Symptoms of Pectoralis Major Strains
Primary Clinical Presentation
Pectoralis major strains typically present with acute anterior chest/axillary pain, visible bruising and swelling, a palpable defect in the muscle, asymmetric appearance of the anterior axillary fold, and weakness with shoulder adduction and internal rotation. 1, 2
Acute Injury Symptoms
Audible "snap" or "pop" at the time of injury, most commonly occurring during bench press or similar weightlifting exercises involving eccentric muscle loading 2, 3
Immediate pain in the anterior chest wall and axilla, with pain severity correlating with degree of injury 2, 4
Rapid swelling and bruising over the anterior axillary wall and chest, typically appearing within hours of injury 1, 2
Visible deformity with loss of the normal anterior axillary fold contour and asymmetric chest appearance compared to the uninjured side 2, 3
Physical Examination Findings
Palpable defect in the muscle or tendon, most commonly at the humeral insertion site where complete ruptures typically occur 2, 4
Ecchymosis extending from the anterior chest to the upper arm, often appearing 24-48 hours post-injury 2
Asymmetric webbing of the anterior axillary fold when comparing the injured to uninjured side 2
Weakness on resisted testing of shoulder adduction and internal rotation, which are the primary functions of the pectoralis major muscle 5, 2
Restricted range of motion of the affected arm due to pain and mechanical disruption 1
Tenderness to palpation over the injury site 1
Injury Location Patterns
The inferior sternal head fibers are most commonly torn, with the humeral insertion being the most frequent site of complete rupture 5, 2. Musculotendinous junction tears and intramuscular injuries typically result from direct trauma rather than eccentric overload 2, 4.
Diagnostic Imaging Confirmation
MRI is the mainstay for diagnosing pectoralis major tears and determining tear location and severity, which directly guides surgical versus conservative management 1, 5. High-resolution ultrasound also has diagnostic value and can identify the specific anatomical location of injury 5.
Treatment Approach
Conservative Management Indications
Rest, activity modification, ice application, NSAIDs (ibuprofen or acetaminophen if no contraindications), and progressive strengthening once pain subsides constitute the conservative protocol for partial tears and strains 6. This approach is now recommended primarily for older sedentary patients or proximal muscle belly tears 2.
Surgical Management Indications
Operative management is recommended for complete tears at the humeral insertion, musculotendinous junction tears with severe cosmetic/functional deformity, complete intra-tendinous tears, and tears at the sternal head/posterior lamina 5. Surgery consistently yields superior results compared to nonsurgical management, with prompt diagnosis and timely intervention producing the best outcomes 2, 4.
Hematoma Management
Meticulous hemostasis is critical, as hematoma formation complicates physical examination and future imaging interpretation 6. Large hematomas may require aspiration or surgical evacuation if causing significant pain or functional limitation 6. Avoid routine drain placement unless hematoma formation is a significant concern, and if used, limit to 24 hours 6.
Critical Pitfall
Delayed diagnosis and delayed repair may prevent excellent results 4. The earlier a repair is performed, the easier the surgery and the better the surgical outcome 1, 2.