Can I Use My Right Arm After A Pec Repair

• Journal List
• N Am J Sports Phys Ther
• v.ii(1); 2007 Feb
• PMC2953288

North Am J Sports Phys Ther. 2007 February; 2(1): 22–33.

Pectoralis Major Tendon Repair Postal service Surgical Rehabilitation

Robert C. Manske

^aWichita State Academy, Section of Physical Therapy, Via Christa Orthopedic and Sports Physical Therapy, Wichita, Kansas

Dan Prohaska

^bAdvanced Orthopedic Assembly, Wichita, Kansas

Abstruse

Pectoralis major tendon rupture is a rare shoulder injury, well-nigh normally seen in weight lifters. This injury is being seen more regularly due to the increased emphasis on good for you lifestyles. Surgical repair of the pectoralis major tendon rupture has been shown to provide superior outcomes regarding strength return. Thus it appears that surgical repair is the treatment of choice for those wishing to return to competitive or recreational able-bodied action. This article describes the history and physical examination process for the athlete with pectoralis tendon major rupture. Surgical vs bourgeois treatment volition be discussed. This manuscript provides post surgical treatment guidelines that tin can be followed after surgical repair of the pectoralis tendon rupture.

Keywords: weightlifting, pectoralis major, rupture

INTRODUCTION

Patissier¹ initially described rupture of the pectoralis major muscle in 1822. Although, initially described as a rare injury, the numbers of athletic patients requiring surgical repair of the ruptured pectoralis tendon is increasing. This injury tin can exist devastating to the active athletic patient if treatment does not return total functional strength and range of motility of the injured upper extremity.² The objectives of this article are to describe the relevant beefcake of the pectoralis region and discuss evaluation, operative, and rehabilitative approaches to treatment of this potentially disabling upper extremity injury.

Anatomy/Kinesiology

The pectoralis major muscle is a very powerful shoulder musculus during its function - that of shoulder adductor, internal rotator, and flexor of the humerus. Origins of the pectoralis major include the clavicle, sternum, ribs, and external oblique fascia³ also as cartilage of the starting time six ribs.⁴ This big muscle, located on the anterior chest wall overlying the pectoralis pocket-sized, has both a sternal and a clavicular head. The clavicular portion of the pectoralis major originates on the lateral clavicle and upper sternum and inserts onto the inferior surface of the humerus at the crest of the greater tuberosity. The sternal head of the pectoralis major originates on the manubrial end of the sterum and inserts onto the lower humerus with the clavicular portion. The insertion of the pectoralis tendon onto the humerus occurs with the musculus twisting on itself so that the everyman fibers of the tendon insert at the highest location on the humerus.^5,6 Wolfe et al^vii accept previously demonstrated that this attachment results in significant tension in the inferior portion of the pectoralis muscle and predisposes this portion to rupture when stretched and loaded. Wolfe and collegues^seven measured excursion of individual pectoralis muscle fibers at seven different points along the origin by the utilise of fine wires continued to humeral insertion and to punch gauges. Inferior fibers of the pectoralis major muscle lengthened disproportionately during the concluding 30 degrees of humeral extension. This attachment organisation may result in partial tears being much more common than that of complete ruptures.

Machinery of Injury

Although pectoralis tendon ruptures are near usually seen in weight lifting, ruptures have also been reported in many other sporting activities such as boxing, football, rodeo, water skiing, and wrestling.^8–12 These injuries tend to occur more commonly in patients during their 2nd to fourth decade of life.ⁱⁱ To date, this rupture is a totally male dominated athletic injury with not fifty-fifty a single case study report of injury to the female able-bodied population. The diagnosis of pectoralis tears is generally non elusive. Patients oft give a history of doing a maximal elevator or endeavor and feeling something in the shoulder giving or ripping; while the injury is ofttimes accompanied by an audible "snap" or "pop".^11–18 Mild swelling and often ecchymosis^{two,viii,xiv,xviii,nineteen–23} follows. Bruising can be seen over the anterior lateral chest wall or in the proximal arm.²⁴ Paingenerally is non intense.²⁴

Concrete exam reveals a loss of the inductive axillary fold and normal pectoralis contour ( Figure one ). Asking patients to press the hands together in a "prayer position" ( Figure 2 ) eliciting an isometric contraction will reveal asymmetry to the chest wall. This asymmetry can be easily confirmed past looking for medial movement of the nipple on the breast wall.Often a distinct deformity or hollow exists where the pectoralis muscle volition move medial. Loss of force is particularly notable to internal rotation of the arm when tested at neutral.

Loss of normal pectoralis profile.

Disproportion seen with isometric contraction of pectoralis major A) anterior view, B) lateral view.

Diagnostic testing may include plain radiographs which are commonly not diagnostic, although reports of bony abnormalities accept been noted.^{2,21,22,25,26} Magnetic resonance imaging (MRI) can be helpful and is becoming the imaging method of choice and can be helpful where a partial tear is suspected.^27–29 The partial tear may be difficult to evaluate. An MRI tin exist helpful in assessing location and severity of the tear.^thirty The tendon fibers from the clavicular head may be intact and be interpreted as an intact tendon.This finding must be interpreted carefully every bit partial tears which do not include the clavicular head have significant morbidity and should be given consideration for operative handling. If edema is present, careful scrutiny should exist given to the tendon to appraise for pathology.

Bourgeois VS. SURGICAL TREATMENT

Historically, non-operative treatment has been advocated for older or sedentary individuals or for those with incomplete tears.²¹ Unfortunately, rarely does non-operative treatment result in render of normal strength.^{xiv,twenty,31} Wolf et al⁷ has reported upward to a 26% loss of peak torque and a 39.9% work deficit in shoulder adduction in un-repaired ruptures. Furthermore, numerous studies have demonstrated that surgical treatment of complete pectoralis tendon ruptures has a defined advantage in regards to increased strength over that of non-operative handling, particularly in athletes.^{five,9,xiii,17–19,23,27,32–42}

SURGICAL Handling

The authors preferred method of repair of the pectoralis major tendon is with the patient on the operative table in a embankment chair position with the arm draped free. The incision is placed in the anterior axillary fold ( Effigy 3 ). A short incision of v-8 cm is usually used in astute cases, or longer if the tendon tear is more chronic. This incision is very cosmetic and can be placed posterior enough in the axillary fold to allow the incision to be hidden when the arm is at the side. When done at this position, the resultant fine scar volition often alloy in and appear as a stretch mark which is met with favorable acceptance by the typical patient with this injury.

The surgical approach is begun past developing soft tissue planes and identifying the torn tendon finish ( Figure 4 ). If the tendon is identified subsequently finding the deltopectoral interval and appears intact, the arm should exist abducted and externally rotated. This maneuver will often identify a partial tear of the sternal caput, which should exist repaired.More chronic cases will require mobilization of the tendon. This mobilization of the tendon tin can be performed with careful dissection recognizing potential hazards posterior and medial to the pectoralis tendon.

Identifying pectoralis major.

The tendon can rupture from the attachment to bone or as a musculotendinous junction tear. If the tendon has ruptured proximal to the bony insertion, the tendon is repaired with permanent sutures, preferably a polyblend for strength to allow for mobilization.

If the tendon ruptures from the bony zipper, then the repair tin can be performed with os tunnels and sutures, or by the authors' preference of using suture anchors. This technique will require pre-drilling bone tunnels for suture anchor placement ( Effigy 5 ). The suture anchor technique has some pitfalls every bit this os is very difficult and care has to be taken not to fracture a bioabsorbable anchor on insertion or twist off a metal ballast if this is how information technology is inserted. Training of the insertion site tin be performed with a rongeur (a leap-loaded forceps with a precipitous blade), or if concerned about the healing potential, the cortex can exist further abraded with a burr. Three to four anchors are placed in a typical consummate tear. Sutures are so passed using a grasping suture technique with one strand, such as the Modified Mason-Allen. The second strand is brought into the cease of the tendon and then out the anterior aspect 5-10 mm from the lateral border. This technique allows for the suture to slide through the anchor and the tendon to pull the grasping arm down and allows the tendon to have total interface with the bone. This technique also places the suture knot on the inductive aspect of the tendon where the knot will not cause whatsoever irritation.

Drilling tunnel for suture anchor placement.

Before and subsequently the tendon is repaired the range of motion of the shoulder is assessed while observing the repair site. Early on repairs, less than 3 weeks, are often very mobile. This mobility allows for a more rapid return of shoulder motion mail service-operatively.

One time the repair is finished, ( Figure6 ) the wound is airtight in layers with a dermal subcuticular closure for cosmesis. Subcuticular injection of local anesthetic is used. The arm is placed in a sling immobilizer, unless concern exists almost abduction and so consideration is given to a simple sling.

Completed pectoralis tendon repair.

POST-OPERATIVE REHABILITATION

Because no studies have been published that talk over pectoralis major tendon repair strain backdrop, the corporeality of stress this tissue can tolerate prior to rupture or compromise in the post surgical patient is not fully understood.Therefore, post surgical rehabilitation soft tissue healing time frames following pectoralis tendon repair are based on clinical impression and empirical prove in treating these athletes. Additionally, some general assumptions can be made based on previous literature related to soft tissue healing of other mutual tendon rupture repairs including the rotator cuff and Achilles tendons.^43–52

Mail-operative rehabilitation post-obit pectoralis major tendon repair is dependent on several surgical considerations. Directly repairs of pectoralis major muscle to tendon is hard because the power to obtain a firm anchorage for suture in soft muscle tissue is express.¹² For this reason, speculation is that direct repairs of muscle to tendon or those from tendon to tendon may crave greater soft tissue time constraints. This repair may be so tenuous that some authors even suggest bourgeois treatment following a tear in the musculotendinous region.^36,37 Post surgical rehabilitation requires a balancing act of maintaining plenty brake of range of motion to allow acceptable soft tissue healing, yet still allowing enough activity and motion to restore shoulder mobility, all the while gradually returning functional strength to let a return of full unrestricted functional activities. In numerous instances these functional activities are to return the athlete to very loftier levels of strength since a large majority of these injuries occur in competitive or recreational weightlifters. Because dissentious the healing tendon immediately following surgery is contraindicated, the patient'southward shoulder is generally placed in an immobilizer or a sling for the start three-four weeks, depending on the type of surgery required ( Table 1 ).

Table ane.

Pectoralis tendon repair guidelines

Type of Repair	Guidelines	Full AROM/PROM
Tendon – tendon	Sling 4 weeks	14–xvi weeks
Bone – tendon	Sling 3 weeks	12–14 weeks

Equally with most post-operative rehabilitation, the ultimate goals following pectoralis major repair include i) maintaining structural integrity of the repaired soft tissues, ii) gradually restoring total functional range of move, 3) restoring or enhancing full dynamic musculus control and stability, and 4) return of full unrestricted upper extremity activities including activities of daily living and recreation and sporting athletic endeavors. The ultimate goal is to return the patient to their preferred level of activity equally speedily and safely as possible. The ability to achieve this goal must rely on utilizing progressive treatment phases that are delineated with specific goals and achievements.

Immediate Post-operative Phase (0-2 weeks)

Goals for the firsthand post-operative phase are 1) protect the healing tissue, 2) diminish post-operative hurting and swelling, and 3) limit the furnishings of prolonged immobilization. Direct soft tissue repairs (tendon to tendon or muscle-tendon unit to tendon) require a slight rehabilitation delay to let for adequate soft tissue healing earlier placing considerable stress to the repaired tissue. The immediate post-operative phase lasts for upward to iii weeks. In this time frame a gradual progression of passive range of motion (PROM) is began at 2 weeks. The patient is maintained in sling immobilization for 3 weeks. Passive ROM is taken to neutral external rotation and allowed to be increased by 5 degrees per week. Forward flexion is passively taken to 45 degrees increasing five-10 degrees per calendar week ( Tabular array 2 ). Passive ROM is performed to aid soft tissue healing past increasing collagen synthesis and promoting right alignment of fibers that are oriented parallel to the movement that is required to render full functional use of the upper extremity. No agile range of motion (AROM) is immune in the shoulder, but AROM is promoted for the rest of the upper extremity including elbow, forearm, and wrist/paw.

Table 2.

Range of Motion Guidelines

Week	ER @ 0° Shoulder Adduction	Forward Flexion	Abduction
2	0	45	30
3	v	l–55	35
4	ten	55–65	40
5	15	60–75	45
6	20	65–85	l
7	25	seventy–95	55
viii	xxx	75–105	60
9	35	80–115	65
10	40	85–125	70
11	45	90–135	75
12	50	95–145	80

As with whatever surgical procedure, controlled trauma is function of the surgical procedure.Therefore, recognizing pain and localized edema is common.Since this surgical procedure is extracapsular, an actual joint effusion should not occur. To help decrease these physical symptoms, electrical stimulation and cryotherapy are recommended. Spear et al⁵³ has demonstrated that cryotherapy appears to exist an constructive adjunct following shoulder surgical procedures. Interferential electric stimulation or high volt galvanic stimulation tin exist used to assist in decreasing mail service-operative pain, soreness, and swelling.^54,55

In this phase, PROM is performed past the clinician to decrease the hazard or unwanted adhesion formation in and effectually the mail service-operative surgical site. Because this surgical procedure does not require entrance into the joint cavity, intra-articular adhesions are by and large not ane of post surgical sequelae. Of more concern with these procedures are extra-articular adhesion formation effectually the surgical incisions, which volition create mobility problems. Additionally, an cruddy and unfavorable scar can be emotionally and socially devastating, especially to bodybuilders whose main want is anatomical symmetry and cosmetic perfection. Once the incisions are healed and closed, gentle superficial scar tissue mobilization can be initiated. Scar mobilization should occur parallel to the superficial incision, progressing to running beyond the actual scar. Scar massage should exist with plenty pressure to flinch the scar.⁵⁶ Scar massage will exist helpful to break up collagen fibers, resulting in a softer, flatter, paler scar with better cosmesis,⁵⁷ in addition to promoting soft tissue mobility.⁵⁸

Passive pendulum exercises are likewise encouraged equally office of the dwelling house practise program to increase mobility of the shoulder articulation. Active assistive range of motion (AAROM) and gentle submaximal isometrics are began at two-4 weeks post-operatively to brainstorm stressing the contractile properties of the repaired tissue and surrounding musculature which helps retard muscle cloudburst and loss of muscle control. To maintain cardiovascular condition the athlete should continue with prior aerobic training on recumbent or standard exercise cycle, but is asked not to perform aerobic exercises such equally elliptical runners, crosscountry machines, or running/jogging on treadmills to decrease adventure of injury in case of adventitious loss of residuum ( Tabular array 3 ).

Table 3.

Pectoralis Tendon Post-operative Protocol

POST-OPERATIVE REHABILITATION FOLLOWING PECTORALIS TENDON REPAIR
PHASE I - Immediate Mail service-OPERATIVE Phase (WEEKS 0-ii)
Goals	Protect healing repaired tissue
	Decrease pain and inflammation
	Plant express range of motion (ROM)
Exercises	No exercise until end of twond calendar week
Sling	Sling immobilization for 2 weeks
	Passive rest for full 2 weeks
	Allow soft tissue healing to begin uninterrupted
	Permit acute inflammatory response to run normal course
Stage II - INTERMEDIATE POST-OPERATIVE Stage (WEEKS 3-6)
Goals	Gradually increase ROM
	Promote healing of repaired tissue
	Retard muscular cloudburst
Calendar week two	Sling immobilization until 3rd calendar week
	Brainstorm passive ROM per guidelines (Tabular array two)
	External rotation to 0 outset twond calendar week
	Increasing 5 degrees per week
	Forward flexion to 45 degrees
	Increasing five-10 degrees per week
Calendar week iii	Wean out of sling immobilizer - week three
	Continue passive ROM per guidelines (Table ii)
	Begin abduction to 30 degrees
	Increasing 5 degrees per week
	Begin gentle isometrics to shoulder/arm EXCEPT pectoralis major
	Scapular isometric exercises
End of Week 5	Gentle submaximal isometrics to shoulder, elbow, paw, and wrist
	Active scapular isotonic exercises
	Passive ROM per guidelines (Table two)
	Flexion to 75 degrees
	Abuction to 35 degrees
	External rotation at 0 degrees of abduction to 15 degrees
Stage III - LATE POST-OPERATIVE Phase (WEEKS 6-12)
Goals	Maintain full ROM
	Promote soft tissue healing
	Gradually increase muscle strength and endurance
Week 6	Keep passive ROM to full
	Continue gentle sub maximal isometrics progressing to isotonics
	Begin sub maximal isometrics to pectoralis major in a shortened position progressing to neutral muscle tendon length.
	Avoid isometrics in total elongated position
Calendar week 8	Gradually increase muscle forcefulness and endurance
	Upper body ergometer
	Progressive resistive exercises (isotonic machines)
	Theraband exercises
	PNF diagonal patterns with manual resistance
	May use techniques to alter incision thickening
	Scar mobilization techniques
	Ultrasound to soften scar tissue
Week 12	Full shoulder ROM
	Shoulder flexion to 180 degrees
	Shoulder abuction to 180 degrees
	Shoulder external rotation to 105 degrees
	Shoulder internal rotation to 65 degrees
	Progress strengthening exercises
	Isotonic exercises with dumbbells
	Gentle 2-handed sub maximal plyometric drills
	Chest pass
	Side-to-side throws
	BodyBlade
	Flexbar
	Total arm strengthening
PHASE IV - Advanced STRENGTHENING PHASE (WEEKS 12-16+)
Goals	Full ROM and flexibility
	Increase musculus strength and power and endurance
	Gradually introduce sporting activities
Exercise	Proceed to progress functional activities of the unabridged upper extremity
	Avert bench press motion with greater than 50% of prior 1 repetition max (RM)
	Gradually work up to fifty% of one RM over next month.
	Stay at 50% prior 1 RM until 6 months post-operative, then progress to full slowly afterwards vi month fourth dimension frame
KEYS	Don't rush ROM
	Don't blitz strengthening
	Normalize arthrokinematics
	Utilize full arm strengthening

Intermediate Post-operative Phase (3-half-dozen weeks)

This phase is a brusque 3 week phase in which PROM is slowly avant-garde. Goals in the Intermediate Postal service-operative Stage include 1) Continued progression of ROM, two) heighten neuromuscular control, and 3) increase muscular strength. Prior ROM is advanced per before discussion, while shoulder abduction is began at 30 degrees increasing five degrees per week, with abduction and external rotation performed terminal. Toward the stop of this phase AAROM is began and patient's performance of PROM is allowed. Because in this phase soft tissue healing should already be initiated, patient AAROM is started. Range of motion of the shoulder can be performed with a pikestaff or L-bar into gentle flexion, scaption, and external rotation. Patient education regarding ROM limitations that still be are imperative for condom return of full mobility without re-rupture, stretching, or loosening of repaired soft tissue. No AROM is immune early on in this stage, while gentle express AROM is immune toward the finish of this phase. Painful peak or agile mobility of the shoulder is detrimental to the healing soft tissue and, therefore, should non be allowed.

Gentle sub-maximal isometrics are performed for the rotator cuff muscles at this time to enhance dynamic shoulder stability. Known equally "rhythmic stabilization" exercises, these isometric exercises are performed with the patient lying supine with the arm in the balance position of 90 degrees of flexion. The athlete is asked to maintain a position of full elbow extension while the arm is in xc degrees of flexion while the clinician applies small joint perturbations in various directions. These exercises are performed in a manner initially in which the athlete can view and prepare for the wrinkle needed to continue the arm stable in a proactive fashion, known as proactive training. This stabilization can be progressed to performing these perturbations in randomized patterns followed past increasing speed in which perturbations are made. These exercises can further be progressed from eyes open to optics closed pattern, which is known equally reactive training.⁶⁰ Performance of these stabilization exercises with eyes closed is done to heighten reactive musculus functioning. These exercises are generally performed in multiple angles at approximately 20 degree intervals through a safety range of motion. The isometrics are performed in this fashion because of a xx degree range of motion physiological overflow found with isometric exercises.⁵⁹

In this stage, exercises for the scapula can be initiated. Scapular "setting" exercises are performed with the scapula in a retracted position to enhance postural control. Early in the intermediate phase, internal shoulder rotation and shoulder flexion isometrics are not performed to subtract gamble of excessive activation of the pectoralis major muscle contractions during those movements. Toward the terminate of this phase (5-six weeks), gentle sub-maximal isometrics with the pectoralis major in a shortened position can begin and carried into the next phase. Judicious use of extension, abduction, and external rotation isometrics are performed. It should be cautioned that during this early fourth dimension frame that exercises such every bit "rhythmic stabilization" are performed initially at very depression levels, reaching forces of 2-4 pounds at most.

Additionally scapulothoracic isometrics and AROM exercises are used during this time frame. Davies and Ellenbecker⁶⁰ accept described total arm strengthening that tin have a positive effect on the entire upper extremity. These exercises should be initiated early to ensure adequate strength of other remaining upper extremity musculature.

Late Strengthening Phase (6-12 weeks)

The advanced strengthening phase begins at around 6 weeks and extends to effectually 16 weeks. Goals to be obtained at this time include achieving and maintaining full shoulder mobility both actively and passively, and gradually increasing muscular strength and endurance. Davies⁵⁹ has described an practice progression continuum every bit a means of integrating a safe and systematic process of progressing patients through an exercise programme. Therapeutic exercises in this phase should begin with gentle submaximal isometrics for the pectoralis. These exercises should initially exist performed with the shoulder adducted to place the pectoralis in a relatively shortened position. This activeness should not be performed in full horizontal adduction as the pectoralis would exist placed in a position nearing active insufficiency. Isometric exercises should be progressed to neutral shoulder or the "balance position" ( Figure 7 ) and toward the stop of this phase performed in a more than lengthened position. Rarely should these isometric exercises be performed in full horizontal abduction with the pectoralis musculus in a fully diffuse position, which may identify excessive strain on the repaired tissue.

Isometrics for the shoulder in the "balance position."

Usually by the 12 week period gentle isotonic tubing exercises can be started in a safe ROM that does not identify excessive stretch on the repair site. At the end of this phase proprioceptive neuromuscular facilitation (PNF) techniques can be helpful by simultaneously recruiting all the muscles in the upper extremity by incorporating both screw and diagonal patterns of motion.⁶¹ In the overhead athletes, the PNF patterns of diagonal 2 (D2) flexion and extension movements are performed because these patterns are very similar to overhead throwing patterns. Initially, the PNF patterns should be concentric against gentle transmission resistance. Following tolerance of transmission techniques, PNF can exist performed using exercise tubing. Progressive resistance can exist increased by using tubing for eccentric command.

Total AROM exercises can exist performed at this time. Careful emphasis should exist placed on normalizing glenohumeral arthrokinematics to permit unrestricted mobility. Due to prolonged immobilization with this surgical process some arthrokinematic limitations are common that demand to be addressed. Arthrokinematic bug that commonly remain include a decrease in anterior, junior, and posterior glide passive motions of the glenohumeral articulation. Joint mobilizations for these restrictions should exist initiated ( Figure 8 ). Additionally, arthrokinematic limitations of the sternoclavicular and acromioclavicular should be assessed with appropriate interventions, as needed.

Joint mobilization to address inferior capsule contracture limiting normalization of glenohumeral joint arthrokinematics.

Because the scapulothoracic articulation is not a true synovial joint, rarely does this pseudo-joint incur movement bug. Motion restrictions of the scapulothoracic articulation can result from excessive use and compensation of the posterior scapular muscles. Commonly during this fourth dimension the patient may exhibit a compensatory "shrug sign," also known as scapular "hiking" or a contrary scapulohumeral rhythm in which the scapula moves more than the humerus.⁶² When initiating shoulder height movements, if the entire shoulder girdle or scapula elevates, a faulty neuromuscular design is occurring. In this course of compensation the weaker rotator cuff muscles are being overpowered by the stronger deltoid muscles. If this blueprint of movement occurs, information technology should be stopped and addressed immediately. Continuation of this faulty pattern will only prolong its apply and potentially ready the patient upwards for rotator gage impingement problems and possible rotator cuff tear. If these compensations are occurring, the patient should limit AROM in shoulder elevation to below 90 degrees and begin dynamic stabilization drills for the scapular and rotator cuff muscles.

Advanced Strengthening Phase (12-16+ weeks)

The final stage of the post-operative program following pectoralis tendon repair is the Render to Activity Phase and occurs subsequently 12-16+ weeks. The goals for this period include total AROM/PROM of the shoulder and a gradual return of full strength for resumption of all prior activities of vocation or daily living. Handling at this stage can brainstorm to be more aggressive, merely meaning, weight can be increased and multi planar exercises can be begun. If shoulder ROM is full, light overhead activities can be progressed. These activities can include gentle advanced activities that employ concentric/eccentric contractions such equally plyometric activities with plyoball catches or apply of the BodyBlade ( Figure 9 ). For the weightlifter or bodybuilder a slow progression of calorie-free shoulder printing and bench press can now be performed. No lifting greater than 50% of the athlete's previous 1 repetition maximum should exist performed until 6 months afterward surgery. Additionally, the use of heavy weighted pec dec and flys should exist avoided for up to 6 months after surgery due to abnormally large amounts of stress to the pectoralis major. A pec dec refers to the seated pectoralis exercise machine in which the arms/elbows of the participant are placed effectually pads bilaterally and the participant horizontally flexes or adducts the shoulders toward each other. The fly is a similar movement done with impaired bells in each hand on a flat or incline bench. When performing these exercises it may be wise to slightly alter the lift allowing maintenance of the humerus in a position anterior to the frontal plane, which drastically reduces the amount of strain on the pectoralis major muscle and tendon.

Surgical Outcomes

Reviewing 16 repairs, Kretzler and Richardson²⁴ reported full forcefulness return in 13 cases. 2 of the three who did not take total force presented for testing more than than 5 years after the repair. Despite this delay, and the fact that full strength was non attained, all three experienced significant improvements in their pre-surgery force. All 16 had a return of normal pectoralis profile and relief of hurting.

Schepsis et al⁶³ assessed surgical outcomes post-obit 13 patients undergoing pectoralis major repair. Surgical patients were broken into acute and chronic repairs, both of which faired significantly better with subjective reports of function rated at 96% and 93%, respectively, compared to 51% in a group of non-operative treated patients. Isokinetic strength was greatest in the astute group (102%) of the contrary side, compared to 94% with the chronic group, while non-operative patients only achieved 71% of the contralateral upper extremities strength.

Zeman and colleagues¹⁹ reported on nine athletes that sustained pectoralis major tears. Five of their patients were treated conservatively and obtained good results in that they were able to achieve normal ROM, with only mild pain and weakness. Four of the patients were treated surgically and obtained excellent results which were described equally normal ROM and splendid strength.

McEntire and colleagues^twenty reported on eleven cases of pectoralis rupture and noted that the muscle belly injuries practise well when treated not-operatively, equally long as there is not a large hematoma or infection. Finally, Wolfe and colleagues^seven reported superior results with surgical repair vs bourgeois treated patients. Their surgically treated grouping had acme torque and depression-speed work values of 105.8% and 109.0% that of the uninvolved side, respectively, compared with 74.0% and 60.one% which was that of the conservatively treated group.

Bak and colleagues⁸ performed a meta-assay of 112 cases of pectoralis major rupture and found that excellent or good results were reported for 88% of surgically treated cases versus 27% of those treated conservatively. These authors concluded that with rare exceptions, no indication for nonsurgical treatment of pectoralis tendon ruptures was indicated. In a more recent meta-analysis, Aarimaa and colleagues³ analyzed final outcomes following surgical repair of the pectoralis major using 33 patients with operative treated pectoralis major rupture patients of their own and combined these with a meta-assay of previously reported cases in the literature. The authors found that both their cases and those from the literature demonstrated that early operative treatment is associated with better event than delayed handling, while delayed handling had better outcomes than not-surgical treatment.

Return to Play Guidelines

The return to play criteria presented in this manuscript is somewhat dependent upon the activity that the athlete plans to continue. Although a cookbook arroyo should non be used for return to play criteria, several commonalities do exist. To begin with, the athlete's willingness to return to play both physically and mentally is very important. Because a gradual progressive rehabilitation program has been utilized, a general idea of the athlete'south physical capabilities is well known. In general, to exist released from the physician the athlete must have a satisfactory clinical exam which consists of pain-free total, or adequate ROM, and normal force. When available, isokinetic testing can be utilized to gain a more than objective measure of muscle strength. As mentioned previously, for the weightlifter or bodybuilder a slow progression of weight training should be followed. A strong recommendation is that no lifting greater than 50% of the athlete'south previous 1 repetition maximum be performed until vi months post-operative. Additionally, the use of heavy weighted pec december and flys should be avoided for up to 6 months due to abnormally big amounts of stress to the pectoralis major.

SUMMARY

Early recognition and surgical treatment of a ruptured pectoralis major tendon followed by a graded post surgical rehabilitation plan that incrementally increases ROM and stress to the repaired tendon allows a total return of functional force and mobility. This manuscript outlines a graduated postal service-operative protocol for return following pectoralis major tendon repair.

REFERENCES

1. Patissier P. Traite des Maladies Artisans. Paris, 1822:162-164 [Google Scholar]

ii. Butcher JD, Siekanowicz A, Pettrone F. Pectoralis major rupture: Ensuring accurate diagnosis and constructive rehabilitation. Md Sportsmed. 1996;24:37-44 [PubMed] [Google Scholar]

iii. Aarimaa V, Rantanen J, Heikkila J, et al. Rupture of the pectoralis major muscle. Am J Sports Med. 2004;32:1256-1262 [PubMed] [Google Scholar]

iv. Quinlan JF, Molloy M, Hurson BJ. Pectoralis major tendon ruptures: When to operate. Br J Sports Med. 2002;36:226-228 [PMC gratis article] [PubMed] [Google Scholar]

5. Delport HP, Piper MS. Pectoralis major rupture in athletes. Arch Orthop Trauma Surg. 1992;100:135-137 [PubMed] [Google Scholar]

half dozen. Breda K, Continenza MA, Ricciardi G, et al. Anatomical findings of the beliefs of the pectoralis major muscle fibers. Boll Soc Ital Biol Sper 1977;53:1512-1516 [PubMed] [Google Scholar]

seven. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle, an anatomic and clinical analysis. Am J Sports Med. 1992;20:587-593 [PubMed] [Google Scholar]

8. Bak K, Cameron EA, Henderson IJP. Rupture of the pectoralis major: A meta-assay of 112 cases. Knee Surg Sports Traumatol Arthrosc. 2000;eight:113-119 [PubMed] [Google Scholar]

9. Bersen BL. Surgical repair of pectoralis major rupture in an athlete: Example report of an unusual injury in a wrestler. Am J Sports Med. 1979;vii:348-351 [PubMed] [Google Scholar]

10. Dunkelman NR, Collier F, Rook JL, et al. Pectoralis major muscle rupture in windsurfing. Curvation Phys Med Rehabil. 1994;75:819-821 [PubMed] [Google Scholar]

eleven. Manjarris J, Gershuni DH, Moitoza J. Rupture of the pectoralis major tendon. J Trauma. 1985;25:810-811 [PubMed] [Google Scholar]

12. Rijnberg WJ, van Linge B. Rupture of the pectoralis major muscle in body-builders. Arch Orthop Trauma Surg. 1993;112:104-105 [PubMed] [Google Scholar]

13. Alho A. Ruptured pectoralis major tendon. A case written report on delayed repair with muscle advancement. Acta Orthop Scand. 1994;65:652-653 [PubMed] [Google Scholar]

fourteen. Pavlik A, Csepai D, Berkes I. Surgical treatment of pectoralis major rupture in athletes. Knee Surg Sports Traumatol Arthrosc. 1998;6:129-133 [PubMed] [Google Scholar]

15. Roi GS, Respizzi S, Dworzak F. Fractional rupture of the pectoralis major muscle in athletes. Int J Sports Med. 1990;11:85-87 [PubMed] [Google Scholar]

16. Simonian PT, Morris ME. Pectoralis tendon avulsion in the skeletally immature. Am J Orthop. 1996;25:563-564 [PubMed] [Google Scholar]

17. de Roguin B. Rupture of the pectoralis major muscle: Diagnosis and treatment. Report of 3 cases. Rev Chir Orthop Reparatrice Appar Mot. 1992;78:248-250 [PubMed] [Google Scholar]

18. Liu J, Wu JJ, Chang CY, et al. Avulsion of the pectoralis major tendon. Am J Sports Med. 1992;20:366-368 [PubMed] [Google Scholar]

19. Zeman SC, Rosenfeld RT, Lipscomb PR. Tears of the pectoralis major muscle. Am J Sports Med. 1979;vii:343-347 [PubMed] [Google Scholar]

20. MacEntire JE, Hess We, Coleman SS. Rupture of the pectoralis major muscle. J Bone Joint Surg. 1972;54A:1040-1046 [PubMed] [Google Scholar]

21. Griffiths GP, Selesnick FH. Rupture of the pectoralis major muscle: Diagnosis and treatment. Phys Sportsmed. 1997;25:118-125 [PubMed] [Google Scholar]

22. Kawashima G, Sato M, Torisu T, et al. Rupture of the pectoralis major: Report of 2 cases. Clin Orthop. 1975;109:115-119 [PubMed] [Google Scholar]

23. Hayes WM. Rupture of the pectoralis major musculus. Review of the literature and report of two cases. J Int Higher Surg. 1950;14:82-88 [PubMed] [Google Scholar]

24. Kretzler HH, Richardson AB. Rupture of the pectoralis major muscle. Am J Sports Med. 1989;17:453-458 [PubMed] [Google Scholar]

25. Orava Due south, Sorasto A, Aalto K, et al. Total rupture of pectoralis major muscle in athletes. Int J Sports Med. 1984;5:272-274 [PubMed] [Google Scholar]

26. Verfaillie SM, Claes T. Bony avulsions of the pectoralis major muscle. J Bone Joint Surg. 1996;5:327-329 [PubMed] [Google Scholar]

27. Miller Doctor, Johnson DL, Fu FH, et al. Rupture of the pectoralis major muscle in a collegiate football player. Am J Sports Med. 1993;21:475-477 [PubMed] [Google Scholar]

28. Shellock FG, Mink J, Deutsch AL. MR imaging of muscle injuries. Appl Radiol. 1994;1:xi-16 [Google Scholar]

29. Ohashi G, El-Khoury GY, Albright JP, et al. MRI of complete rupture of the pectoralis major muscle. Skeletal Radiol. 1996;25:625-628 [PubMed] [Google Scholar]

xxx. Zvijac JE, Schurhoff MR, Hechtman KS, et al. Pectoralis major tears. Correlation of magnetic resonance imaging and treatment strategies. Am J Sports Med. 2006;34:289-294 [PubMed] [Google Scholar]

31. Park JY, Espiniella JL. Rupture of pectoralis major muscle. A case study and review of the literature. J Bone Joint Surg. 1970;52A:577-581 [PubMed] [Google Scholar]

32. Bakalim G. Rupture of the pectoralis major muscle. Acta Orthop Scand. 1965;36:274-279 [PubMed] [Google Scholar]

34. Carek PJ, Hawkins A. Rupture of pectoralis major during parallel bar dips: Example report and review. Med Sci Sports Exerc. 1998;30:335-338 [PubMed] [Google Scholar]

35. Egan RM, Hall H. Avulsion of the pectoralis major tendon in a weight lifter: Repair using a barbed staple. Can J Surg. 1987;xxx:434-435 [PubMed] [Google Scholar]

36. Gudmundsson B. A case of agenesis and a instance of rupture of the pectoralis major muscle. Acta Orthop Scand. 1973;44:213-218 [PubMed] [Google Scholar]

37. Hanna CM, Glenny AB, Stanley SN, et al. Pectoralis major tears: comparing of surgical and conservative handling. Brit J Sports Med. 2001;35:202-206 [PMC complimentary article] [PubMed] [Google Scholar]

38. Herrick RT. Pectoralis tendon and pectoralis muscle injuries (letter). Am J Orthop. 1997;26:334 [PubMed] [Google Scholar]

39. Krishne ND, Jani DM. Surgical repair of rupture of the pectoralis major musculus: A case written report. J Trauma. 1976;xvi:749-750 [PubMed] [Google Scholar]

twoscore. Lindenbaum BL. Delayed repair of a ruptured pectoralis muscle. Clin Orthop. 1975;109:120-121 [PubMed] [Google Scholar]

41. Marmor L, Bechtol CO, Hall CB. Pectoralis major musculus: Role of sternal portion and mechanism of rupture of normal musculus: example reports. J Bone Joint Surg. 1961;43A:81-87 [Google Scholar]

42. Pulaski EJ, Chandler BH. Ruptures of the pectoralis major muscle. Surgery. 1941;10:309-325 [Google Scholar]

43. Assal M, Jung Chiliad, Stern R, et al. Limited open repair of Achilles tendon ruptures. A technique with a new musical instrument and findings of a prospective multi-center study. J Bone Joint Surg. 2002;84A:161-170 [PubMed] [Google Scholar]

44. Carter TR, Fowler PJ, Blokker C. Functional postoperative treatment of Achilles tendon repair. Am J Sports Med. 1992;twenty:459-462 [PubMed] [Google Scholar]

45. Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative handling of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21:71-79 [PubMed] [Google Scholar]

46. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med. 1995;23:392-395 [PubMed] [Google Scholar]

47. Leggin BG, Kelley MJ. Rehabilitation of the shoulder following rotator cuff surgery. U Penn Orthop J. 2000;13:x-17 [Google Scholar]

48. Kunkel SS, Hawkins RJ. Open repair of the rotator cuff. In: Andrews JR, Wilk KE. (eds): The Athletes Shoulder. New York: Churchill Livingstone; 1994 [Google Scholar]

49. Timmerman LA, Andrews JR, Wilk KE. Mini-open up repair of the rotator gage. In: Andrews JR, Wilk KE. (eds): The Athletes Shoulder. New York: Churchill Livingstone; 1994 [Google Scholar]

50. Wilk KE, Crockett HC, Andrews JR. Rehabilitation subsequently rotator cuff surgery. Tech Shoulder Elbow Surg. 2000;1:128-144 [Google Scholar]

51. Wilk KE, Andrews JR, Crockett HC. Rehabilitation later rotator cuff surgery: Techniques in shoulder and elbow. Am J Acad Orthop Surg. 1997;5:130-140 [Google Scholar]

52. Ellenbecker TS, Bailie DS, Kibler WB. Rehabilitation after mini-open and arthroscopic repair of the rotator cuff. In: Manske RC. (ed) Post Surgical Orthopedic Sports Rehabilitation: Knee and Shoulder. St. Louis: Mosby; 2006 [Google Scholar]

53. Speer KP, Warren RF, Horowitz L. The efficacy of cold therapy in the postoperative shoulder. J Shoulder Elbow Surg. 1996;five:62-68 [PubMed] [Google Scholar]

54. Prentice Nosotros. (ed). Therapeutic Modalities for Physical Therapists. 2d ed.New York: McGraw-Loma; 2002 [Google Scholar]

55. Cameron MH. (ed). Physical Agents in Rehabilitation. From Research to Do. Philadelphia, PA: Saunders; 1999 [Google Scholar]

56. Barasch T.Scar management. In: Burke SL, Higgens JP, McClinton MA, et al. (eds). Manus and Upper Extremity Rehabilitation: A Practical Guide. St. Louis: Churchill Livingstone; 2006 [Google Scholar]

57. Edwards J. Scar management. Nurs Stand up. 2003;17:39-42 [PubMed] [Google Scholar]

58. Micholovitz SL. Ultrasound and selected physical agent modalities in upper extremity rehabilitation. In Mackin EJ, Callahan Advertizing, Skirven RM, et al. (eds). Hunter-Mackin-Callahan Rehabilitation of the hand and Upper Extremity. 5th ed.St. Louis: Mosby; 2002 [Google Scholar]

59. Davies GJ. A Compendium of Isokinetics in Clinical Usage and Rehabilitation Techniques, 4th ed.Onalaska, WI: Due south & S Publishers; 1992 [Google Scholar]

60. Davies GJ, Ellenbecker TS. Total arm strength for shoulder and elbow overuse injuries. In: Upper Extremity. Timm Thousand. (ed). Orthopaedic Habitation Report Course, LaCrosse, WI; 1993 [Google Scholar]

61. Borsa PA, Lephart SM, Kocher MS, et al. Functional assessment and rehabilitation of shoulder proprioception for glenohumeral instability. J Sports Rehabil. 1994;three:84-104 [Google Scholar]

62. Magee DJ. Orthopedic Concrete Cess. quaternary ed.St. Louis, MO: Saunders; 2006 [Google Scholar]

63. Schepsis AA, Grafe MW, Jones HP, et al. Rupture of the pectoralis major muscle. Outcome after repair of astute and chronic injuries. Am J Sports Med. 2000;28:9-fifteen [PubMed] [Google Scholar]

---

Manufactures from Due north American Periodical of Sports Concrete Therapy : NAJSPT are provided here courtesy of The Sports Physical Therapy Section of the American Concrete Therapy Association

---

Can I Use My Right Arm After A Pec Repair,

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953288/

Posted by: flahertybrall1995.blogspot.com

Share this post