A pectoralis major tendon rupture is a rare shoulder injury most commonly seen in weightlifters. The incidence of such injuries is increasing due to the increasing emphasis on healthy lifestyles. 
Clinically Relevant Anatomy
The pectoralis major (PMM) is a very powerful shoulder muscle in its function – the shoulder adductors and humerus flexors. The origin of the pectoralis major includes the clavicle, sternal ribs and external oblique fascia and the cartilage of the first six ribs. As the pectoralis major tendon inserts into the humerus, the muscle twists itself so that the lowest fibers of the tendon insert into the highest portion of the humerus. Wolfe et al. This attachment has previously been shown to cause significant tension in the lower extremities Part of the pectoral muscle and makes that part prone to rupture when stretched and loaded. Using a thin wire attached to the humeral insertion and a dial gauge, Wolfe and colleagues measured the excursions of individual pectoralis fibers at seven different points along the origin. During the last 30 degrees of humeral extension, the lower fibers of the pectoralis major lengthen disproportionately.  This arrangement of attachments may result in partial tears that are more common than complete ruptures.  Studies have shown that complete rupture of PMM is Associated with sports such as weightlifting, wrestling, rhythmic gymnastics, and windsurfing. 
Mechanism of Injury
Injuries are most common among people who go to the gym. While pectoral tendon ruptures are most commonly seen in weightlifting, they have also been reported in many other sports, such as boxing, soccer, rodeo, water skiing, and wrestling. These injuries tend to occur more easily It is common in patients between the ages of 20 and 40. To date, such ruptures have been an exclusively male-dominated sports injury, and there are not even case study reports of injuries in female sports populations. 
The diagnosis of a pectoralis tear is usually not elusive. Patients usually have a history of maximal lifting or exertion and feel something bending or tearing in the shoulder; the injury is usually accompanied by an audible “snap” or “pop.”
- Mild swelling and ecchymosis follow.
- Bruising may be seen on the anterolateral chest wall or proximal arm.
- Pain generally is not intense.
- Physical examination revealed disappearance of the anterior axillary fold and normal pectoral muscle contour.
- Asking the patient to clasp their hands in a “prayer position” to induce isometric contractions will reveal chest wall asymmetry. This asymmetry is easily confirmed by looking for medial movement of the nipple on the chest wall.
- Often there is a pronounced deformity or depression where the pectoralis major muscle has moved medially.
- Pronation of the arm especially causes a loss of strength during the neutral test. 
- Traditional classification systems divide pectoralis major ruptures into 3 main categories ranging from contusions to partial tears to complete tears. Complete tears are further subdivided into anatomical location, whether musculoabdominal junction of muscle origin or tendon insertion.  classify as follows:
- Type I contusion, Type II partial injury, Type III complete rupture; and
- A starts from the sternum B starts from the muscle belly C starts from the tendon D starts from the insertion point of the humerus.
A complete rupture of the sternocostal portion may result in a loss of horizontal adduction force, similar to certain ruptures of the clavicle and sternocostal portion in other athletes. Dislocation or type III-D seen in cases of indirect trauma associated with weightlifting bench press. Even accounting for the loss of adduction force due to PMM rupture, the variable range of lesions may include tendon type III-C and muscle type III-B rupture.
- Magnetic resonance imaging (MRI) is especially useful when a partial tear is suspected 
Management / Interventions
Pain is a major concern and should be managed by a doctor. Importantly, patients need to be educated about the side effects of analgesics, and nonpharmacological measures such as ice massage and acupressure should be used for pain relief . Conservative management does not resulting in significant loss of function. Nonsurgical treatment has historically been advocated for the elderly or those who are sedentary or have incomplete tear flow. . However, young active individuals seeking faster recovery require referral to a plastic surgeon. Wolfe et al. have In unrepaired fractures, up to 26% loss of peak torque and 39.9% reduction in shoulder adduction work have been reported. . In addition, numerous studies have shown that surgical treatment of complete pectoralis tendon ruptures has definite advantages in terms of increased strength. Nonsurgical treatment, especially in athletes. 
Because no studies have been published discussing the repair strain properties of the pectoralis major tendon, the amount of stress this tissue can withstand before rupture or postoperative patient impairment is not fully understood. Therefore, postoperative soft tissue healing time The framework for post-pectoralis tendon repair is based on clinical impressions and empirical evidence from the treatment of these athletes. In addition, some general assumptions can be made based on previous literature related to soft tissue healing in other common tendon rupture repairs, including Rotator Cuffs and Achilles. 
As with most postoperative rehabilitation, the ultimate goals after pectoralis major repair include:
- Preserve the structural integrity of the repaired soft tissue;
- Gradual restoration of full functional range of motion (ROM);
- Restoring or enhancing full-motion muscle control and stability;
- Resume full and unrestricted upper body activities, including activities of daily living and recreational and athletic activities.
The ultimate goal is to allow patients to return to their preferred activity level as quickly and safely as possible. 
Immediate postoperative phase (0-2 weeks)
Aim to protect healing repair tissue Reduce pain and inflammation Establish limited ROM Exercise Do not exercise until the end of week 2 Sling immobilization for 2 weeks Passive rest for the full 2 weeks Allow soft tissue healing to begin uninterrupted Allow acute inflammatory response to function normally
Mid postoperative period (3-6 weeks)
Aim to gradually increase ROM Promote healing of repaired tissue Delay muscle atrophy Week 2 Sling immobilization until week 3 Passive ROM External rotation Beginning at week 2 Increase forward flexion by 5 degrees per week to 45 degrees Increase by 5-10 degrees per week Week 2 3 weeks stop sling Braces – Continue passive ROM at week 3 Begin abduction to 30 degrees, increase 5 degrees per week B Begin gentle isometric contraction of shoulder/arm except pectoralis major Scapula isometric contraction Exercises End week 5 for shoulder and elbow Gentle submaximal isometric contraction of hands and wrists Active scapula isotonicity Practice Passive ROM Flexion to 75° Abduction to 35° External Rotation 0° Abduction to 15°
Late Strengthening Phase (6-12 weeks)
Aim to maintain full ROM Promote soft tissue healing Gradually increase muscle strength and endurance Continue passive ROM to full at week 6 Continue gentle submaximal isometric contractions, progressing to isotonic exercises Begin performing submaximal isometric isometrics of pectoralis major in shortened position contraction, gradually develops into neutral muscle Tendon length Avoid isometric measurements in fully elongated position Week 8 Gradually increase muscle strength and endurance Upper body ergometer Progressive resistance exercises (isotonic machine) Theraband exercises PNF Diagonal pattern with manual resistance May be varied using techniques incision thickening scar Mobilization Techniques Ultrasonic Softening of Scar Tissue Week 12 Total Shoulder ROM Shoulder Flexion to 180 Degrees Shoulder Abduction to 180 Degrees Shoulder External Rotation to 105 Degrees Shoulder Internal Rotation to 65 Degrees Progression Strengthening Exercises Dumbbell Isotonic Exercises Gentle 2 Hands Max Plyometrics Chest Pass Side Toss Body Blades Flexbar Total Arm Strengthening
Advanced Intensive Phase (12-16+ weeks)
Aim for full ROM and flexibility Increase muscle strength Strength and endurance Gradually introduce physical activity Exercises Continue to advance functional activity of the entire upper body Avoid bench press movements beyond 50% of maximum (RM) for the first 1 repetitions Gradually increase to 50% of 1 RM for the next month is maintained at 50% of pre-1 RM until 6 months post-op, then slowly progresses to full Keys after the 6-month time frame Do not rush ROM Do not rush reinforcement Normalize joint kinematics Utilize full arm reinforcement
Role of Multidisciplinary Team
The recovery period after conservative treatment is often lengthy; surgery is quicker, but there is still a risk of complications. Regardless of the approach, patients should be encouraged to seek physical therapy. Studies show that the majority of patients have good outcomes.
For optimal patient outcomes, all members of a multidisciplinary medical team (sports physician, orthopedic surgeon, rehabilitation specialist, specialist-trained orthopedic nurse) must interact and have access to the same level of case-related information. 
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- Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle, an anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.
- de Castro Pochini A, Andreoli CV, Belangero PS, Figueiredo EA, Terra BB, Cohen C, Andrade MD, Cohen M, Ejnisman B. Clinical considerations for the surgical treatment of pectoralis major muscle ruptures based on 60 cases: a prospective study and literature review. The American Journal of Sports Medicine. 2014 Jan;42(1):95-102.
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