Who would you refer a patient with a pectoral (pec) muscle tear to?

Pectoralis Major Tear Referral

Patients with pectoralis major tears should be referred to an orthopedic surgeon for evaluation and potential surgical repair, particularly for complete tears or in active individuals where surgical management consistently yields superior results compared to nonsurgical treatment. 1

Clinical Presentation and Assessment

• Typical presentation includes:

  • History of sudden onset of pain during weightlifting (especially bench press) or contact sports
  • Audible "snap" at time of injury
  • Pain, weakness, swelling, and possible muscular deformity
  • Ecchymosis, palpable defect, asymmetric axillary fold
  • Weakness on resisted shoulder adduction and internal rotation 1

• Diagnostic imaging:

  • MRI is the preferred imaging modality for confirming diagnosis and determining extent of injury
  • Ultrasound can be used as an alternative but may underestimate the severity (as seen in the case where ultrasound showed partial tear but surgery revealed complete tear) 2

Referral Algorithm

1. Acute presentation (0-2 weeks post-injury):

   • Immediate referral to orthopedic surgeon for evaluation
   • Early surgical repair produces improved results for complete tears 1

2. Delayed presentation (>2 weeks):

   • Still refer to orthopedic surgeon
   • Surgical repair, even when delayed, yields superior results compared to nonsurgical management 1

3. Exceptions for non-surgical management:

   • Older, sedentary patients
   • Proximal muscle belly tears (rather than tendon avulsions) 1

Rationale for Orthopedic Referral

• Complete ruptures are most commonly avulsions at or near the humeral insertion requiring surgical repair
• Surgical treatment consistently yields superior outcomes compared to nonsurgical management 1
• Patients treated surgically achieve excellent results with normal range of motion, excellent strength, and ability to return to vigorous athletic performance 3
• Nonsurgical treatment results in cosmetic deformity and deficit in adduction strength 4

Pitfalls in Management

• Misdiagnosis is common - in one case report, a pectoralis major tear was initially diagnosed as a shoulder strain 5
• Failure to refer for appropriate imaging and surgical evaluation can lead to suboptimal outcomes, especially in active individuals 5
• Delayed diagnosis may complicate surgical repair, though surgery can still yield better results than conservative management 1

Rehabilitation Considerations

• Post-surgical rehabilitation should follow a progressive program to ensure full recovery and return to function 5
• Careful progression of strengthening exercises is important to prevent re-injury
• Patients should be monitored for return to full range of motion and strength before resuming full activities

The evidence strongly supports orthopedic surgical referral for pectoralis major tears, particularly in active individuals, as surgical repair consistently produces better functional outcomes than conservative management.