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The pectoralis major muscle is the large muscle in front of the upper chest. There are two parts of the pectoralis muscle, the pectoralis major and the pectoralis minor. The pectoralis major is the larger of the two and works to push the arms in front of the body like doing a push-up or bench press exercise. Pectoralis major tendon rupture is a rare shoulder injury, commonly seen in weightlifters and football players. This injury is being seen more often due to the increased emphasis on healthy lifestyles and weightlifting in older age groups. Most injuries occur as a bone-tendon avulsion injury. Surgical repair of the pectoralis major tendon rupture has been shown to provide the best outcomes for strength return, because of this surgical repair is the most common choice for those wishing to return to competitive or recreational athletic activity. Without surgery it is highly likely that the injury will cause persistent weakness, which may be acceptable for some people with more sedentary lifestyles.
Surgical repair involves using cortical buttons or suture anchors to re-approximate and attach the tendon to the bone. The pec major muscle has 2 heads, sternal and clavicular. The tendon arises from the muscular portion and then inserts near the top of the humerus (upper arm bone). This muscle functions to assist in flexion, adduction and internal rotation of the shoulder. This is important to understand because motion in the opposite direction will be limited early on in post-operative rehab.
Phase I (surgery to 2 weeks after surgery)
Rehabilitation appointments
- Physician appointment 2 weeks after surgery
- Rehabilitation appointments begin 2 weeks of surgery
Rehabilitation goals
- Reduce pain and swelling in the shoulder after surgery
- Maintain active range of motion (AROM) of the elbow, wrist and neck
- Protect healing of repaired tissues and implanted devices Precautions (^) • Continuous use of the sling
Suggested therapeutic exercise (^) • Elbow, wrist and neck AROM
Cardiovascular exercise (^) • Walking and stationary bike with sling on
- No treadmill Progression criteria (^) • 2 weeks after surgery
Phase III (begin 6 weeks after surgery)
Rehabilitation appointments (^) • Rehab every 1-2 weeks
Rehabilitation goals (^) • Functional, gently progressive shoulder range of motion in
all planes with full range of motion by week 12
- Progressive strengthening of the shoulder and chest
- Correct any postural dysfunction Suggested therapeutic exercises
- Begin sub maximal isometrics to pectoralis major (shoulder IR, adduction and flexion) in a shortened position progressing to neutral muscle tendon length. Avoid isometrics in full elongated position
- Shoulder ER, abduction and extension strengthening can be initiated in ways that does not overly stretch or tension the pec major tension (should be no pain at the repair site during these exercises)
- Side lying shoulder flexion
- Scapular strengthening
- Active, active assistive and passive range of motion at the shoulder as needed
- Core strengthening
Precautions (^) • Slowly begin to wean out of the sling
- External rotation range of motion limited to 45 degrees in abducted positions
- Shoulder extension limited to 20 degress
- Avoid any horizontal abduction Cardiovascular exercise (^) • Walking and stationary bike
- No treadmill or swimming
- Avoid running and jumping because of landing impact Progression criteria (^) • 12 weeks after surgery
Phase IV ( 12 weeks after surgery if meeting phase 3 goals)
Rehabilitation appointments (^) • Physician appointment 12 weeks after surgery
Rehabilitation goals (^) • Normal (rated 5/5) rotator cuff strength and endurance at
90 degrees of shoulder abduction and scaption
- Advance proprioceptive and dynamic neuromuscular control retraining
- Achieve maximal shoulder external rotation (no limitations)
- Correct postural dysfunctions with work and sport specific tasks
- Develop strength and control for movements required for work or sport Suggested therapeutic exercises
- Progressive pectoralis strengthening, beginning with isotonics in a shortened range, gradually progressing to eccentrics then to an increased range.
- Multi-plane shoulder active range of motion with a gradual increase in the velocity of movement while making sure to assess scapular rhythm
- Shoulder mobilization as needed
- Rotator cuff strengthening in 90 degrees of shoulder abduction and overhead (beyond 90 degrees of shoulder abduction)
- Scapular strengthening and dynamic neuromuscular control in open kinetic chain and closed kinetic chain positions
- Core and lower body strengthening Precautions (^) • Loaded horizontal abduction (bench press, push ups, etc)
should begin and progress in a very gradual manner. Bench should include protecting the range and limiting to a maximum of 50% of pre-injury max for the first 18- weeks.
Cardiovascular exercise (^) • Walking, stationary bike and stair master
Phase V (begin after meeting Phase IV criteria, usually 18 weeks after surgery)
Rehabilitation appointments (^) • Physician appointment 18 weeks after surgery
Rehabilitation goals (^) • Normal (rated 5/5) strength at 90 degrees of shoulder
abduction
- Advance proprioceptive and dynamic neuromuscular control retraining
- Develop strength and control for movements required for work or sport
- Develop work capacity cardiovascular endurance for work/sport Suggested therapeutic exercises
- Progressive pectoralis strengthening to full range of motion, beginning with isotonics gradually progressing to eccentrics and plyometrics
- Rotator cuff strengthening in 90 degrees of shoulder abduction as well as in provocative positions and work/sport specific positions, including eccentric strengthening, endurance and velocity specific exercise
- Scapular strengthening and dynamic neuromuscular control in overhead positions and work/sport specific positions
- Work and sport specific strengthening
- Core and lower body strengthening
- Work specific program, golf program, swimming program or overhead Precautions (^) • Soreness should go away within 12 hours of exercise
Cardiovascular exercise (^) • Use work and sport specific energy systems
Progression criteria (^) • Return to sport after receiving surgeon clearance and
passing upper extremity progressive testing
- Return to sport is based on meeting goals
These rehabilitation guidelines were developed by the UW Health Sports Medicine group.
- Robert C. Manske, PT, DPT, SCS, ATCa and Dan Prohaska, MDb Pectoralis Major Tendon Repair Post Surgical Rehabilitation. N Am J Sports Phys Ther. 2007 Feb; 2(1): 22–33.
- Gupton M and Johnson J. Surgical Treatment of Pectoralis Major Muscle Ruptures: A Systematic Review and Meta-analysis Orthop J Sports Med 2019 Feb 7;7(2)
- Yu et al. Outcomes and Return to Sport After Pectoralis Major Tendon Repair: A Systematic Review. Sport Health. 2019 11(2): 134-141.
At UW Health, patients may have may receive direction or educational materials that vary from this information. This information is not intended to replace the care or advice given by your physician or health care provider. It is neither intended nor implied to be a substitute for professional advice. Call your health provider immediately if you think you may have a medical emergency. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any question you may have regarding a medical condition.
