Treatment of Pulled Pectoralis Muscle
For a pulled pectoralis major muscle (strain), initiate conservative management with rest, ice application, NSAIDs for pain control, and progressive strengthening exercises once acute pain subsides. 1
Initial Conservative Management (First-Line Treatment)
Rest and activity modification is the cornerstone of treatment for pectoralis muscle strains, requiring cessation of activities that stress the muscle (particularly bench pressing and overhead movements). 1
Ice application should be used in the acute phase to manage pain and reduce inflammation, particularly if an intramuscular hematoma is present. 1
NSAIDs (ibuprofen or acetaminophen) are recommended for pain control if no contraindications exist (such as gastrointestinal bleeding risk or renal impairment). 1
Progressive Rehabilitation Protocol
Progressive strengthening exercises should be initiated once acute pain subsides, focusing on gradual restoration of muscle function. 1 This typically begins 7-10 days after injury for mild strains.
Range of motion exercises should emphasize controlled movements, avoiding positions that place the muscle fibers under mechanical disadvantage (such as the bottom position of bench press with excessive shoulder extension and external rotation). 2
Management of Complications
Intramuscular Hematoma
Meticulous monitoring of hematoma is critical, as changes due to hematoma formation can complicate physical examination and future imaging interpretation. 1
Large hematomas may require aspiration or surgical evacuation if causing significant pain or functional limitation. 1 This decision should be made based on size (typically >5cm), progressive expansion, or failure to resolve with conservative measures.
Avoid routine drain placement unless hematoma formation is a significant concern; if used, limit drainage to 24 hours to prevent infection risk. 1
When to Consider Surgical Intervention
While the provided evidence focuses on conservative management of strains, complete ruptures (particularly at the humeral insertion or musculotendinous junction with severe cosmetic/functional deformity) require surgical repair for optimal outcomes. 3, 4
Operative management is indicated for:
- Complete tears at the humeral insertion 3
- Musculotendinous junction tears with severe cosmetic or functional deformity 3
- Complete intra-tendinous tears (mid-tendon substance) 3
- Tears at the sternal head/posterior lamina 3
Surgery consistently yields superior results compared with nonsurgical management for complete ruptures, whether performed early or delayed. 4
Clinical Pitfalls to Avoid
Do not miss a complete rupture masquerading as a strain—look for ecchymosis, palpable defect, asymmetric webbing of the axillary fold, and marked weakness on resisted shoulder adduction and internal rotation. 4 These findings mandate imaging with MRI or high-resolution ultrasound. 3
Do not allow premature return to activity, particularly bench pressing, as this places the healing muscle fibers in a position of mechanical disadvantage under heavy load and risks progression to complete rupture. 2, 5
Do not neglect assessment for associated injuries, including rotator cuff pathology or shoulder impingement, which may coexist and require concurrent management. 6
Expected Timeline
For mild to moderate strains (Grade I-II), expect 4-8 weeks for return to full activity with appropriate conservative management. 1 More severe strains or those with significant hematoma may require 8-12 weeks.