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Acute pectoralis major tendon rupture — MSRA MCQ

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HardSoft Tissue InjuryAcute pectoralis major tendon ruptureMSRA

A 36-year-old right-hand-dominant gym instructor attends a GP-led urgent treatment centre 3 hours after bench-pressing. During the lowering phase, with his right shoulder abducted and externally rotated, he felt a sudden painful snap across the anterior chest and stopped immediately. There is bruising extending from the right axilla to the proximal medial upper arm. Compared with the left side, the anterior axillary fold is flattened and there is a palpable defect lateral to the pectoralis major muscle belly. Shoulder abduction is painful but preserved. Adduction and internal rotation against resistance are markedly weak and painful. Distal neurovascular examination is normal. Shoulder and humeral radiographs show no fracture or dislocation. What is the most appropriate management today?

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Correct answer: A — Provide analgesia and a sling, and make a same-day emergency referral to the orthopaedic on-call service

Explanation lettering: C = shown as A · D = shown as C · E = shown as D · A = shown as E

This presentation is strongly suggestive of an acute pectoralis major tendon rupture: the mechanism is eccentric loading during bench press with the shoulder abducted and externally rotated; the bruising and loss of the anterior axillary fold indicate disruption rather than a simple strain; and marked weakness of resisted adduction and internal rotation localises the functional deficit to pectoralis major. Normal radiographs exclude neither tendon rupture nor the need for specialist assessment. UK NHS referral guidance specifically lists suspected acute pectoralis major tendon rupture as requiring emergency referral to orthopaedics/on-call services. Same-day specialist assessment permits confirmation, appropriate imaging arranged by the receiving team, and timely consideration of repair. Operative treatment has better pooled functional, strength and cosmetic outcomes than non-operative treatment in the available systematic-review evidence, although the decision to operate remains individualised. A is appropriate for an uncomplicated muscle strain without deformity or major power loss. B is attractive because imaging may confirm the diagnosis, but outpatient imaging must not delay emergency specialist referral where acute rupture is suspected. D underestimates the required urgency. E may suit selected stable fractures or minor soft-tissue injuries but is inappropriate for a suspected acute pectoralis major rupture requiring on-call orthopaedic assessment.

Reference: TARGET AUDIENCE PATIENT GROUP: Primary Care – GPs (2023) — https://www.rightdecisions.scot.nhs.uk/media/2385/physiotherapy-musculoskeletal-june-short-version-20.pdf Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment (2020) — https://pubmed.ncbi.nlm.nih.gov/32083144/