive resistance - elastic bands and light dumbbells (2-5 lbs) up to about 50 percent of the contralateral side | | 4 Return to activity | 4-6 months | None | Sport-specific training and functional drills; bench press progressed to 50-60 percent of pre-injury max | | 5 Full activity | 6-12 months | None | Non-contact sport at 6 months; contact sport, heavy bench press and maximal loading at 9-12 months | Most patients return to desk work by about 6 weeks and heavy manual work by 4-6 months. Expect a 5-10 percent strength deficit versus the uninjured side even after a successful acute repair (acceptable); chronic repairs may carry a 20-30 percent deficit. Return to contact sport and heavy bench press is delayed to 9-12 months to minimise re-rupture risk. Complications

Epidemiology. Pectoralis major rupture is uncommon, representing roughly 1 percent of all shoulder soft-tissue injuries. It occurs overwhelmingly in men (greater than 95 percent), peaks in the 20-40 year age group, and is most frequent in weightlifters and contact athletes. The mechanism is an eccentric load to a maximally contracted muscle - bench press about 80 percent, wrestling and tackling 15 percent, other 5 percent. Use of anabolic steroids is a recognised risk factor. Pathoanatomy. The muscle has two heads - clavicular (superior, smaller) and sternal (inferior, larger). The tendon twists 180 degrees so that the inferior sternal fibres insert most superiorly and the superior clavicular fibres insert inferiorly; the sternal head ruptures most commonly. The footprint lies on the lateral lip of the bicipital groove, a 5-8cm array beginning about 5cm distal to the greater tuberosity. Sixty percent of tears are at the musculotendinous junction, 30 percent are bone avulsions (the best prognosis for healing), and 10 percent are intramuscular (the worst prognosis).

Key evidence. The consistent message is that surgical repair is superior to non-operative treatment and that earlier repair is better. Schepsis (2000) reported subjective ratings of 96 percent (acute repair), 93 percent (chronic repair) and only 51 percent (non-operative), with isokinetic adduction strength of 102 percent, 94 percent and 71 percent respectively, with no significant difference between acute and chronic operative repair. de Castro Pochini (2010), in a prospective study of 20 athletes, found an isokinetic strength deficit of 13.7 percent after surgery versus 53.8 percent non-operative. Bak (2000), in a meta-analysis of 112 cases, showed repair within the first 8 weeks gave significantly better outcomes, independent of age or rupture location. ElMaraghy and Devereaux (2012) proposed the three-axis classification now in standard use. Butt (2015) confirmed MRI as the investigation of choice and that graft reconstruction has a role when direct repair is not achievable in the chronic setting.