by G. John Mullen, DPT 2011 | firstname.lastname@example.org
Whether yours are large or small, everyone is familiar with the pectoral muscles (not to be confused with breast tissue). Regardless of their size, they are an area of both admiration and concern for all genders…and an area that no one wants to injure! Lucky for us, pectoral tears and strains are as uncommon as a gringo in Shanghai (trust us, we know). These injuries are bothersome and painful and, unfortunately, can be overlooked if without proper screening by a professional. Historically, pectoral tears were work related. Hop in your Delorian and travel back to a time in which we performed infinitely more manual labor. Imagine tearing your pectoral muscle while moving a giant hanging calf carcass…not fun. Nowadays, pectoral injuries are caused by 1) sports injury (typically football or basketball when the arm is in extension and externally rotated or 2) the ever popular bench press (performed improperly 90% of the time; a trip to 24 Hour Fitness makes us cringe!).
Stat Fact: Nipple piercing is associated with a 10- to 20-fold increase in the development of a subareolar abscesses (i.e. a ball of infected pus under your nipple). The other most significant risk factor was smoking, which increases your risk six- to eightfold.
Double Stat Fact: Greater breast elevation and compression has been shown to provide significantly increased breast and bra comfort compared with a standard encapsulation sports bra during physical activity for women with large breasts…which you probably already knew. Just a friendly scientific reminder.
The pectoralis major muscle has two heads: sternal and clavicular. These two heads have similar functions: internally rotating the arm, bringing the arm towards midline (adduction) and flexion when the arm is in an extended or neutral position. The sternal portion performs the majority of internal rotation and the clavicular portion is involved in flexion. These two subsections of the muscle are commonly grouped together because they are controlled by the same nerves (the lateral pectoral nerve and the medial pectoral nerve). The two heads both insert their muscle belly into the bicipetal groove of the humerus (upper arm).
Stat Fact: We’re going to get technical on you for a second. It turns out that the inferior portion of the pectoral has a distinct mechanical disadvantage when the arms are extended at approximately 30 degree. For this reason, it is the sternal portion of the muscle that often ruptures first in exercises such as the bench press, putting greater stress on the remaining muscle and increasing your risk of further rupture (3). OK, the physics lesson is officially over.
As discussed, sporting injuries and bench pressing are the most common sources of pectoral injuries today. When the arm is externally rotated and extended (i.e. sticking straight out to your side), the inferior portion of the muscle is under high levels of stress. If the external force on the muscle overcomes the tensile strength of the sliding filaments in your muscle (actin and myosin, duh…don’t you remember from your anatomy & physiology course?), you may hear that infamous “pop.”
Stat Fact: Pectoral injury is almost exclusively seen in men (sorry guys, but women have enough breast pathology as it is). Scientists have postulated that this difference exists because women have a larger tendon-to-muscle diameter, greater muscular elasticity, and less energetic injuries than men (3).
Swelling and redness are the common signs of a pectoral tear (plus the severe pain and classic mechanism of injury!). These symptoms often improve within 48 hours of the injury. Asymmetry between sides can indicate a disruption in the muscle belly, so don’t be afraid to check out your situation in the mirror and compare sides (who doesn’t do a daily mirror check?). You may also notice a loss of the roundness of your pectoralis during your self examination. More often than not, we can make a diagnosis based on these signs and symptoms but our procedure-heavy health care system likes to take pictures of things we think are broken. Therefore, doctors will often order an MRI and/or ultrasound.
Stat Fact: Magnetic resonance imaging has been advocated as a useful tool in diagnosing a rupture; however, it is not clearly shown to be 100% accurate in confirming a tear (3).
Most pectoral injuries (strains and ligamentous sprains) will resolve with conservative therapy which includes strengthening of weak muscles, lengthening of tightened muscles, and improved muscle coordination. If you have a solid pectoral tear, however, surgery is the way to go.
Regardless of the long-term treatment plan, initial care should involve rest, including sling immobilization with the arm against the side, cold compression, and pain medication. Passive and active range of motion exercises should begin after 1 to 2 weeks and continue through week 6 after the injury. This, in combination with decreasing the tone in hyperactive muscles, will bring relief. Heat and ultrasound therapy may also be helpful. Provided there is adequate range of motion and pain control, you can start resistance exercises 6 weeks after injury, with return to unrestricted motion at 8 to 12 weeks.
Stat Fact: “Results have been reported to be excellent in no more than 27% of patients treated non-operatively” (3).
Surprisingly, the pectoral major isn’t needed for activities of daily living (washing hair, cleaning house, etc.) so surgical repair isn’t necessary for everyone. More active patients will need an operation, however. The commonly used surgical approaches are the deltopectoral approach (where the shoulder and pecs intersect, favored by most surgeons) and the anterior axillary approach (armpit). Postoperatively, the affected arm will be placed in a sling and/or Velpeau dressing and immobilized for 3 to 6 weeks. We start pendulum exercises within the first or second week post-op. Similar to non-operative rehabilitation, soft tissue release of your hyperactive compensating muscles can be incorporated to decrease symptoms. Immobilization is followed by passive and then active range of motion exercises from 4 to 8 weeks. Lift resistance training is incorporated following an increase in range of motion, usually no earlier than 3-4 months post-op with a subsequent return to unrestricted activity at about 6 months. Overall, the reported length of time to restore your full function ranges from 6 weeks to 24 months, although the majority of the patients return to their previous activity levels within 4 to 12 months.
Stat Fact: One study found that 88% of surgically treated patients with ruptures experienced excellent results versus 27% of those treated non-surgically (3).
Athletic injuries are hard to prevent, but proper muscle balance and strength is a great start when it comes to athletic injuries. Pectoral tears in the weight room are commonly caused by poor biomechanics and lifting too much weight. Make sure to perform pectoral flys with correct weight and, when bench pressing, don’t externally rotate the weight as you descend the dumbbell.
Take Home Points
- Pectoral tears are rare
- Pectoral tears typically take 4-12 months to return to full function (3)
Choosing the Denver Bronco’s defense in fantasy was a bad choice due to Dumervil’s pectoralis tear…which their season proved.
1. Gollapalli V, Liao J, Dudakovic A, Sugg S, Scott-Conner C, Weigel R. Risk factors for development and recurrence of primary breast abscesses. J Am Coll Surg. Jul 2010;211(1):41-48.
2. McGhee D, Steele J. Breast elevation and compression decrease exercise-induced breast discomfort. Med Sci Sports Exerc. Jul 2010;42(7):1333-1338.
3. Provencher M, Handfield K, Boniquit N, Reiff S, Sekiya J, Romeo A. Injuries to the pectoralis major muscle: diagnosis and management. Am J Sports Med. Aug 2010;38(8):1693-1705.