141. Pec Major Tears: What PTs Need to Know

Join us as we dive deep into pectoralis major tears. We'll discuss the anatomy of the pectoralis major, typical mechanisms of injury, and examination methods to diagnose these tears accurately. We also cover risk factors, differential diagnosis, and imaging options. Finally, we'll talk about treatment plans, both conservative and surgical, and the importance of understanding tissue healing timelines. 

00:00 Introduction to the Podcast and Today's Topic

01:18 Anatomy of the Pectoral Major

02:10 Mechanism of Injury and Common Symptoms

03:53 Assessment and Diagnosis

06:38 Imaging and Differential Diagnosis

07:31 Treatment Options: Conservative vs. Surgical

08:44 Post-Surgical Rehabilitation Phases

11:00 Key Takeaways and Conclusion

Transcript

0:27

Let's say you have a patient that came in that felt a popping sensation in their shoulder area during their bench press, had immediate pain, they've noticed some bruising, really limited in what they can do with their arm overall, and definitely haven't been able to binge since. What are some things that you're thinking? I am gonna PTs next podcast. This is Casey Rost, and if you're tuning in for the very first time. What you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time. And today what we're gonna cover more on are pectoral major tears, which is not the most common thing in the world, but these do happen every once in a while. And so we're gonna talk about just a brief overview of the anatomy of the pectoral major. The mechanism of injury that we usually see with this kind of thing. And then what sort of things to assess in an exam to see if this is actually the case. Now before we do, if you've listened to three or more shows and you felt like this was pretty helpful to you, if you wouldn't mind leaving a review on wherever you're listening to this podcast, that really helps a lot. Or you can share it with somebody that you know, but definitely really appreciate when you guys do that. Now diving into today's topic, let's go over anatomy really quick. So with the pictorial major, keep in mind that there are multiple heads. The origin of the sternal head is at the sternum, which makes sense, and the six superior cosal cartilages. The origin of the clavicular head is the medial half of the Clvi clavicle. Which also makes sense just based on the name. Now this, these heads are gonna insert into the lateral lip of the bicipital groove of the humerus, and it is innervated by the medial and lateral pectoral nerves C five through T one. The main job of this muscle is shoulder abduction, ad internal rotation, and horizontal flexion, especially under load. So what happens a lot of times when this is torn is usually the mechanisms injury is an eccentric contraction. While the shoulder is extended in the final 30 degrees abducted and externally rotated, like in the descending part of a binge press, that person's usually gonna feel a pop, a tearing sensation, have immediate weakness and potential bruising or bawling up of the muscle belly. We generally see this in males from. We say range 20 to 50 years old. But really narrowing in on thirties and forties, and it's often during a binge press or other shoulder extension. Shoulder extension exercises that are under tension. So we can see this in things like martial arts, football, that kind of stuff. But as I said, it's not the most common injury in the world if you do treat a large barbell lifting population. Something to have on your radar. So some risk factors include anabolic steroid use things that put. Put that person under a heavy eccentric loading specifically for the pectoral major and fatigue and poor control over the load. And usually these are, these tears are tendon avulsions at the site of the insertion rather than a myotendinous junction tear with things like a binge press. So probably the most common mechanism is during the binge press, in the eccentric portion. Now, here's the thing, it's 50% of pec tears are often mis missed or misdiagnosed at initial contact, so definitely something to have on a differential diagnosis list. Now when that person is coming in to see you during the assessment, they, if they have this, are probably gonna complain about having acute tearing a pop, a sharp pain during the mechanism of injury. They'll probably have pain with any sort of pushing or loading in the a horizontal plane, and they might even have some bruising or anterior shoulder fullness that they might complain of. Now when you are doing an objective exam. You're looking for if there's bruising along the anterior aula, loss of anterior axillary fold. If you're palpating it, do you feel any gaps or defects in the muscle, belly or tendon? That might be a sign of a tear. And then in terms of strain testing, there're probably gonna be weak and potentially painful depending on the degree of tear with resisted horizontal abduction ad and internal rotation. Now beyond between the clavicle, clavicular, and sternal portions for testing, sternal tends to rupture more often. And in terms of functional testing, things like a pushup or resisted press may reproduce the symptoms or show weakness. So essentially what we're doing here is if we're suspicious of a pectoral major tear, we are trying to see if it shows any signs of, if it's a muscle, a deficit in its ability to contract or any bawling up in the muscle bruising, things like that. A special test that you can't have people do, it's called a hug test. So you're asking the patient to press the palm, their palms together in front of their chest like they're going to pray. And as they're pressing, see if they know any weakness or pain. Now some things to include on your differential diagnosis list. Some are more high on the list than others would be long head of the bicep rupture, which is gonna be more proximal for the shoulder and it involves more elbow function. You can look into if there's another sort of muscle strain of some sort or tear injury. Anterior deltoid pec minor strain, which is pretty rare considering the blueprint. The footprint of that muscle. If there's a rotator cuff tendon tear shoulder dislocation, depending on the mechanism of injury looking at subscapularis, all of those things are good to roll out, which you can look at in terms of screening out the joints above, screening out range of motion, muscle testing, look at the joints above, below, et cetera. But. Ideally their history and their exam should all make sense in terms of what you're suspicious of. Now in terms of imaging, they may come with imaging before they even see you, which is awesome. But typically, MRI is gonna be a gold standard just considering if we're looking at muscle tear suspicions. An x-ray is gonna rule out some sort of fracture or something like that. But in terms of being able to view the. If the muscle is torn or not, MRI is gonna be gold standard. An ultrasound is still an option though, that can be utilized if you have one in your clinic. But if you are looking at this patient and they haven't had any imaging at all, they're showing signs and symptoms that are suggested of a tear and they have a strength deficit of more than let's say 30%. Might be good to point them back to physician who can order. Imaging or if you're in a place where you can order imaging yourself something to consider. Now in terms of treatment, it really depends on the degree of tearing whether they're gonna go conservative care or surgical care. So if it is maybe something that's determined non-surgical management, maybe it's just a partial tear, or there's minimal loss this is maybe more so indicated in older adults or patients who have a low demand of activity, partial tears, they may start off with conservative care. With early isometrics starting to progress the resistance and the range of motion that they're going through, and then work towards tric and sport or work like activities. In terms of if it's a complete tear, this is probably gonna be surgical management and ideally it's done within the first two to three weeks of injury. So if you remember before I said. About 50% of pec tears are missed or misdiagnosed at initial contact. Imagine someone is misdiagnosed and they're waiting a couple weeks for it to get better. It doesn't get better. It takes a while to get an actual diagnosis, and that's less ideal. So the more that we can really dial in on what's going on and be proactive with this, the better it is for those patients. Now with the surgery, essentially the tendon is gonna be reattached. And so anytime we have a surgery where something is reattached, there needs to be a time period where we allow healing to occur and for it to integrate. So if we're breaking it up into phases,'cause again, the actual weeks can. Bend on surgical preference, and I think it's always good to see what the surgeon suggests considering they're the one that did the surgery in the first place. But there's usually gonna be a phase of very maybe gentle passive range of motion or very little motion really just to allow it to heal. There's usually gonna be an initial phase where we're trying to mainly allow for healing. At some point they may initiate gentle passive range of motion only starting with ranges of motion that don't add quite as much of a strain on that complex. Essentially that's healing. In another phase, phase two that's when someone might start active assist range of motion, active range of motion isometrics to get the muscles firing. And then moving on to phase three where they're doing progressive strengthening, eccentric loading, and then eventually return to sport. So understanding tissue healing timelines, though is very important. Even if your patient is rearing to go back to the binge press it's very important to educate your patient on the fact that muscles or really the body heals on a timeline regardless of what we want for it or not. So an example timeline can be phase one, zero to six weeks. We allowing just passive range of motion, phase two, six to 12 weeks active range of motion isometrics, allowing that tendon to integrate into where it's. Attached. And then by about three months, three months plus, they're ready to start gentle strengthening return to sport, five to six months, depending on the sport. Again, there's, it is dependent on a lot of factors with the patient as well too. Make sure that you keep in mind the preferences of the surgeon, the patient and their progressions that. They would need to be deemed viable to move on to the next step. Are they getting appropriate range of motion? Are they getting appropriate muscle activation? Do objective testing to measure progress. So essentially main takeaways. We wanna make sure that we get really good at diagnosing pec major strains. So added onto your differentials with things that make sense, especially if someone's coming in with a popping sensation. And the earlier we recognize them, the better the outcomes for the patients. So knowing your anatomy, your loading positions understanding how to actually test for what you think you're testing, those are all gonna be plea, essential for really any diagnosis, but essentially knowing your, especially knowing your anatomy and physiology with this muscle and this topic of today, a pectoral major that's gonna be clutch. So if you have any questions at all, feel free to reach out at PTs x podcast@gmail.com. I'll help you the best way that I can. Now, if you are looking to basically. Take deeper dives, get CCUs for your license renewal. Maybe you're prepping for a specialty exam prep. Med Bridge is actually offering listeners over a hundred dollars off their year subscription just by using the promo code in the podcast description. So definitely make sure you utilize that if you want that. And for students, if you're a student, you get an even better discount. So make sure to use your own student promo code. But that's it for today, guys. I hope you have a great rest of your day, and until next time.