Isolated Tears of Pectoralis Minor Muscle in Professional Football Players: a Case Series John E

(aspects of sports medicine)

Isolated Tears of Pectoralis Minor Muscle in Professional Football Players: A Case Series John E. Zvijac, MD, Bashir Zikria, MD, and Angie Botto-van Bemden, PhD

Abstract ciae covering the intercostals, passing sent mechanisms of injury, clinical Our objective is to include pectoralis superiorly and laterally to insert on presentations, appropriate diagnostic minor injuries in the comprehensive the coracoid process of the scapula. studies, and treatments. assessment of differential diagnoses It provides an anatomical landmark for anterior chest wall pain or medi- for deeper structures, specifically Materials and Methods al anterior shoulder pain sustained the axillary artery, the medial pec- during blocking activities, which Case 1 may present in football players. toral nerve, and the brachial plexus A right-hand–dominant man in his In this article, we report 2 cases cords. The pectoralis minor origin late 20s presented with pain in the of isolated pectoralis minor tears and insertion are subject to variation.6 anterior region of the left shoulder in professional football players and The pectoralis minor action includes just inferior to the clavicle. The present mechanisms of injury, clini- protraction and depression of the lat- patient was a fullback in the US cal presentations, appropriate diag- eral angle of the scapula. National Football League (NFL). nostic studies, and treatments. A multitude of differential diagno- His injury initially occurred during ses may be considered when athletes practice; when performing blocking ith individuals’ present with anterior chest wall pain. drills, he experienced increasing increasing participa- Our objective is to include pectoralis pain in the left shoulder and chest. tion in competitive minor injuries in the comprehensive Approximately 1 week later, he sports and weight lift- assessment of differential diagnoses discontinued his practice sessions Wing, tears of the pectoralis major for anterior chest wall pain or medial because of the pain. He said he was muscle and tendon are no longer anterior shoulder pain sustained dur- having significant difficulty with uncommon.1-3 In contrast, an iso- ing blocking activities, which may abduction and external rotation. lated pectoralis minor injury, to our present in football players. Physical examination revealed no knowledge, has been reported only In this article, we report 2 cases of apparent ecchymosis or deformity. On once in the orthopedic literature.4 isolated pectoralis minor tears in pro- palpation, there was significant ten- The pectoralis minor, a triangular fessional football players (each player derness over the sternal portion of the muscle situated deep in the pectoralis provided informed consent) and pre- pectoralis major and in the area of the major,5 originates from the second to the fifth ribs and the overlying fas-

Dr. Zvijac is Orthopaedic Surgeon, UHZ Sports Medicine Institute, Coral Gables, Florida. Dr. Zikria is Orthopaedic Surgeon, Johns Hopkins Medicine, Lutherville, Maryland. Dr. Botto-van Bemden is Director of Research, UHZ Sports Medicine Institute, Coral Gables, Florida.

Address correspondence to: Angie Botto- van Bemden, PhD, UHZ Sports Medicine Institute, 1150 Campo Sano Ave, Suite 200, Coral Gables, FL 33146 (tel, 305- 669-3320 ext 6224; fax, 786-308-6274; e-mail, [email protected]).

Am J Orthop. 2009;38(3):145-147. Copyright, Quadrant HealthCom Inc. Figure 1. Case 2—anteroposterior magnetic resonance imaging shows iso- 2009. All rights reserved. lated tear of pectoralis minor muscle.

March 2009 145 Isolated Tears of Pectoralis Minor Muscle in Professional Football Players

ralis major lacked increased signal, indicating that it was intact. Thus, MRI confirmed an isolated pectoralis minor tear. The prescribed treatment and rehabilitation consisted of scapular retraction/protraction and shoulder depression exercises. The patient returned to play during week 3.

Discussion Considering the variation in the origin and insertion of the pectoralis minor muscle, it is impera- tive to consider all the differential diagnoses, including costal injuries, high rib (ie, second rib) fractures, sternoclavicular injuries, pectoralis major tears, and pectoralis minor tears.7 Pectoralis minor inju- Figure 2. Case 2—cross-sectional magnetic resonance imaging shows iso- ries present with anterior shoulder lated tear of pectoralis minor muscle. pain immediately inferior to the clavicle. Our 2 patients sustained coracoid. During bilateral contraction shoulder region, just inferior to the their pectoralis minor injuries dur- of the pectoralis major, there was clavicle, during blocking drills, with ing blocking drills, in each case no significant asymmetry. The patient the shoulder in flexion and the arms with arms in extension and shoul- had full active and passive range of in extension. He continued practic- der in abduction and flexion. In motion during forward flexion and ing, without restriction, through his previous reports, the mechanism internal rotation; however, moder- discomfort. His primary complaint of injury for the pectoralis minor ate pain was elicited with abduction was weakness while blocking, during was a direct blow to the front of the and external rotation. Neurovascular passing drills. shoulder.4 Comprehensive evalua- examination of the left upper extrem- Physical examination revealed no tion combined with MRI studies ity was normal. The pectoralis major apparent ecchymosis or deformity. will ensure an accurate diagnosis. tendon appeared to be intact. Significant tenderness was elicited An advantage in using MRI is that

“...an injury sustained during blocking drills or from a direct blow to the anterior chest wall or shoulder could be a pectoralis minor injury...”

Magnetic resonance imaging (MRI) over the sternal portion of the pec- it can be used to diagnose pectoralis confirmed an isolated pectoralis minor toralis major and in the area of the minor injuries and exclude pectora- tear, and conservative treatment was coracoid. During bilateral contraction lis major injuries.8,9 prescribed. The rehabilitation protocol of the pectoralis major, there was no Whereas patients with complete consisted of scapular retraction/pro- significant asymmetry. The patient pectoralis major tears are encouraged traction and shoulder depression exer- had full active and passive range to undergo surgery to regain opti- cises for shoulder stabilization. During of motion during forward flexion mal function, conservative treatment week 3, function and pain improved, and internal rotation. He felt moder- was recommended for our 2 patients. and the patient returned to play. ate pain with abduction and external We based this treatment on reports rotation. Neurovascular examination of patients with Poland syndrome, Case 2 was normal. The pectoralis major congenital absence of the pectoralis A left-hand–dominant man in his tendon appeared to be intact. minor, which poses no functional lim- late 20s, an NFL offensive tackle, MRI was performed subsequent itations.10 Furthermore, Mysnyk and presented with left anterior shoulder to symptoms persisting (Figures 1, Johnson,11 reporting on 2 wrestlers pain. His initial injury occurred dur- 2). Increased signal throughout the with Poland syndrome, stated that ing practice. He became increasingly entire pectoralis minor indicated a Cybex testing revealed no appreciable aware of discomfort in the anterior complete tear. However, the pecto- decrease in shoulder internal rotation

146 The American Journal of Orthopedics® J.E. Zvijac et al strength but did show a 20% to 30% Authors’ Disclosure 6. Homsi C, Rodrigues MB, Silva JJ, Stump decrease in shoulder horizontal adduc- Statement X, Morvan G. Anomalous insertion of the tion strength (though the anomaly The authors report no actual or poten- pectoralis minor muscle: ultrasound findings. J Radiol. 2003;84(9):1007-1011. imparted no functional impairments). tial conflict of interest in relation to 7. Bhatia DN, de Beer JF, van Rooyen KS, Lam Thus, patients similarly affected may this article. F, du Toit DF. The “bench-presser’s shoulder”: be advised that shoulder strength may an overuse insertional tendinopathy of the pectoralis minor muscle. Br J Sports Med. be slightly decreased but that func- References 2007;41(8):e11. tional limitations are unlikely.11 1. Aarimaa V, Rantanen J, Heikkila J, Helttula 8. Carrino JA, Chandnanni VP, Mitchell DB, I, Orava S. Rupture of the pectoralis major Our main point is that an injury Choi-Chinn K, DeBerardino TM, Miller muscle. Am J Sports Med. 2004;32(5):1256- MD. Pectoralis major muscle and tendon sustained during blocking drills or 1262. tears: diagnosis and grading using mag- 2. Bak K, Cameron EA, Henderson IJ. Rupture netic resonance imaging. Skeletal Radiol. from a direct blow to the anterior of the pectoralis major: a meta-analysis of 112 2000;29(6):305-313. chest wall or shoulder could be a cases. Knee Surg Sports Traumatol Arthrosc. 9. Zvijac JE, Schurhoff MR, Hechtman KS, Uribe 2000;8(2):113-119. pectoralis minor injury. Remaining JW. Pectoralis major tears: correlation of mag- 3. Potter BK, Lehman RA Jr, Doukas WC. Pectoralis netic resonance imaging and treatment strate- aware of the clinical presentation major ruptures. Am J Orthop. 2006;35(4):189- gies. Am J Sports Med. 2006;34(2):289-294. of this injury and conducting MRI 195. 10. Suzuki T, Takazawa H, Koshino T. Computed studies will permit an accurate, early 4. Mehallo CJ. Isolated tear of the pectoralis minor. Clin J Sport Med. 2004;14(4):245- tomography of the pectoralis muscles in diagnosis. Early diagnosis will ensure 246. Poland’s syndrome. Hand. 1983;15(1):35-41. that the athlete receives appropri- 5. Turan-Ozdemir S, Cankur NS. Unusual varia- 11. Mysnyk MC, Johnson DE. Congenital tion of the inferior attachment of the pectoralis absence of the pectoralis muscles in two ate treatment and rehabilitation and minor muscle. Clin Anat. 2004;17(5):416- collegiate wrestling champions. Clin Orthop. returns to the field of play. 417. 1991;(265):183-186.

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