What is your diagnosis?

The patient is diagnosed with a pectoralis major tendon tear. This injury is often seen with heavy lifting or weightlifting and most commonly occurs in males ages 20-40 [1].

• Pearl: There is a greater risk of this injury with anabolic steroid use [1].

What is included in your differential?

Differential diagnoses include biceps tendon rupture, rotator cuff tear, acromioclavicular injury, humeral fracture, deltoid injury.

How does this injury present? What are some key exam findings?

During the initial presentation, patients may complain about shoulder pain and ecchymosis may be noted over the medial aspect of the humerus and the lateral chest. A defect may or may not be palpated. There may be a “dropped nipple sign”, chest bulge, and/or loss of the normal axillary contour due to muscle/tendon disruption [1]. On strength testing, decreased strength will be present with adduction and internal rotation of the shoulder [2]. 

• Pearl: A “dropped nipple sign” is when the ipsilateral nipple sits lower than the contralateral side [1]. This occurs because of medial retraction of the torn muscle body.

How is it diagnosed?

The modality of choice for diagnosis is an MRI of the chest, which can be obtained non-emergently. Oftentimes, however, the mechanism of injury and physical exam findings can clue you into the diagnosis. 

• Pearl: Consider ultrasound to aid in bedside diagnosis as well. Image 2 shows an intact long-axis view of the pectoralis major tendon. To obtain this image,  position the patient with their shoulder slightly abducted and externally rotated. Using a linear transducer, position it transversely on the proximal aspect of the humerus to obtain a short axis image of the biceps tendon. In short-axis, slide down the humerus, and the pectoralis major tendon should come into view. You can then rotate the probe 90º to obtain a short-axis view of the tendon and muscle body [3]. Image 3 shows an abnormal ultrasound. 

Image 2:  Intact long-axis view of the pectoralis major tendon. Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 72993

Image 3: Loss of the normal muscular pattern within the sternal head of the pectoralis major muscle. Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 72993

What is your management in the ED? What is your disposition?

In the ED, an x-ray should be obtained to rule out bony avulsion. The patient can be discharged with a sling to maintain an adducted and internally rotated position [2]. Patients should have urgent referral to orthopedics as these have better outcomes with surgical management [4]. Furthermore, delayed management can result in retraction of the tendon and a more complicated operation [1].