Managing Pectoralis Major Ruptures in Football Players

John E. Kuhn, MD Kenneth D. Schermerhorn Professor of Orthopaedics Chief of Shoulder Surgery Director of Vanderbilt Sports Medicine Vanderbilt Sports Medicine Disclosure Information TRIA Orthopaedic & Sports Medicine Conference: Tackling Football Injuries John E. Kuhn, MD MS Disclosure of Relevant Financial Relationships

I have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative Uses

I will not discuss off label use and/or investigational use in my presentation.

Vanderbilt Sports Medicine Origin • Medial 1/3 of Clavicle • Anterior Aspect of Manubrium and Length of Body of Sternum • Cartilaginous Attachments of upper 6 Ribs • External Oblique’s Aponeurosis

Vanderbilt Sports Medicine Insertion • Lateral Lip of Bicipital Groove to the Crest of the Greater Tuberosity • Clavicular Fibers insert Distally and Superficially • Sternal Fibers insert Proximally and Deep

Vanderbilt Sports Medicine Two Heads

• Clavicular Head • Sternal Head

Vanderbilt Sports Medicine Many Segments to Sternal Head

• Fan Shaped Muscle

ElMaraghy AW, Devereaux MW. A systematic review and comprehensive classification of petoralis major tears. JSES 2012;21:412-422

Vanderbilt Sports Medicine Insertion • Anterior Leaflet – Clavicular Head – Upper part of Sternal Head • Posterior Leaflet – Lower Part of Sternal Head – Good for Transfers!

Vanderbilt Sports Medicine Action

• Adduction of Humerus • Medial Rotation of Humerus • Flexion of arm from Extension (Clavicular Portion) Incline Bench Press

Vanderbilt Sports Medicine Blood Supply • Pectoralis Branch of Thoracoacromial Artery • Runs with Lateral Pectoralis Nerve

Vanderbilt Sports Medicine Innervation

• Clavicular Head: Lateral Pectoral Nerve (C5,6,7) • Sternal Head: Medial Pectoral Nerve (C8, T1)

Vanderbilt Sports Medicine Reported Frequency of Injury

ElMaraghy AW, Devereaux MW. A systematic review and comprehensive classification of petoralis major tears. JSES 2012;21:412-422 Vanderbilt Sports Medicine Demographics • Males: Age 20-39 • Females: Elderly and Dependent • Hand Dominance not a factor • Increased Risk – Anabolic Steroids – Muscle Fatigue/Micro trauma

Vanderbilt Sports Medicine Mechanisms of Injury • Bench Press • Sports: (power lifting, rugby, snow skiing, water skiing, football, wrestling, parallel bar dips, boxing, sailboarding, parachuting, hockey) • Work: (first case Paris 1822- butcher boy lifting meat) • Transfers in the Elderly (stiff and atrophied muscle-a

crush injury) Vanderbilt Sports Medicine History • Audible POP • Tearing Sensation • Immediate Pain and/or Weakness

Vanderbilt Sports Medicine Vanderbilt Sports Medicine Classification of Injury

ElMaraghy AW, Devereaux MW. A systematic review and comprehensive classification of petoralis major tears. JSES 2012;21:412-422

Vanderbilt Sports Medicine Physical Exam • Can be Difficult to Determine Type:

Vanderbilt Sports Medicine Physical Exam • Deformity • Ecchymosis • Swelling may Mask Extent

Vanderbilt Sports Medicine Physical Exam • Indentations with Flexing

Vanderbilt Sports Medicine Physical Exam • Things to Look For: – Loss of Axillary Fold – Fullness in Belly of Muscle

Vanderbilt Sports Medicine Some Hints • If there is NO Ecchymosis on the Humerus • AND the Axillary Boarder is Intact • Then Possibly a Muscle Origin or Muscle Belly Injury

Vanderbilt Sports Medicine MRI Imaging-Normal

• Pectoralis tendon • Latissimus Tendon • Triceps • Quadrilateral Space Vanderbilt Sports Medicine MRI Imaging Muscultotendonous Junction Tear

Case courtesy of Dr Ajay C Desai, Radiopaedia.org Vanderbilt Sports Medicine MRI Imaging Muscultotendonous Junction Tear

Vanderbilt Sports Medicine Case courtesy of Dr Ajay C Desai, Radiopaedia.org MRI Imaging Muscultotendonous Junction Tear

Case courtesy of Dr Ajay C Desai, Radiopaedia.org Vanderbilt Sports Medicine MRI Imaging Tendon Avulsion

• Tendon Off Bone • Tendon is Wavy • Biceps sits Anterior

Vanderbilt Sports Medicine Acute Injury Treatment Option

• Nonoperative • Surgical repair

Vanderbilt Sports Medicine ARS Question 2 What are the Indications for Surgical Repair?

A.) Low Demand, Elderly Patient B.) Muscle Origin Tear C.) Muscle Belly Tear D.) Active High Demand Patient E.) Muscle Strain

Vanderbilt Sports Medicine ARS Question 2 What are the Indications for Surgical Repair?

A.) Low Demand, Elderly Patient B.) Muscle Origin Tear C.) Muscle Belly Tear D.) Active High Demand Patient E.) Muscle Strain

Vanderbilt Sports Medicine Nonoperative Management • Low Demand • Elderly

Vanderbilt Sports Medicine Nonoperative Management • Sling • Cryotherapy • Passive exercises as tolerated • Active assisted and active exercises over next six weeks • Resisted therapy at 2-3 months Vanderbilt Sports Medicine Nonoperative Management

• Muscle Belly Tear Diffuse Strain • Focal Tear- • Difficult to Repair • Muscle Tears

Vanderbilt Sports Medicine Surgical Management

• Literature Comprises Case Series • OVERWHELMINGLY Supports Surgery for Active Patients

Vanderbilt Sports Medicine Surgical Management

De Castro Pochini A et al. Clinical consideration for the surgical treatment of pectorals major muscle ruptures based on 60 cases Am J Sports Med 42(1):95-102, 2013 Vanderbilt Sports Medicine Surgical Management

• Transosseous • Trough and Drill Holes

Petilon J, et al Pectoralis Major Muscle Ruptures. Oper Tech Sports Med 13:162-188, 2005 Vanderbilt Sports Medicine Surgical Techniques • Suture Anchor Repair

Provencher MT, et al Injuries to the Pectoralis Major Muscle: Diagnosis and Management, Vanderbilt Sports Medicine Am J Sports Med 38:8:1693- 1705, 2010 Surgical Techniques • Knotless Anchor Repair

Samitier GS, et al. Pectoralis major transosseous equivalent repair with knotless anchors Int Vanderbilt Sports Medicine J shoulder Surg 9(1):20-23, 2015 Surgical Techniques • Unicortical Endobuttons

Metzger PD et al. Pectoralis major muscle rupture repair: Technique using unicortical Vanderbilt Sports Medicine buttons. Arthrsocpy Techniques 1(1): 119-125, 2012 Chronic Injury Surgical Techniques

• Hamstring Graft • Fascia Lata Allograft

Schachter AK et al. Revision reconstruciont of a pectoralis major tendon rupture using hamstring autograft. Am J Sports Med 32:2:295-298, 2006 and Sikka RS. Et al Reconstruction of the pectoralis major tendon with fascia lata allograft Orthopaedcis 28(10):1199-201, 2005. Vanderbilt Sports Medicine Postoperative Management • Sling 4-6 weeks • Passive Pendulums + Scapula Motion immediately • Gentle Passive ROM begins at 6 weeks to full Active ROM by 12 weeks • Progressive Strengthening at 12 weeks • Unrestricted Activity at 4-6 Months

Vanderbilt Sports Medicine Complications of Injury/Treatment

• Acute Compartment Syndrome (Smith et al JSES 2015)

• Exercise Induced Compartment Syndrome (Tarkin JSES 2009)

• Infected Hematoma (Pai et al Aust N Z J Surg 1995)

• Proximal Humerus Fracture (Silverstein Orthopedics 2011)

Vanderbilt Sports Medicine Thank You

Vanderbilt Sports Medicine