Hi my name is Justin Griffin. I'm going to be talking to you today about management of pectoralis major tendon tears, as well as management of other large tendon injuries in the shoulder, and potentially even touch on Terry's major tears. So let's just go ahead and get started here. So pectoralis major tendon tears are a challenging tear to manage. We know some of the characteristics of these include a peak incidence between the ages of 20 and 40. Most of the time this is going to occur most commonly in bench pressing for weightlifters. There's others that we do worry about these tears in. I've seen a number of patients that have had this from other injuries that require a torsional or high energy force to the shoulder. There's some very nice articles that review this and some recent case reports of even some injuries in the elderly which we tend to manage a little bit differently. So here's a case just to start us out here. This is a 35 year old gentleman who felt a sharp pain, a popping in his left chest while bench pressing. And initially a lot of these patients as you can see in this picture have a significant amount of swelling. He was a longtime weightlifter, competitive, and denied any steroid use at that time and was evaluated in the emergency department where they told him rest is probably a muscle strain. And what you'll see with a lot of these patients is once the swelling goes down that's when they'll really have the deformity and so you want to make sure to get to these early and get an MRI. Here we can see the MRI. These are a little difficult to interpret. It's nice to partner with your radiologist to get a sense for what's going on. But we can see here the lack of that tendon reaching over. We can see the free edge of the tendon retracted away from its insertion onto the humerus. Well certainly we took we talk about non-surgical management of a lot of injuries. For most of these young active patients this is going to be a surgical problem but it's always worth talking with patients about the non-surgical treatment choice. A good example of this is a PGA golfer with Pullen syndrome. He's obviously PEC deficient and is able to perform at a very high level. If we look at the non-operative versus operative treatment conversation, well non-operative treatment, well you could consider it for more proximal tears or partial tears or lower demand patients. But if you look at the good to excellent results they weren't as high in the non-operative population. Most of the time these are patients that are going to be better for surgery because a lot of these are more high demand patients by nature. They care about the cosmetic difference between their sides and there may be a performance difference especially in some of these higher level patients like football players and weightlifters that are going to want to have maximum push force to their shoulder. Timing is really important. We don't want to delay surgery for these patients. Most of my patients that I see or suspect this on because of their clinical exam, we try to get to these within the first four weeks or sooner. It's a lot easier if you can get it while there's still a hematoma or fluid in place from the injury. But if you look at the data even when you get to it later the patients are still happier than they would have been without surgery. So for operative treatment we typically use an axillary based approach but you can go deltopectral. If you're more comfortable with that it could be considered. It can just be a little bit difficult to retrieve the tendon. The humeral side of the operation is going to be easier but you may have a little bit more difficult time finding the pec itself. Some of these larger bigger tears that are more chronic may be better through a larger incision. You want to make sure you really mobilize the muscle well in all of these planes especially as you move down more inferiorly in that axillary fold. It's good to really create a nice soft tissue envelope to be able to retrieve the tendon nicely. And this is what that tendon looks like. It doesn't always look great. A lot of times you feel like you're not getting a lot of purchase in the tendon but the tendon is on the underneath surface of the pec so that's what you really want to find is that nice tendon layer underneath the pec major tendon. You can see here that this is kind of what it looks like when you pull it over and you can mimic a reduction of that tendon. So most of the time this is going to be more the sternal head that tears. The clavicular head will remain intact which masks this from being obvious. We mobilize the muscle. We usually do a modified Kessler or something like a Krakow suture. You don't have to go way over medially but you want to get enough purchase of that under surface of the good tendon to be able to get a nice reduction. Even those that have more of a muscle tendon injury where they left some of this tendon on the footprint can be repaired very nicely with modern tapes and sutures. This is more historical but you can create a bone tunnel through a native pec insertion if you're limited in terms of your resources. You could do this through curved drill holes which is the historical way to fix it. Now most of us are using more suture anchors or strong pec buttons through kits and other options that are available to us surgically. The bone tunnel technique you can see here where you're sort of in that more groove. We're moving the pectoralis over to the lateral footprint but then we're freshening that footprint with a burr. Every case I sort of sweep the long head of the biceps more medially. I want to make sure I don't capture it and quite honestly I worry about in every case that I might have the patient have persistent bicep symptoms because you're so close to it even though you're repairing just lateral to the biceps but to be honest I've never had to go back and do a biceps tenodesis on one of these patients. We have bone tunnels. We also have suture anchors or buttons. Some of these have a tape first and then anchor second option versus bone tunnels where you're going to be suturing and then placing this through bone tunnels. I personally prefer more of a suture first or tape first and then putting these into the anchors and placing them in and tensioning them after the fact. So we've talked about this a little bit but there's two distinct heads of the pec muscle. One is the clavicular head and the other is the sternal head. You can see here this depiction showing how they both come off. We know about the pec minor but what we're really talking about here is the pec major and again almost always this is going to be a complete avulsion of the sternal head in those patients that you're taking for surgery and this is what it looks like. You really want to find in that axillary fold that bottom portion where you can typically fall into some fluid if it's more acute and subsequently you can think about your repair. This is supplied by different nerves and you have to be careful obviously about the arterial supply making sure that you don't get any concerning bleeding. It can be hard to find some of these so really stick with it make sure you're defining the anatomy and being very careful of the unprotected nerves in that region and they have different functions so we have to just understand and explain to our patients you may do okay without surgery if an older individual which we manage typically non-surgery but making sure they understand the potential cosmetic downsize as well as the potential strength deficit if they are a higher level person or a weightlifter. Many many of these are bench press injuries even if they're football players that are bench pressing you oftentimes will see this in weightlifters they oftentimes get this on the heavy negative that eccentric force on the muscle certainly that's going to increase their bench press weight but this is typically how we see the sternocostal fibers fail and they usually come into you with this ecchymosis now if they come in after the ecchymosis after the swelling's gone not as ideal because it'll be a little bit more difficult surgically might be harder to repair but even if it's quite tight and you can get a repair in some of these more chronic passing that four-week mark they still tend to like it better than the non-surgical route. This is what our patients look like they think they tore their biceps but in fact it's the pec muscle that's been torn and and so this is what they look like this is a couple of patients here you can see the real key difference is the change in the vertical contour of the pec muscle I've seen this in patients I saw a gentleman recently who was surfing at the BSR surf ramp put his arm down during a tube and had an avulsion from that event so it's not always just weight lifting on the imaging we always get plain films and this is just to rule out a bony injury we always use MRI as the gold standard but you could use ultrasound I personally favor the MRI just to get more information and this is what they look like we see that lack of the pec muscle coming over and inserting directly on oftentimes you'll see that biceps kind of moved out of the way a bit too here's a muscle tendon injury oftentimes we'll see this where you see that split more immediately this is a conversation point saying look we might not be able to fix this if it's more that muscle tendon junction there's a classification system this is for historical purposes but those myotendinous junction injuries are problematic when you're getting to the muscle belly more of a strain obviously those we can manage non-surgically partial tears non-surgically but the best ones for surgery are those 3ds the one that are really the tendon avulsing off the bone so my typical setup in the operating room if it's helpful to you as I set it up I plan for my incision I make sure I drape out fairly medially we're going to identify the intact muscle after splitting the fascia and working my way more anterior inferior and then gaining control of that tendon putting a couple of nice tapes in and exposing the humerus I like tapes here personally because of the fact that I can get more purpose and excuse me purchase in some of that poor muscle that it just holds a little bit better in that aspect and then we're going to drill flip our buttons or our sutures and then tie so typical suture pattern you can use a crack owl or a modified mason allen if you'd like trans-osseous tunnels if you're using those or suture anchors and then there's commercially available repair kits you can use this for the latissimus tears as well which we'll see in a moment here this is what it looks like in the operating room this is a left shoulder patient of mine that patient I was describing from the surf ranch and you know I put those tapes through and you can get very nice mobilization where you can get a good reduction and then get your exposure we want to restore the footprint when this was studied there's really not a big difference in pre and post repair footprint regardless of the technique that you use but you want to make sure to really spread that out on that native pec footprint our rehab we use a sling for six weeks six to twelve weeks we do light strengthening more at the three month time point is when we're thinking about light bench press or push-ups for these active patients four months we can return to full activity and high weight bench press you can tell your patients not to do it but for most of these patients they're going to do it this is a patient of mine high level olympic weight lifter and these are the kind of folks that they're not going to give it up but hopefully they can moderate to a degree that's not a problem so here's just some a case here you can see an incision more axillary based raising some skin flaps here we can see once those are raised we'll be able to access that anterior inferior right down at that axillary fold i use coat use an ioband just to create a better environment for avoiding infection once we see this here we place some gelpy retractors we're able to get more anterior inferior and this is the key here you find that inferior fascia you can then split that fascia with the bovior with suture scissors and then once you're in there and once we split this fascia we can see there's the the sternal excuse me the clavicular head but we're looking for that sternal head so we're going to go right inferior we're going to pop into that layer where we can see some fluid and this is more of an acute tear which is nice and you can see outlining that clavicular head but then you can see coming in here we're going to get right into this and bluntly dissect down and you'll be able to see a fluid wave which is always nice to see because it's preserved that attendant mobilization for you so you can see here this is that inferior edge you can see the fluid returning right there you can see that fluid and then we'll get a retractor underneath that proximal head and be able to access the tendon so reaching in here you can see now we have a clamp you can use an allen clallis clamp but there's that avulsed head we have control of it now you can do some blunt releases by hand or with blunt retractors i don't place anything sharp underneath or on top of that pec we can get a good mobilization of that it doesn't always look great as this one doesn't do you want to make sure you have the whole thing so you can get good purchase here you can see here now we're cleaning off that tendon footprint to create good biology and then subsequently getting good purchase with these two allis clamps you can then place the the tape suture do a running locking a suture you don't have to go way up medially but you want to make sure you get that good under surface of the tendon once we have good purchase in those sutures we can think about our second step of drilling so now you can see a good purchase with three different tapes there next step here is to expose your humerus i'll typically put two cobras on the outside there we can then create a nice footprint we swept that biceps more medially you can drill with a drill there to create a spot for the suture anchors or buttons in this case once those are done then you can sequentially flip those i usually load this just one time you don't want to go back and forth it creates too much suture there's also larger sutures that you can place in addition to tapes i'm usually just using one tape with two ends that are loaded into these buttons that tends to be enough and you can flip these directly into the bone and then subsequently you're going to repair this you can see once that's done you flip it and then you can sequentially just remove the inserter and then you can do some tensioning right down of the tendon right to the bone i usually tie as i go once that's fully reduced i try to stagger my drill holes just to avoid a stress riser avoid any issues in the future and so typically we'll get an x-ray at our first post-op visit so let's get in a little bit to latissimus tendons so as a different one i'm moving away from the pec here for a moment we can see this is a classic well-known latissimus tendon injury in a well-known major league baseball pitcher had an acute avulsion and this is somewhat synonymous to the pec tendon big muscle comes around the back inserts obviously medial to the biceps groove in this case requires a different approach more of a supine axillary based incision here you can see this is what that latissimus looks like you can see the tendon having been nicely exposed through an axillary incision and you're going to want to make sure that you can get that back up to the footprint but again big tendon injury similar but a little bit of a different exposure because you need to be able to get more posterior but the repair is done similarly this is a very uncommon injury certainly much less common than the pec which is also an uncommon injury so when you're dealing with these patients you're going to see that they come in with typically an acute event a popping sensation unable to return to throwing a lot of these are throwing athletes i've seen some in water skiers as well they have soft tissue swelling but they have good range of motion so it requires you being clinically suspicious on exam you may see some ecchymosis a little mass in their axilla as you can see here but they have weakness with the specifically extension and internal rotation they don't have instability here you can see the samurai you can see that wavy wispy looking acute rupture that latissimus on that right image well a acute latissimus dorsi avulsion rare injury it can occur in competitive athletes wrestlers steer wrestlers specifically have been described we see this in water skiers and also in rock climbers and professional baseball pitchers well the anatomy of this you can see here that latissimus dorsi inserts right there and then you've got the terry's major right behind it which sometimes can come off with it so you have to be aware of that and look at that talk to your musculoskeletal radiologists about this it depresses the elevated arm against resistance compresses the inferior scapula when it's recorded and pulls the trunk upward and forward flexes it's the accelerator the core stabilizer and the compressive force to the glenohumeral joint it reduces the rotator cuff stress so overall good results in non-pitching athletes who are treated non-operatively or operatively so there's really no current standard of care it depends on several factors we have to consider the patient of course we don't just treat mris we have to consider their level and then if it's a combined injury with the latissimus dorsi plus the terry's major in this patient so the advantages of surgery is that it restores the patient's full anatomy potentially decreases their ability to lose strength and velocity especially if they're an athlete but the disadvantage is you're close to some very important structures neurologic damage of the radial nerve has been reported infection and it's a difficult area to access so this is the latissimus insertion site you can see the biceps groove to your left the terry's major insertion site and then the latissimus right there in the middle and this is what it looks like in the operating room the tendon is being lifted up out through that very posterior axillary based incision and this is what the tendon can look like you're going to create that nice bleeding footprint and then do a similar technique it's also with buttons or suture anchors if you're more comfortable with that and you can see this is a post-operative mri of an elite baseball pitcher showing that tendon has healed back to its footprint we published a paper looking at the performance and return to sport and elite baseball players following repair of the latissimus they tend to do quite well and recreational athletes as well with minimal pain and ability to return to their prior athletic activity so again very challenging rare injuries but hopefully this helps you as you develop your practice if you see these i'm always a phone call away if i can help any further thank you

pectoralis major tendon tears

shoulder injuries

surgical management

MRI diagnosis

tendon repair