Pectoralis Major Tears

Pec major tear chronic




Men aged 20 - 40




Usually occurs in gym

Bench press

Increased risk with steroid use / growth hormone


Bodendorfer et al Orthop J Sports Med 2020

- systematic review of 23 papers and 664 injuries

- all male, average age 31

- 63% occurred during weight training




P Major anatomy


Clavicular head

- attaches: medial clavicle and upper sternum

- inserts: lowermost aspect of bicipital groove


Sternal head

- sternum, aponeurosis external oblique and costal cartilages of first 6 ribs

- inserts at uppermost aspect of bicipital groove


2 tendons converge and rotate 90o

- insert lateral to bicipital groove

- superior fibres insert inferiorly and vice versa


Tendon is composed of two lamina

- anterior lamina is clavicular head

- posterior lamina is sternal head


Nerve supply


Lateral pectoral nerve C5-7

- clavicular head

- part of sternal head


Medial pectoral nerve C8-T1 

- sternal head

- passes through and supplies pec minor




Powerful adductor, flexor and internal rotator




Usually recall significant incident

- tearing sensation

- may hear a pop

- often severe swelling and bruising


Only later when it settles is the cosmetic and functional deficiency apparent




Significant bruising in the acute phase


Acute pectoralis major tear


Pec Major RupturePec major rupture palpable cord

Asymmetry of chest wall


Frequently palpable cord present

- is pectoral fascia still attached to antebrachial fascia

- not to be mistaken for pectoralis tendon

- prevents full retraction


In chronic setting, ask patient to adduct against hip / resistance


Pectoralis Major TearPectoralis Tear 2


Usually complain of weakness, mainly in gym




MRI P Major tear 1MRI Pec major tear 2

Coronal T2 MRI Right shoulder


Chronic Pectoralis Major 1

Coronal T1 MRI Left shoulder


Pectoralis Major 3Pectoralis 3

Coronal T1 MRI Left shoulder




Bony avulsion

Tendon avulsion

Isolated clavicular or sternal head tears

Musculotendinous tears


Musculotendinous tears


Avulsion of muscle off tendon at musculotendinous junciton

- not amenable to suture repair

- need allograft reconstruction


Synovec et al Orthop J Sports Med 2020

- MRI study of 72 patients

- 75% sensitive and 80% specific for musculotendinous tears




Non operative


Elderly / low function

Chronic setting


Bodendorfer et al Orthop J Sports Med 2020

- systematic review of operative versus nonoperative treatment

- operative treatment superior in functional outcomes / strength / cosmesis






Acute tears in young patients

Cosmesis i.e. body builders


Acute repair



- suture anchor

- cortical anchor

- bone trough


Incision Pec Major RepairPect Major Repair Through Bone Trough

Axillary incision right shoulder


Bone Trough Technique


Beach chair

- deltopectoral approach

- can also make incision in axillary skin crease

- find pectoralis major tendons medially

- Krackow with high strength sutures

- place Hohmann retractor under deltoid to expose humerus

- identify long head of biceps

- can usually identify previous pectoralis major insertion

- drill one inch trough in humerus lateral to long head of biceps

- make drill holes with 2 mm drill lateral to trough

- use suture passer to pass sutures into trough and out lateral drill holes

- pull tendon into trough and tie sutures


Pec major repair 1

Axillary crease incision in right shoulder, with Kocher forceps on the torn pectoralis major tendon


P Major tear surgeryPec major tear humerus

Right shoulder, with Hohmann retractor exposing humerus


P Major trough in bone

Bone trough with sutures passed through lateral drill holes


Completed repairPec major repair complete

Completed repair


Cortical button technique


Arthrex surgical technique video pectoralis major


Vumedi pectoralis major repair with cortical button




Bodendorfer et al Am J Sports Med 2020

- systematic review of operative repair

- no difference between different surgical techniques

- acute repair superior to chronic repair


Bodendorfer et al Orthop J Sports Med 2020

- systematic review of operative v nonoperative treatment

- complication rate 14%

- infection <1%

- DVT < 1%

- re-rupture 3%

- persistent pain 3%


Balazs et al Am J Sports Med 2016

- 214 military patients undergoing surgery

- at 12 months, 95% return to active duty


Chronic Reconstruction of Pectoralis Major tendon




Vumedi video


Surgical technique video allograft reconstruction


Tendoachilles graft with bone block cut off

- pass through allograft tendon through muscle in pul ve taft method

- tie down into bone trough in humerus as per usual technique


Pect Major Reconstruction 14 Suturing allograftPec Major Reconstruction 3

Right shoulder.  Allograft has been passed through sternal and clavicular muscle bellies and is being sutured back onto itself


Nute et al JBJS Am 2017

- 9 military patients requiring allograft reconstruction

- 5/9 had good or excellent results