PECTORALIS MAJOR TENDINITIS/ TEAR

The pectoralis muscle is located in front of your chest and upper arm. It helps in bending your arm, rotational movements of your shoulder and in maintaining stability in the shoulder joint. The pectoralis muscle has two tendons, the part that arises from the collar bone (clavicle) called the clavicular head and the other that arises from the breast bone (sternum) called the sternal head. The tendon flips 180 deg before it attaches at the upper arm. Of the two that attach it to the arm the sternal head is the one that often tears. A tear in this tendon will make it painful and difficult for you to move your shoulder and weaken your arm. Once the tendon is torn, it cannot regrow back to the bone and heal by itself. Permanent weakness during movements of the shoulder may occur, if the tendon is not repaired surgically.

Pectoralis major tendon tears can be complete or partial although mostly complete. In partial tendon tear, the tendon does not tear completely but is often painful. A complete tendon tear means it ruptures completely off the arm bone.

Causes

Pectoralis Major tendon ruptures most often result from a sudden injury or lifting a heavy object usually during a bench press in weightlifters or body builders. Additional risk factors, such as advancing age, smoking and use of corticosteroid medications, can also result in increased muscle and tendon inflammation and weakness, which can lead to the tendon rupture.

Signs and symptoms

The most common symptom is a sudden, severe pain in the upper arm or shoulder.¬† You may feel a “pop” at the shoulder when the tendon tears. Other symptoms include swelling, visible bruising along the chest and upper arm, weakness in the shoulder and arm, trouble turning your arm, and a gap in the axillary fold at the front of the shoulder, caused by the absence of the tendon.¬† A bulge may also appear in your chest caused by the recoiled, shortened muscle.

Diagnosis

Pectoralis tendon rupture is usually diagnosed based on your symptoms, medical history, and physical examination. During the physical examination, Dr Bala will look for a gap in the tendon by palpating the front part of your axillary fold. He will also look for weakness of movement of the shoulder especially during adduction and internal rotation. Dr Bala will diagnose a partial tear by asking you to place your hands on your hips and tighten the pectoralis muscle, and identify weakness and pain if there is a partial tear. Rarely x-rays can show a fleck of bone with a bony avulsion. Using an Ultrasound or MRI scan, Dr Bala can determine whether the tear is partial or complete. If the tear is acute the exact type of the tear pattern may be determined and if it is chronic tendon retraction may be assessed with scans.

Non operative treatment 

Tendinitis of the pectoralis major tendon without tears or partial tears of the pectoralis can be managed conservatively with rest, painkillers and graded physiotherapy to strengthen the tendon especially in elderly or non-athletes. If this has failed to relieve your symptoms Dr Bala may inject the shoulder joint and the front of the shoulder (where the tendon lies outside the joint) with steroids.

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In rare instances Dr Bala may opt to use cells from your own blood that are rich in undifferentiated cells. This preparation is called Platelet Rich Plasma or PRP. This injection may aid healing of partial tears of the pectoralis tendon.

Treatment

If it is your non-dominant shoulder that is involved and your age and activity level does not require strength, surgery may not be required. If you are younger or this problem involves your dominant shoulder and your work or profession demands shoulder strength Dr Bala may decide to fix the cut end of the tendon to the arm bone. If you are a professional athlete or bodybuilder and have significant weakness or cosmetic deformity, Dr Bala may suggest surgery. During surgery Dr Bala will open the shoulder through the front to visualize the tendon tear. The portion of the tendon may need to be cleaned and mobilized. The humerus bone is then prepared for tendon reattachment and to promote healing. Thick flat suture tapes are passed through the tendon in a particular interlocking manner to ensure a strong tendon repair. Dr Bala prefers to fix the tendon to the humerus using a device called a Pec button and uses a single incision for this procedure. Normally 3 to 4 buttons are required as the footprint of the native tendon is about 5 to 7 cm. Sometimes if the tendon has been chronically retracted, tendon substitutes either from one’s own body or from donors may be required.

As this procedure is performed near important nerves that supply the shoulder Dr Bala will explain in more detail the risks involved with this surgery and what precautions he takes to prevent them from happening. Dr Bala takes special precautions while performing this surgery to protect important structures near the shoulder to prevent complications. In the event you may have a tattoo on the shoulder Dr Bala is well versed in suturing tattoos back accurately with absorbable sutures. 2 weeks after the surgery gentle exercises are instituted to regain range of movement and strength to the shoulder over the next 6 to 12 weeks. Sports persons can expect to return to competition in about 6 months. Dr Bala is also trained to deal with revisions for failed primary repairs.