import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Pierces coracobrachialis 5-8cm distal to coracoid tip (range 3-10cm) **Protection**: Avoid inferior/deep dissection beyond conjoint tendon. Gentle retraction of conjoint only. No inferiorly-placed retractors **Location**: Enters deep surface of pectoralis major from laterally, 2-4cm from clavicle (thoracoacromial artery branch) **Protection**: Avoid aggressive superior retraction of pectoralis major. Identify during superior dissection if mobilizing clavicular head **Location**: Pierces pectoralis minor to enter deep surface of pectoralis major medially **Protection**: Avoid deep medial dissection when mobilizing chronically retracted tendon. Stay superficial to pectoralis minor **Location**: Passes through quadrangular space approximately 5-7cm below acromion, along inferior border of subscapularis **Protection**: Stay superior to surgical neck of humerus. No inferior retractors. Limit inferior exposure during chronic tendon retrieval **Location**: Run along inferior border of subscapularis at surgical neck, medial to bicipital groove **Protection**: Control bleeding if encountered during inferior humeral decortication. Cauterize or ligate if injured. Avoid aggressive inferior preparation ## Indications for Surgery ### Absolute Indications - Complete pectoralis major tendon rupture (Grade III) in active patient - Acute complete rupture in athletes or high-demand workers - Bone avulsion fractures with displacement - Failed non-operative management of partial tears with persistent symptoms ### Relative Indications - Symptomatic partial tears (Grade II) with weakness or pain - Chronic ruptures (>6 weeks) with cosmetic deformity and functional deficit in motivated patients - Revision of failed primary repair - High-demand occupation requiring strength (manual labor, military) ### Contraindications - Medical comorbidities precluding surgery - Low-demand elderly patients with minimal symptoms - Complete muscle belly tears with severe retraction (poor tissue for repair) - Significant muscle atrophy in chronic tears (>6-12 months) - consider tendon transfer instead - Active infection ## Pre-operative Assessment ### History - Mechanism: Eccentric load to contracted muscle (bench press 80%, wrestling/tackling 15%, other 5%) - Sudden pop or tearing sensation with immediate pain - Rapid swelling and ecchymosis in anterior shoulder/chest - Weakness with adduction and internal rotation activities - Timing: acute (<6 weeks) vs chronic (>6 weeks) - affects surgical approach ### Physical Examination - **Inspection**: Loss of anterior axillary fold (visible defect), asymmetric chest contour, ecchymosis - **Palpation**: Palpable gap at insertion (acute), retracted tendon mass medially (chronic) - **Modified push-up test**: Patient unable to perform push-up from floor, or pain/weakness during attempt - **Strength testing**: Weakness with resisted adduction, internal rotation. Compare to contralateral - **Range of motion**: Usually full passive ROM, limited active due to pain/weakness ### Imaging - **Plain radiographs**: AP and axillary shoulder views. Usually normal, but may show bone avulsion fragment - **Ultrasound**: Dynamic, can show tendon retraction and gap. Operator-dependent - **MRI** (gold standard): Confirms diagnosis, shows rupture location (musculotendinous vs bone), degree of retraction, muscle atrophy (chronic), associated injuries. T2 shows fluid/edema at injury site - **CT**: Not routinely needed unless bone avulsion requires detailed assessment ### Classification - **Grade I**: Muscle contusion/strain, fibers intact, full strength - **Grade II**: Partial tear, some function preserved, pain with activity - **Grade III**: Complete rupture, no function, visible deformity - **Location**: Muscle belly (10%, worst prognosis), musculotendinous junction (60%, most common), tendon avulsion from bone (30%, best prognosis) ## Surgical Anatomy ### Pectoralis Major - **Two heads**: Clavicular (superior, smaller) and sternal (inferior, larger) - **Insertion**: Lateral lip of bicipital groove of humerus, 5-8cm long footprint starting 5cm distal to greater tuberosity - **Tendon twist**: Inferior sternal fibers insert most superiorly (tendon twists 180°), superior clavicular fibers insert inferiorly - **Innervation**: Lateral pectoral nerve (C5-7) to clavicular head, medial pectoral nerve (C8-T1) to sternal head - **Blood supply**: Pectoral branch of thoracoacromial artery, lateral thoracic artery, perforators from internal mammary - **Actions**: Adduction, internal rotation, horizontal flexion of shoulder ### Deltopectoral Interval - **Boundaries**: Deltoid (lateral, axillary nerve C5-6) and pectoralis major (medial, pectoral nerves) - **True internervous plane**: Safe dissection with no motor nerve crossing - **Landmark**: Cephalic vein runs in groove (preserve and retract laterally, or ligate if necessary) - **Deep structures**: Conjoint tendon (coracobrachialis and short head biceps), long head biceps in groove, subscapularis medially ### Neurovascular Structures at Risk - **Musculocutaneous nerve**: Lateral cord branch, pierces coracobrachialis 5-8cm (3-10cm) distal to coracoid, descends between biceps and brachialis - **Lateral pectoral nerve**: From lateral cord, enters pec major 2-4cm from clavicle with thoracoacromial vessels - **Medial pectoral nerve**: From medial cord, pierces pec minor to supply sternal head of pec major - **Axillary nerve**: Posterior cord branch, quadrangular space, runs inferior to subscapularis 5-7cm below acromion - **Anterior humeral circumflex vessels**: Along surgical neck inferior to subscapularis ## Patient Positioning - **Beach chair**: 60-70° elevation, head secured, or - **Supine**: Bump under ipsilateral scapula (10-15° elevation) - **Arm**: Draped free with mobile arm board or assistant holding - **Allows**: Full ROM during repair for tensioning and testing ## Deltopectoral Approach - **Skin incision**: 8-12cm along deltopectoral groove, starting 2cm below clavicle at coracoid level, extending toward axilla - **Landmark**: Palpate coracoid (medial), identify deltopectoral groove (may palpate defect in acute ruptures) - **Cephalic vein**: Identify in interval, preserve and retract laterally with deltoid (preferred), or ligate and divide - **Interval**: Blunt dissection between deltoid (lateral) and pectoralis major (medial) - **Exposure**: Visualize conjoint tendon deep, long head biceps in groove, subscapularis medially, pectoralis insertion laterally - **Extensions**: Can extend distally along anterior humerus if needed, or medially for chronic retracted tendons ## Step-by-Step Surgical Technique ### Step 1: Incision & Deltopectoral Interval **Technique**: - Palpate coracoid process medially and deltopectoral groove - In acute ruptures, may palpate defect at anterior axillary fold - Make 8-12cm incision along deltopectoral groove from 2cm below clavicle extending toward axilla - Incise skin and subcutaneous tissue - Identify cephalic vein in deltopectoral groove - Preserve vein and retract laterally with deltoid (preferred), or ligate and divide if necessary **Examiner Question**: "What is your surgical approach for pectoralis major repair?" **Model Answer**: "I use the deltopectoral approach, starting 2cm below the clavicle at the coracoid level and extending 8-12cm distally toward the axilla. The cephalic vein marks the interval - I prefer to preserve and retract it laterally with the deltoid to avoid venous congestion, though ligation is acceptable. This is a true internervous plane between the axillary nerve supplying deltoid and the pectoral nerves supplying pectoralis major." - Incision must be centered on anticipated pectoralis insertion (lateral lip of bicipital groove) - Cephalic vein injury causes bleeding - have cautery ready - Avoid incision too medial (enters muscle belly) or too lateral (difficult deltoid retraction) ### Step 2: Develop Deltopectoral Interval **Technique**: - Identify interval between deltoid (lateral) and pectoralis major (medial) - In acute rupture, evacuate hematoma obscuring anatomy - Develop interval with blunt finger dissection - Retract deltoid laterally, pectoralis major medially with self-retaining retractor - Visualize deep structures: conjoint tendon, long head biceps in groove, pectoralis insertion site **Examiner Question**: "What makes this a safe interval?" **Model Answer**: "The deltopectoral interval is a true internervous plane. Deltoid is supplied by the axillary nerve from the posterior cord, while pectoralis major is supplied by the lateral and medial pectoral nerves. No motor nerves cross this plane, making it safe for dissection. The conjoint tendon is visible deep in the interval." - Musculocutaneous nerve in conjoint tendon 5-8cm distal to coracoid - avoid inferior dissection - Lateral pectoral nerve entering pectoralis superiorly - gentle retraction only - Axillary nerve inferiorly below subscapularis - stay above surgical neck ### Step 3: Identify and Mobilize Ruptured Tendon **Technique**: - **Acute rupture** (<6 weeks): Tendon retracted 3-5cm medially, surrounded by hematoma - palpate medially to find stump - **Chronic rupture** (>6 weeks): Tendon retracted 5-10cm, scarred to chest wall, significant muscle atrophy - Assess rupture location: musculotendinous junction (60%), bone avulsion (30%), muscle belly (10%) - Evaluate tissue quality: acute tears have good tissue, chronic may be friable - Mobilize tendon by releasing adhesions and scar tissue - May need to extend exposure medially/inferiorly to retrieve chronically retracted tendon - Assess both heads: typically sternal head tears, clavicular may be intact **Examiner Question**: "How do acute and chronic tears differ intraoperatively?" **Model Answer**: "Acute tears have minimal retraction, usually 3-5cm, with good tissue quality and minimal adhesions. The tendon is easily retrieved. Chronic tears have significant retraction, often 5-10cm, with muscle atrophy, scar tissue adherent to the chest wall, and friable tissue quality. Extensive mobilization is required, and I may need larger exposure. Despite this, repair is still worthwhile as outcomes show 70-80% good results compared to 85-95% for acute repairs." - Excessive medial dissection risks medial pectoral nerve injury - Chronically retracted tendons may be difficult to find - extend exposure as needed - Friable tissue in chronic tears may not hold sutures well - use larger bites and consider augmentation ### Step 4: Prepare Humeral Insertion Site **Technique**: - Identify lateral lip of bicipital groove on proximal humerus (anatomic insertion) - Insertion starts approximately 5cm distal to greater tuberosity, extends 5-8cm distally - Use arm abduction and external rotation to visualize - Decorticate insertion site with rongeur/curette/rasp to bleeding bone - Create 2-3cm wide footprint area for tendon contact - Do NOT excessively decorticate - preserve bone stock for anchor purchase - Excise any remaining tendon fibers at insertion to create clean surface **Examiner Question**: "Describe the pectoralis insertion anatomy" **Model Answer**: "The pectoralis major inserts on the lateral lip of the bicipital groove of the humerus, creating a 5-8cm long footprint starting about 5cm distal to the greater tuberosity. The tendon twists 180 degrees, so the inferior sternal fibers insert most superiorly, and the superior clavicular fibers insert inferiorly. I prepare this site by decorticating to bleeding bone while preserving bone stock for solid anchor purchase." - Aggressive decortication weakens bone and compromises anchor fixation - Inadequate preparation impairs tendon-bone healing - Long head biceps lies in groove medially - avoid injury - Anterior humeral circumflex vessels run inferiorly - control if encountered ### Step 5: Place Suture Anchors **Technique**: - Place 2-4 suture anchors (typically 3) along lateral lip of bicipital groove - Position anchors 1-1.5cm apart along humeral insertion footprint (5-8cm linear array) - Insert at 45° 'deadman' angle distally to resist proximal pull of tendon - Use 5.0-5.5mm metal or PEEK anchors, double-loaded with #2 high-strength suture - Ensure anchors fully seated in bone, not proud - Test suture purchase before passing through tendon - May use knotless anchors or suture bridge technique for increased footprint **Examiner Question**: "Describe your anchor configuration" **Model Answer**: "I place 3-4 double-loaded 5.5mm anchors along the lateral lip of the bicipital groove, spaced 1-1.5cm apart to recreate the normal footprint. Critical technique: anchors are inserted at 45 degrees distally - the 'deadman' angle - to resist the proximal pull of the tendon. This provides 6-8 sutures for secure fixation. I test each anchor's purchase before proceeding." - Anchors not fully seated will pull out during rehabilitation - Insufficient depth gives poor purchase and early failure - Divergent anchors reduce overall construct strength - Fracture through weak bone is rare but possible ### Step 6: Prepare Tendon with Whipstitch **Technique**: - Mobilize tendon to reach insertion without excessive tension - Release adhesions between pectoralis and chest wall (chronic tears) - Gently stretch contracted tendon and muscle (chronic cases) - Whipstitch end of pectoralis tendon with #2 high-strength suture using Krackow or locking running technique - Ensure locked sutures pass through robust tissue - If tendon quality poor (chronic, friable), incorporate more proximal muscle-tendon junction - Test mobilization: tendon should reach insertion with arm in neutral without excessive tension **Examiner Question**: "How do you ensure adequate mobilization?" **Model Answer**: "Adequate mobilization is critical for repair success. I release all adhesions and scar tissue, particularly in chronic tears where the tendon may be adherent to the chest wall. I whipstitch the tendon end with heavy locking sutures using a Krackow technique for strong purchase. I then test that the tendon reaches the insertion site with the arm in neutral position without excessive tension. Inadequate mobilization leads to excessive tension on the repair and early failure." - Inadequate mobilization creates excessive repair tension and predisposes to failure - Whipstitch through poor quality tissue will cut through - use healthy proximal tissue - Overtensioning during testing can damage tissue before repair is complete ### Step 7: Pass Sutures Through Tendon **Technique**: - Pass sutures from bone anchors through tendon in mattress configuration - Create horizontal mattress sutures approximately 1cm from tendon edge - Space sutures along tendon width to distribute load evenly - Ensure good tissue bites (at least 1cm of tendon substance) - Keep sutures organized with clamps - multiple sutures can be confusing - Alternative: tie anchor sutures to whipstitch sutures (less secure than mattress) **Examiner Question**: "Describe your suture technique through the tendon" **Model Answer**: "I pass the sutures from the bone anchors through the tendon in horizontal mattress configuration, approximately 1cm from the edge. This is superior to simple sutures as it distributes forces and resists cut-through. I space the mattress sutures along the width of the tendon to create even load distribution. Good tissue bites of at least 1cm are essential. I keep all sutures organized with clamps to avoid confusion with multiple suture limbs." - Sutures too close to edge will cut through tendon - Inadequate tissue bites create weak points and repair failure - Uneven tension distribution causes gap formation - Poor organization of multiple sutures leads to technical errors ### Step 8: Reduce Tendon and Tie Knots **Technique**: - Position arm in 30-45° abduction and neutral rotation (functional position) - Reduce tendon to bone footprint - Sequentially tie knots from proximal to distal anchor - Use sliding-locking knot technique (SMC, surgeon's sixth) - Tighten with appropriate tension - snug contact without overtightening - Verify all knots secure with additional half-hitches - Check repair: tendon flat against bone with even contact, no gaps - Test with gentle passive ROM - repair should remain secure without gapping **Examiner Question**: "What arm position do you use for tensioning the repair?" **Model Answer**: "I reduce the tendon to bone with the arm in 30-45 degrees of abduction and neutral rotation. This is a functional position that allows healing at appropriate length. Excessive adduction would overtension the repair and risk failure, while excessive abduction would undertension it and allow lengthening. I tie the knots sequentially, creating snug tendon-bone contact without strangulating the tissue. I then test the repair with gentle passive motion to ensure no gapping occurs." - Overtensioning strangulates tissue and causes repair failure - Undertensioning creates gaps and poor healing - Knots not secure lead to early failure - Testing too aggressively can cause intraoperative failure ### Step 9: Augmentation (Chronic or High-Demand Cases) **Technique**: - Consider in chronic tears (>6 weeks), poor tissue quality, revision, high-demand athletes - **Graft augmentation**: Use semitendinosus autograft, allograft, or dermal graft to bridge tendon to bone - Weave through tendon substance - Secure to bone with additional anchors or tie to existing anchor sutures - Creates load-sharing during healing phase - **Internal brace**: High-strength suture tape from tendon to bone parallel to repair - Acts as internal splint - Shares load during early healing - **Additional anchors**: Extra fixation points for increased security - Not always necessary: acute tears with good tissue may not need augmentation **Examiner Question**: "When would you augment a pectoralis repair?" **Model Answer**: "I consider augmentation in high-risk scenarios: chronic tears beyond 6 weeks where tissue quality is poor and retraction is significant, revision surgery where the primary repair failed, and high-demand athletes who will return to maximal loading activities like powerlifting. Options include tendon graft augmentation with allograft or autograft to bridge the gap and share load, or internal bracing with suture tape. Evidence suggests augmentation may reduce re-rupture rates from 15-20% to under 10% in these high-risk cases. However, acute tears with good tissue don't routinely need augmentation." - Autograft harvest creates donor site morbidity - Overtightening augmentation excessively constrains the shoulder - Added cost and operative time - use judiciously - Allograft carries theoretical disease transmission risk ### Step 10: Final Assessment and Closure **Technique**: - **Final checks**: - Repair secure without gapping with gentle passive ROM - Full passive ROM (elevation, rotation) achieved without excessive tension - Hemostasis adequate - cauterize all bleeding vessels - No tethered structures or injured neurovascular elements - Copious irrigation of wound - Consider closed suction drain if significant dead space (remove POD 1-2) - Repair deltopectoral fascia if divided - Close subcutaneous tissue in layers with 2-0 Vicryl - Skin closure with staples or subcuticular 3-0 Monocryl - Sterile dressing and sling in neutral position - Counsel patient: strict protection protocol, NO active pectoralis contraction for 6 weeks minimum **Examiner Question**: "What do you tell the patient about post-operative precautions?" **Model Answer**: "This is critical counseling. I emphasize that the tendon repair requires 6 weeks of strict protection to heal to bone. During this time, absolutely no active pectoralis muscle contraction - no pushing, pressing, lifting, or reaching activities. Violations of this protocol are the leading cause of repair failure and re-rupture. The patient can perform gentle passive range of motion with a therapist, but no active motion. I explain that rushing the rehabilitation is the primary cause of failure, and adherence to this protocol is essential for successful healing." - Inadequate hemostasis leads to hematoma formation - Early active motion causes re-rupture (most common cause of failure) - Patient non-compliance with rehabilitation protocol increases failure rate from 5% to 20% - Infection risk is 1-2% - prophylactic antibiotics and sterile technique essential ## Recognition and Management ### Overall Complication Rates - **Re-rupture/failure**: 5-10% acute repairs, 15-20% chronic repairs (higher if protocol violation) - **Persistent weakness**: 10-15% acute, 20-30% chronic - **Stiffness**: 10-15% overall - **Infection**: 1-2% with prophylaxis - **Nerve injury**: 1-2% (mostly temporary neuropraxia) - **Need for revision**: 5-10% overall ## Comprehensive Rehabilitation Protocol ### Phase 1: Protection (Weeks 0-6) **Goals**: Protect repair, prevent re-rupture, maintain passive ROM **Immobilization**: - Sling worn at all times except for hygiene and therapy - Arm positioned in neutral rotation (some surgeons use slight abduction/IR - controversial) - Sleep in sling for 6 weeks **Restrictions**: - **CRITICAL**: NO active pectoralis contraction (no pushing, pressing, lifting, reaching) - No resisted motions - No active elevation or IR - No lifting (even lightweight objects that activate pectoralis) **Allowed Activities**: - Passive ROM only: pendulums, passive elevation by therapist to 90°, passive ER to neutral - Elbow, wrist, hand active ROM encouraged to prevent stiffness - Grip strengthening - Gentle scapular retraction isometrics (no pectoralis activation) **Therapy**: - See therapist 2-3x per week - Focus on passive stretching and joint mobilization - Modalities for pain (ice, gentle massage) - Education on protection and avoiding pectoralis activation ### Phase 2: Early Active Motion (Weeks 6-12) **Goals**: Initiate active motion, prevent stiffness, protect healing repair **Progression** (gradual): - Week 6-8: Active-assisted ROM (pulley, cane-assisted), supine elevation - Week 8-10: Light active ROM all planes, gentle isometrics (no pectoralis adduction) - Week 10-12: Progress active ROM to full, light isometrics including gentle pectoralis activation **Restrictions**: - NO resisted adduction or IR until week 12 - No heavy lifting - No eccentric pectoralis loading - Avoid pushing motions **Therapy**: - Progress passive to active-assisted to active ROM - Joint mobilization if stiffness developing - Scapular stabilization exercises - Rotator cuff strengthening (avoid pectoralis recruitment) - Begin proprioception training ### Phase 3: Strengthening (Weeks 12-16) **Goals**: Restore strength, prepare for functional activities **Progression**: - Week 12: Begin light resistance exercises - elastic bands, light dumbbells (2-5 lbs) - Week 14: Progress resistance gradually, isotonic exercises all planes - Week 16: Moderate resistance (up to 50% of contralateral strength) **Exercises**: - Progressive resistance: flexion, abduction, IR, ER, adduction (protected) - Push-up progression: wall push-ups → incline → floor (knees) → standard - Functional activities: lifting light objects, reaching - Scapular stabilization and rotator cuff strengthening continues **Restrictions**: - No heavy bench press or maximal effort - No contact sports or collision activities - Gradual progression - avoid aggressive increases in load ### Phase 4: Return to Activity (Months 4-6) **Goals**: Return to sport/work, restore near-normal strength **Progression**: - Month 4: Sport-specific training begins, functional movement patterns - Month 5: Progress intensity and volume of training - Month 6: Return to light sport participation, work activities **Criteria for Advancement**: - Full passive and active ROM - Strength 80-85% of contralateral - No pain with activities - Cleared by surgeon **Activities**: - Sport-specific drills - Plyometric exercises for athletes - Return to manual labor with gradual increase in demands - Progress bench press to 50-60% of pre-injury max ### Phase 5: Return to Full Activity (Months 6-12) **Goals**: Full return to pre-injury activity level **Timeline**: - **Non-contact sports**: 6 months - **Contact sports/collision**: 9-12 months - **Heavy bench press/maximal loading**: 9-12 months (some surgeons delay to 12 months) **Criteria**: - Full ROM without pain - Strength 90-95% of contralateral (some deficit expected, especially chronic repairs) - Successful completion of sport-specific testing - Psychological readiness - Surgeon clearance **Long-term**: - Expect 5-10% strength deficit compared to pre-injury (acceptable functional outcome) - Chronic repairs may have 10-20% deficit - Maintain shoulder strengthening and flexibility program lifelong - Gradual return to maximum loads over 12 months to minimize re-rupture risk ### Special Considerations **Chronic Repairs**: - May have slower progression due to muscle atrophy - May not achieve full strength (20-30% deficit common) - Counsel on realistic expectations **High-Demand Athletes**: - More aggressive strengthening once healing confirmed at 12 weeks - Sport-specific training critical - Delayed return to competition to ensure healing (minimum 6 months, often 9-12 months) **Augmented Repairs**: - May allow slightly more aggressive early motion (weeks 2-4) due to load-sharing - Surgeon preference varies - Still protect from active pectoralis loading for 6 weeks **Violations of Protocol**: - Leading cause of re-rupture - If patient violates restrictions (early active use), assess clinically and consider MRI - Reinforce education and counseling ## References 1. **Bak K, Cameron EA, Henderson IJ**. Rupture of the pectoralis major: a meta-analysis of 112 cases. *Knee Surg Sports Traumatol Arthrosc*. 2000;8(2):113-119. doi:10.1007/s001670050197. **Evidence**: Meta-analysis demonstrating 26% loss of peak torque and 44% loss of total work with non-operative treatment vs near-normal strength with surgical repair. 2. **ElMaraghy AW, Devereaux MW**. A systematic review and comprehensive classification of pectoralis major tears. *J Shoulder Elbow Surg*. 2012;21(3):412-422. doi:10.1016/j.jse.2011.04.035. **Evidence**: Comprehensive classification system - Grade I (strain), Grade II (partial tear), Grade III (complete rupture). Location: muscle belly (10%), musculotendinous junction (60%), tendon avulsion (30%). 3. **Schepsis AA, Grafe MW, Jones HP, Lemos MJ**. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. *Am J Sports Med*. 2000;28(1):9-15. doi:10.1177/03635465000280011401. **Evidence**: Acute repair <6 weeks: 91% good/excellent results, 94% strength vs contralateral. Chronic repair >6 weeks: 76% good/excellent, 84% strength. Surgery superior to non-operative. 4. **Aarimaa V, Rantanen J, Heikkilä J, Helttula I, Orava S**. Rupture of the pectoralis major muscle. *Am J Sports Med*. 2004;32(5):1256-1262. doi:10.1177/0363546503261137. **Evidence**: Surgical repair resulted in significantly better strength (Cybex testing) and patient satisfaction compared to conservative treatment. 91% patients satisfied with surgery vs 27% with non-operative. 5. **Wolfe SW, Wickiewicz TL, Cavanaugh JT**. Ruptures of the pectoralis major muscle. An anatomic and clinical analysis. *Am J Sports Med*. 1992;20(5):587-593. doi:10.1177/036354659202000517. **Evidence**: Classic anatomic study describing pectoralis insertion anatomy, tendon twist (inferior sternal fibers insert superiorly), and surgical technique for repair with suture anchors. 6. **Hanna CM, Glenny AB, Stanley SN, Caughey MA**. Pectoralis major tears: comparison of surgical and conservative treatment. *Br J Sports Med*. 2001;35(3):202-206. doi:10.1136/bjsm.35.3.202. **Evidence**: Systematic review of 112 pectoralis major ruptures. Surgical repair resulted in 78% excellent outcomes vs 27% with conservative treatment. Surgery recommended for complete ruptures in active patients. 7. **de Castro Pochini A, Ejnisman B, Andreoli CV, et al**. Pectoralis major muscle rupture in athletes: a prospective study. *Am J Sports Med*. 2010;38(1):92-98. doi:10.1177/0363546509347995. **Evidence**: Prospective study of 46 athletes. Surgical repair within 6 weeks resulted in 95% return to sport at same level at mean 6 months. Isokinetic testing showed 8% deficit vs contralateral at 12 months. 8. **Butt U, Mehta S, Funk L, Monga P**. Pectoralis major ruptures: a review of current management. *J Shoulder Elbow Surg*. 2015;24(4):655-662. doi:10.1016/j.jse.2014.10.024. **Evidence**: Comprehensive review of surgical techniques. Recommends 2-4 suture anchors at lateral lip of bicipital groove, mattress sutures through tendon, consideration of augmentation for chronic tears. Emphasizes strict 6-week protection protocol. 9. **Zacchilli MA, Owens BD**. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. *J Bone Joint Surg Am*. 2010;92(3):542-549. doi:10.2106/JBJS.I.00450. **Evidence**: Epidemiologic data on shoulder injuries. Pectoralis major ruptures represent 1% of all shoulder soft tissue injuries, occurring predominantly in males (>95%), peak age 20-40 years, most common in weightlifters and contact athletes. 10. **Provencher MT, Handfield K, Boniquit NT, Reiff SN, Sekiya JK, Romeo AA**. Injuries to the pectoralis major muscle: diagnosis and management. *Am J Sports Med*. 2010;38(8):1693-1705. doi:10.1177/0363546509348051. **Evidence**: Comprehensive review including surgical indications, techniques, and outcomes. Discusses augmentation techniques with allograft or internal bracing for chronic tears and high-demand athletes. Reports re-rupture rates of 5-10% for acute repairs, 15-20% for chronic, reduced to <10% with augmentation.

Pectoralis Major Tendon Repair - Acute and Chronic Reconstruction

Pectoralis Major Tendon Repair - Acute and Chronic Reconstruction