A 27-year-old elite goalkeeper presents with an injury to his right shoulder. He describes an awkward landing while making a save. The ball struck his hand while his arm was in an abducted and externally rotated position. This was immediately painful, and he was unable to continue. The following day he developed bruising over his shoulder and upper arm. On examination there was an asymmetry between the appearance of the player’s right and left chest wall with weakness of combined adduction and internal rotation.
X-ray imaging of the right shoulder was normal. MRI images of the shoulder and chest wall show a near complete avulsion of the pectoralis major tendon from the humerus. There is retraction of tendon fibres measuring up to 35 mm. There is a large volume of oedema, some displacement of the biceps tendon from the bicipital groove and likely haematoma.
This player was managed with surgical repair of the ruptured tendon. Post-surgery, the repair was protected in a sling for six weeks, after which a progressive strengthening programme was delivered. The player was able to return to normal play five months after the surgery. At this time an Isokinetic dynamometer showed no significant difference between the injured and uninjured sides.
Ruptures of the pec major are relatively rare. The pec major is a powerful adductor, internal rotator and flexor of the humerus and is an important dynamic stabiliser of the shoulder. Injuries generally involve a sudden overload of the contracted muscle. MRI is generally considered the best modality to confirm this injury (ultrasound can also be used). It is however important to request dedicated sequences of the pec major and chest wall as the injury can easily be missed on ‘standard’ shoulder images. In most cases surgery is the optimum treatment, and in the acute setting this generally involves direct repair. Direct repair can also be done for some chronic cases however reconstruction may be required.
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