Le diagnostic de la rupture du grand pectoral

Introduction

Tears and ruptures of the pectoralis major and its tendon are violent traumatic events causing sudden, severe pain, bruising, deformity of the muscle and chest wall, and a marked loss of shoulder strength. The injury most often occurs during a weight-training accident on the bench press, but can also occur in contact team sports or combat sports.

Diagnosis must be rapid and accurate to allow appropriate management, which may sometimes require surgery.

When and in what circumstances do pectoralis major ruptures occur?

Tears of the pectoralis major muscle and tendon, once considered rare, are increasingly seen in sports medicine. The sports most at risk are weight training, CrossFit, grappling combat sports (jiu-jitsu, judo, wrestling), and contact team sports (rugby).

The typical traumatic mechanism occurs during weight training, at the end of the eccentric phase of the bench press, when the bar is at its lowest point on the chest, just before the upward phase. The tendon rupture can be very dramatic and dangerous, as it may cause the bar to be dropped if the load is very heavy. It can also occur during dips, particularly weighted dips, or during any exercise that stresses the pectoral muscles.

In close-contact combat sports (judo, wrestling, jiu-jitsu) or in rugby, it often happens during an arm-lock or a strong pulling motion of the shoulder against resistance.

In every case, this is therefore an acute injury with a clearly identified major initial trauma. This clinical picture should not be confused with muscle-soreness-type pain, DOMS, or other pain of spontaneous or gradual onset in the chest region. There is therefore very little chance that pain in the pectoralis major region is related to a traumatic tendon or muscle injury if there was no specific initial injury episode. In cases of chest pain or atypical circumstances, as always in medicine, serious cardiac, pulmonary or abdominal causes should be ruled out with your treating physician or in the emergency department.

Symptoms of a pectoralis major rupture

At the time of the accident, the patient most often feels a distinct, sometimes audible snap at the front of the shoulder, with immediate loss of strength. In some cases the sensation may be less sudden, with a feeling of progressive tearing. In the immediate aftermath, the pain is often very severe, making it impossible to use the shoulder, which is supported with a sling or an immobilising vest.

In the hours and days that follow, diffuse swelling of the pectoralis major can be seen, very often with bruising — sometimes extremely extensive — over the whole muscle. The bruising can, however, sometimes be much less visible, appearing instead on the arm near the biceps. This is accompanied by significant, persistent pain, particularly on movement, and a clear loss of shoulder strength.

Initial diagnosis in the emergency department

During an emergency-department visit or a visit to your doctor, it is common for the diagnosis not to be made immediately, and for treatment to be limited to immobilisation and simple pain relief. The diagnoses first considered are often an anterior gleno-humeral dislocation or subluxation of the shoulder, or a biceps tendon rupture. X-rays are always normal, and further tests (ultrasound and MRI) may not be helpful if they are not specifically focused on looking for this injury.

The initial clinical examination is difficult and can be misleading and falsely reassuring, because the deformity of the pectoralis major and the anterior axillary wall — as can be seen in photos on the site — is not immediate. Initially, swelling and bruising can mask this appearance. It is only later, after the swelling subsides and the muscle retracts, that it becomes visible. In all these cases, it is above all the circumstances of the injury and a precise description of events that allow this condition to be suspected.

Distal pectoralis major injuries