How should a pectoralis muscle tear be managed, including acute care, imaging, rehabilitation, and indications for surgery?

Management of Pectoralis Major Muscle Tear

For complete pectoralis major tears, particularly those at the humeral insertion, early surgical repair is strongly recommended in young, active patients to optimize strength, function, and cosmetic outcomes, while partial tears and musculotendinous junction injuries can be managed conservatively with rest, ice, NSAIDs, and progressive rehabilitation. 1

Acute Care and Initial Assessment

Immediate Evaluation

• Assess for compartment syndrome by checking for severe pain disproportionate to examination, pain with passive stretch, paresthesias, pallor, diminished pulses, or weakness 2
• Evaluate hemodynamic stability including tachycardia, hypotension, orthostatic changes, or hemoglobin drop ≥2 g/dL, particularly if intramuscular hematoma is present 2
• Check anticoagulation status (PT/INR for warfarin or specific assays for DOACs) as anticoagulated patients have significantly higher risk of hematoma expansion 2
• Reverse anticoagulation immediately if life-threatening bleeding or compartment syndrome develops 2

Initial Treatment Protocol

• Rest and activity modification to prevent further injury 2
• Ice application for acute hematoma management and pain control 2
• NSAIDs (ibuprofen or acetaminophen) for pain control if no contraindications exist 2
• Meticulous hemostasis is critical, as hematoma formation complicates physical examination and future imaging interpretation 2

Imaging

Primary Imaging Modality

MRI is the gold standard for evaluating pectoralis major tears, allowing accurate assessment of tear location, degree of tearing, tendon retraction, and differentiation between acute and chronic injuries 3

MRI Findings to Document

• Tear location: humeral insertion (most common), musculotendinous junction, intra-tendinous, or sternal head 4, 3
• Degree of tearing: complete versus partial 3
• Which heads are involved: sternal head (most common), clavicular head, or both 4, 3
• Amount of tendon retraction 3
• Acute versus chronic: acute tears demonstrate hemorrhage and edema, while chronic tears show fibrosis and scarring 3

Alternative Imaging

High-resolution ultrasound has value in diagnosing pectoralis major injuries and can guide clinical management, though MRI remains superior for surgical planning 4

Surgical Indications

Strong Indications for Surgery

Surgical repair should be offered to younger, active patients with:

• Complete tears at the humeral insertion (most common surgical indication) 4, 1
• Musculotendinous junction tears with severe cosmetic or functional deformity 4
• Complete intra-tendinous tears (mid-tendon substance between myotendinous junction and humeral insertion) 4
• Tears at the sternal head/posterior lamina 4

Timing of Surgery

Early surgical repair is preferred, though the exact definition of "acute" versus "chronic" lacks consensus 1. The majority of tears occur as tendon avulsions involving the sternal head, most commonly from bench-pressing or eccentric overloading activities 1, 5. One study showed patients repaired within 3 weeks had better results than those repaired after 3 weeks, though this was for rotator cuff injuries 6. For pectoralis major tears, surgical repair has been performed successfully even months after injury (average 3.8 months in one series), though earlier repair is generally preferred 7

Surgical Technique

Suture anchor fixation provides high patient satisfaction and predictable return of strength, cosmesis, and overall function, with outcomes similar to other repair methods 7. Alternative fixation methods include cortical buttons and bone tunnels, though no consensus exists on the ideal device 1

Conservative Management

Indications for Non-Operative Treatment

• Partial tears (more common than complete tears) 3
• Musculotendinous junction injuries without severe deformity 4
• Older, less active patients who accept cosmetic deformity and strength deficit 1

Conservative Protocol

• Rest and activity modification 2
• Ice application for hematoma management 2
• NSAIDs for pain control 2
• Progressive strengthening once pain subsides 2

Hematoma Management

• Avoid routine drain placement unless hematoma formation is a significant concern; if used, limit to 24 hours 2
• Large hematomas may require aspiration or surgical evacuation if causing significant pain or functional limitation 2

Expected Outcomes with Conservative Treatment

Nonsurgical treatment of complete tears results in cosmetic deformity and deficit in adduction strength, with less satisfactory outcomes compared to surgical treatment 1. However, partial tears treated conservatively can achieve good functional recovery 3

Rehabilitation

Post-Surgical Rehabilitation

No consensus exists on the ideal rehabilitation protocol after pectoralis major repair 1. Based on general principles and available evidence:

• Early passive range of motion is typically initiated
• Progressive strengthening follows once healing permits
• Return to full activity varies by patient and surgical technique

Post-Conservative Management Rehabilitation

Progressive strengthening once pain subsides is the cornerstone of conservative rehabilitation 2

Key Clinical Pitfalls

• Missing complete tears in young athletes: These patients benefit most from surgery and will have permanent strength deficits if treated conservatively 1
• Delaying imaging: MRI should be obtained promptly to guide treatment decisions, as acute versus chronic tears have different surgical considerations 3
• Overlooking compartment syndrome: This is a surgical emergency requiring immediate intervention 2
• Inadequate hematoma management: Large hematomas complicate examination and may require drainage 2

Outcomes

Surgical repair produces excellent to good results in 66% of patients, with average isokinetic strength deficiency in horizontal adduction of 15% at 60°/s and 9% at 120°/s 7. Patient satisfaction is high, with significant improvements in SF-36, DASH, and ASES scores post-operatively 7.