Abstract
Background and Purpose This case report describes a patient who was referred to a physical therapist for treatment of a shoulder strain and was eventually diagnosed with a rupture of the pectoralis major tendon that required surgical repair. The purpose of this case report is to highlight the management of this injury within the unique constraints of a combat environment.
Case Description A 29-year-old man, currently serving as an active duty soldier in the US Army in Iraq, had a sudden onset of right shoulder pain during the concentric portion of a bench press. He was seen by a physician immediately after the injury, diagnosed with a shoulder strain, and referred to a physical therapist for a sling and exercise instruction. On the basis of the history and physical examination findings, which were consistent with a pectoralis major tendon rupture, the physical therapist placed a consult to an orthopedic surgeon in the United States through teleconsultation because orthopedic surgeons were not easily accessible in Iraq for nonemergency musculoskeletal referrals. Subsequently, the orthopedic surgeon advised evacuating the patient out of Iraq for surgical treatment.
Outcomes By means of magnetic resonance imaging, the patient was diagnosed as having a rupture of the pectoralis major tendon at the musculotendinous junction near its insertion into the greater tubercle of the humerus that required surgical repair. At 3 months after surgery, the patient had full pain-free shoulder active range of motion and had progressed well through his strengthening program in a manner that allowed return to full duty. At 6 months after surgery, the patient maintained full duty status, was performing a routine of strength training 3 times per week, and had met all of his rehabilitation and personal goals.
Discussion Successful treatment of this patient depended on analysis of the history and physical examination findings by the physical therapist to form an accurate diagnosis. In addition, timely medical evacuation and referral to an orthopedic surgeon for surgical treatment were coordinated in a combat environment. Completion of a progressive rehabilitation program after pectoralis major tendon repair also contributed to this patient's full recovery and return to duty. Had the physical therapist only followed the initial referral request, given this patient's military duties and sports and recreational activities, this case probably would have resulted in suboptimal outcomes.
In combat, the wellness of the individual soldier is vital for maintaining a healthy fighting force that is prepared to actively engage the enemy. Combat injuries have a deleterious effect, but sports and recreational injuries also may negatively affect unit readiness. Therefore, physical therapists must be able to evaluate, diagnose, and treat a variety of injuries and disorders with the interest of the patient and the larger organization in mind.
Managing musculoskeletal injuries in a combat environment poses unique challenges. Medical capabilities vary with levels of care that range from first aid to established hospital facilities (Table). Travel within a combat environment can be dangerous and can be delayed by operational situations and weather. Specially trained medical personnel, such as orthopedic surgeons, can be difficult to engage because of their small numbers and critical role in managing emergency cases. The case of a pectoralis major tendon rupture is used to highlight unique challenges to caring for a musculoskeletal injury in a combat environment.
Overview of the Military Combat Medical Care Systema
Pectoralis major tendon ruptures are uncommon.1,2 More than 150 cases have been reported in the literature since the injury was first described in 1822.3,4 Pectoralis major tendon ruptures typically occur as a result of resistance to an abduction and external rotation force.1 The pectoralis major can be injured at the origin at the sternum or clavicle, intrasubstance region, myotendinous junction, or insertion at the humerus,1 with ruptures occurring most commonly at the latter 2 sites.1,5 Weight-training activities, particularly the bench press, are frequently associated with this injury.1,3,6,7 Most commonly, it occurs in men between 20 and 39 years of age.7 There is no correlation between injury and arm dominance.7 Anabolic steroid use may increase the risk of tendon rupture.7
Surgical repair is the primary treatment for pectoralis major tendon rupture at the myotendinous junction or insertion at the humerus.1 Early surgical repair is favored over conservative treatment, according to several authors.2,8–11 The purpose of this case report is to highlight the treatment of this injury within the unique constraints of a combat environment. More specifically, this report highlights the value of the physical therapist serving on a brigade combat team (a modular organization of combined arms units for close combat operations) in a deployed combat environment and providing musculoskeletal care in regions where there are few orthopedic surgeons available for treatment of nonemergency surgical cases.
Case Description: Patient History and Systems Review
The patient was a 29-year-old man, currently serving as an active duty soldier in the US Army in Iraq as a member of an explosive ordnance disposal unit. He reported to a level 2 facility (Table) with right shoulder pain and weakness. Immediately after the injury, the patient rated his pain as 10/10 on a verbal analog scale (VAS), with 0 being “no pain” and 10 being “the most intense pain imaginable.” The patient described a loud “pop” and tearing sensation with immediate pain, weakness, and decreased range of motion during the concentric portion of a 142.9-kg bench press. Although he did not complete a warm-up set before attempting this lift, he had been able to perform 3 to 5 repetitions of this weight during the previous week. The patient was seen by a physician immediately after injury and diagnosed with a shoulder strain. He was prescribed cyclobenzaprine (Flexeril, McNeil Consumer & Specialty Pharmaceuticals, Fort Washington, Pennsylvania) and acetaminophen/oxycodone hydrochloride (Percocet, Endo Pharmaceuticals, Chadds Ford, Pennsylvania) and referred to a physical therapist for a sling and exercise instruction. The physical therapist was co-located with the level 2 facility (Table).
The patient was evaluated by the physical therapist the following morning after he was seen by the physician (13 hours after initial injury). At the time of the physical therapist's evaluation, the patient rated his pain as 5/10 on the VAS. During the history portion of the physical therapist's examination, the patient reported that he was taking a daily multivitamin and whey protein; he reported no use of anabolic steroids or other illicit substances. He was well conditioned and had been lifting weights for 3 months. He was otherwise healthy, with no general health concerns, without history of previous shoulder injuries or surgeries. The patient's goals for physical therapy were to have full shoulder range of motion, strength, and function (return to recreational weight lifting). The patient also expressed that cosmesis was a concern.
Clinical Impression 1
The patient's primary problem was the right shoulder pain, weakness, and decreased range of motion after an attempted 142.9-kg bench press. From the patient's history and systems review, the potential differential diagnoses included glenohumeral joint subluxation, labral tear, grade I or II rotator cuff muscle strain versus complete rupture, grade I or II pectoralis minor tendon strain versus complete rupture, and grade I or II pectoralis major tendon strain versus complete rupture. The physical therapist determined that the patient would need an evaluation of shoulder range of motion and muscle strength, a thorough palpatory examination, and possibly special tests to differentiate among the competing diagnoses. On review of the patient's history, there was concern over a musculoskeletal diagnosis (ie, right pectoralis major tendon rupture) that required surgical referral. The physical therapist's ability to recognize this diagnosis and need for surgical referral contributed to the importance of this case report.
Examination
The patient was in no apparent distress and was not pain-dominant during the examination. Visual observation revealed swelling and ecchymosis in the right anterior axillary region. Initially, no defect in the axillary contour was apparent; in a follow-up examination 48 hours after initial injury, a 3-finger defect in the axillary contour in the region of the lateral aspect of the pectoralis major tendon was noted. The patient had full pain-free active range of motion of the cervical spine and right elbow. Active range of motion for right shoulder flexion and abduction was limited to 100 degrees and 40 degrees, respectively. All other right shoulder active range of motion movements were painful but equal to the contralateral upper extremity. The patient had full passive shoulder range of motion bilaterally; however, right shoulder flexion and abduction were painful at end range. The patient was able to perform all gross shoulder manual muscle testing with 5/5 strength. Isolated manual muscle testing of the pectoralis major muscle in horizontal adduction and internal rotation was graded as 1/5. There was tenderness to palpation surrounding the right greater tubercle of the humerus.
The patient's radial pulse, capillary refill, and sensation for light touch were present and equal bilaterally. The skin was warm and was not pale, cyanotic, or mottled in appearance. He was able to actively move his bilateral upper extremities and provide strong, pain-free resistance to gross strength testing of all muscle groups distal to the site of injury. Upper-extremity deep-tendon reflex assessment was normal and equal for the bilateral upper extremities, and Hoffman sign was not present. Clonus was not noted in the bilateral wrists.
Clinical Impression 2
A screening examination of the cervical spine and elbow was used to rule out proximal or distal involvement, and the examination then was centered on evaluation of the shoulder. The examination revealed swelling, ecchymosis, and a defect in the axillary contour in the region of the lateral aspect of the pectoralis major tendon. The patient was able to perform all gross shoulder manual muscle testing with 5/5 strength, probably as the result of the surrounding bulky musculature. However, isolated weakness of the pectoralis major muscle and tenderness to palpation in the region of the right greater tubercle of the humerus also were noted. Because these are common findings in an acute pectoralis major tendon rupture,2,7,12 efforts were immediately geared toward timely surgical referral and medical evacuation.
At this point, a fracture was not included as a differential diagnosis because of the patient's low level of pain, willingness to move the injured upper extremity, and full shoulder passive range of motion bilaterally. Bony abnormalities are rare in pectoralis major tendon rupture,7,13 and, with the physical therapist's limited concern for a fracture, radiographs were not ordered initially.
Intervention
The physical therapist discontinued the patient's acetaminophen/oxycodone hydrochloride (Percocet) and instead prescribed naproxen (Naprosyn, Roche Pharmaceuticals, Nutley, New Jersey) because the pain was well managed but significant swelling was present. Military physical therapists are privileged to write prescriptions for selected medications for musculoskeletal conditions.14 The patient was placed in a sling, treated with cryotherapy, and instructed in a modified Codman pendulum exercise while the physical therapist coordinated for disposition of the patient. The patient was exempted from duty for 24 hours and given a profile for limited duty, allowing only the performance of administrative tasks.
The physical therapist then discussed the management of the patient's case with the referring physician and the need for surgical referral and medical evacuation. Ultimately, however, further medical treatment of the patient would need to be coordinated and decided by the medical or military leadership in the patient's assigned unit. Because the referring physician was not assigned to the same military unit as the patient and had no interaction with the patient's primary medical or military chain of command, it was decided that the physical therapist would assume care of this patient. According to protocol, the next step for initiating medical evacuation was for the physical therapist to contact the brigade surgeon, who was the ranking medical officer for the patient's military unit. However, the brigade surgeon was traveling out of the area of operations for an extended period of time and could not be contacted. In addition, sandstorms were limiting travel and communication. Because the brigade surgeon could not be contacted to discuss the patient's case, the physical therapist initiated coordination through teleconsultation for further patient evaluation and treatment.
Although orthopedic surgeons were not easily accessible in Iraq for nonemergency musculoskeletal referrals, a teleconsultation program was in place. The Office of the Surgeon General teleconsultation program began in 2004 to provide “a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rear-based specialists in a timely and consistent manner.”15(p210) Consultations were answered 7 days per week from providers who were not in the combat zone. Health care providers from all branches of the military, initially in 11 different clinical specialties, submitted their recommendations within 24 hours of receiving a request for a consultation. The physical therapist in this case placed a consult to orthopedic surgery by electronic mail, and within 24 hours, 2 military orthopedic surgeons located in the United States had replied and advised evacuating the patient out of Iraq for surgical treatment. This was the first time a physical therapist had used the teleconsultation program. The support of 2 orthopedic surgeons in conjunction with the physical therapist's recommendations helped to convince the patient's military leadership that medical evacuation was the best course of action. Therefore, medical evacuation out of Iraq was initiated.
While waiting for medical evacuation, the patient continued daily interventions as prescribed by the physical therapist consisting of cryotherapy, a modified Codman pendulum exercise, and active elbow, wrist, and hand range-of-motion exercises. Five days after the initial injury, the patient was evacuated out of Iraq to Landstuhl Army Regional Medical Center in Germany for definitive care. Magnetic resonance imaging revealed a near-complete rupture of the right pectoralis major tendon at the musculotendinous junction near its insertion into the greater tubercle of the humerus (Figure). Hemorrhage within the lateral chest in the region of the pectoralis major muscle was present, and the tendinous attachment on the humerus could not be located. As the result of the timely diagnosis, no atrophy of the pectoralis major muscle was noted. The patient underwent surgical repair of the pectoralis major tendon 15 days after initial injury.
Axial T2–weighted, fat-saturated magnetic resonance image demonstrating hemorrhage and focal discontinuity consistent with a rupture of the right pectoralis major at the level of the musculotendinous junction near its insertion into the greater tubercle of the humerus (arrow).
Rehabilitation After Surgery and Outcomes
After surgery, a progressive rehabilitation program (Appendix) was initiated. The patient spent approximately 3 weeks recovering at Landstuhl Army Regional Medical Center and then chose to return to Iraq for postoperative rehabilitation. For the first 4 weeks after surgery, the treatment goals were to provide protection for the shoulder through the use of a shoulder immobilizer, to adequately control pain, and to maintain full elbow, wrist, and hand range of motion. Despite shoulder immobilization for the first 4 weeks after surgery, the patient had 170 degrees of flexion when active shoulder range of motion was assessed before progressing to phase 2 of the surgical protocol (Appendix). Because there is a chance of extra-articular adhesion formation in and around the surgical site that may adversely influence range of motion and create mobility problems,16 understanding the patient's range of motion capabilities assisted the physical therapist in prescribing range of motion exercises in the context of the patient's rehabilitation program. In this case, given the patient's range of motion capabilities at 4 weeks, the likelihood of a shoulder mobility problem was deemed to be low. Therefore, the goals for phase 2 of the surgical protocol during weeks 5 and 6 after surgery were to continue to provide protection for the shoulder through the use of a shoulder immobilizer, avoid shoulder passive range of motion, and allow supine active-assistive range of motion to 90 degrees of flexion. During the first 6 weeks after surgery, the patient was able to perform low-impact cardiovascular exercise on a stationary bike and lower-body strengthening exercises. Surgical scar massage also was initiated at week 6.
During phase 3 of the surgical protocol during weeks 7 and 8 after surgery, the patient was able to discontinue the use of the shoulder immobilizer, initiate submaximal multiplanar shoulder isometric exercises, and increase shoulder active range-of-motion activities to 120 degrees of flexion. For phase 4 of the of the surgical protocol during weeks 9 to 12 after surgery, the patient was able to gradually progress to full active range of motion by 12 weeks and initiate wall push-ups and other gentle, pain-free, strengthening exercises in positions that avoided horizontal abduction in which the pectoralis major tendon would be stressed in a lengthened position. Cardiovascular exercises also were progressed to include the elliptical trainer and a treadmill jogging progression.
During weeks 3 to 12 after surgery, while the patient was in Iraq, he was limited to light duty and not allowed to go on missions that required travel or probable direct engagement of the enemy. At 3 months after surgery, the patient had full pain-free shoulder active range of motion and had progressed well through his strengthening program in a manner that allowed return to full duty. This decision also was based on the patient's willingness to return to full duty. Regarding rehabilitation 3 to 4 months after surgery, strengthening exercises were progressed by allowing multiplanar isotonic resistance activities that involved the entire upper body. During this phase, precautions included no elbow flexion greater than 90 degrees for pectoralis major muscle–specific exercises (eg, bench press, flys). During the period of 5 to 6 months after surgery, the patient progressed to heavier-resistance upper-body workouts and was able to advance to an outside running program.
At 6 months after surgery, the patient maintained resumption of full military duties and was performing a routine of strength training 3 times per week (chest routine included dumbbell bench presses with weight ranging from 11.3 to 15.9 kg and the ability to perform 50 push-ups without problems) and had met all of his rehabilitation and personal goals.
Discussion
Bony abnormalities are rare in pectoralis major tendon ruptures,7,13 and, given the limited concern for a fracture in this patient, radiographs were not initially ordered. Instead, magnetic resonance imaging was indicated to confirm the suspected diagnosis of a pectoralis major tendon rupture because it is an important modality for accurately determining the site and extent of injury.3,17 However, this type of diagnostic imaging is not available at a level 2 facility (Table). To obtain magnetic resonance imaging would have required evacuating the patient from Iraq to Kuwait. Because there were no orthopedic surgical assets in Kuwait, it was decided that it would be best to evacuate the patient to Landstuhl Army Regional Medical Center (level 4 facility) (Table), where magnetic resonance imaging and orthopedic assets were available. Caring for the patient at the combat support hospital (level 3 facility) (Table) was not considered because only emergent surgical cases were being conducted there. On the basis of the physical therapist's findings and teleconsultation recommendations from the orthopedic surgeons, the patient was referred to an orthopedic surgeon for treatment of a pectoralis major tendon rupture.
Early diagnosis of the patient's orthopedic condition by a physical therapist ensured a timely and appropriate referral for surgical treatment to prevent suboptimal outcomes. A review of the literature indicates that surgical repair of pectoralis major tendon ruptures is superior to conservative treatment.6,8,9 Greater reductions in pain and improvements in strength are seen in patients treated surgically than in those treated with rehabilitation alone.1,5,6,8,18–23 Nonsurgical treatment is generally reserved for elderly and inactive patients.7 Deficits in peak torque and work/repetition during isokinetic testing were noted in patients treated without surgical intervention.18,24 Early surgical repair yields the most favorable outcomes for complete and near-complete pectoralis major tendon ruptures.8 Early surgical repair within the first 2 months after injury is probably better than delayed repair.7 Delaying surgery can lead to adhesions, muscle atrophy and retraction, and delays in return to work or sport.25 Surgical repair also can restore the cosmetic appearance of the chest and axilla.4
A key aspect of this patient's case was that the physical therapist placed a consult to an orthopedic surgeon through teleconsultation. When the Office of the Surgeon General teleconsultation program began in 2004, health care providers from all branches of the military, initially in 11 different clinical specialties, were able to submit their recommendations within 24 hours of receiving a request for a consultation.15 Since then, the participation of health care provider groups has expanded, with orthopedic surgery becoming a formal group member in 2007. Recently, Blank et al26 retrospectively evaluated the use of the orthopedic surgery teleconsultation group during its first 22 months of operation. During this period, 208 consults were received by the telemedicine orthopedic consultation program, with Army providers placing the majority of consults most commonly for musculoskeletal conditions such as fractures, sprains, neuropathies, and tendon injuries.26 Although the majority of the consults sought specific treatment recommendations for patients who probably would have been evacuated for further evaluation, surgical intervention or medical evacuation was only recommended in 25% and 16% of the consultations, respectively.26 Given the austere environment in which this patient case initially occurred and the difficulty with physician communication, teleconsultation with an orthopedic surgeon was vital in ensuring timely and appropriate treatment of the patient's pectoralis major tendon rupture.
We have been unable to locate any studies that discuss pectoralis major tendon repair strain properties or the amount of stress this tissue can tolerate before rupture or compromise after surgery.16 Therefore, healing time frames after pectoralis tendon repair are based on clinical impressions and empirical evidence in treating patients after pectoralis major tendon rupture and some general assumptions based on previous literature related to soft tissue healing of other common tendon rupture repairs (eg, rotator cuff and Achilles tendons).16 The patient described in this case report met some of the goals sooner than described in the surgical protocol. For example, despite shoulder immobilization for the first 4 weeks after surgery, the patient had 170 degrees of flexion when active shoulder range of motion was assessed before progressing to phase 2 of the surgical protocol (Appendix). In addition, at 3 months after surgery, the patient returned to full duty. This decision to return the patient to full duty was based on the patient's willingness to return to full duty and on physical examination findings.
Although physical therapists provide interventions as prescribed by referring physicians on a regular basis, this case serves as a reminder that physical therapists must complete their own qualitative and quantitative musculoskeletal examinations. Physical therapists are able to accurately diagnose and manage musculoskeletal conditions and provide valuable orthopedic expertise, with or without provider referral.27,28 In a combat environment, physical therapists assume an even greater role as qualified primary care extenders to manage musculoskeletal injuries.29 This case presents the unique challenges involved in managing musculoskeletal injuries in a combat environment, to include medically evacuating the patient out of Iraq for diagnostic imaging and definitive care.
Appendix.
Rehabilitation Guidelines After Pectoralis Major Tendon Surgical Repaira
Footnotes
Dr Hoppes and Dr Ross provided concept/idea/project design and project management. All authors provided writing and consultation (including review of manuscript before submission). Dr Hoppes provided data collection, the patient, facilities/equipment, and clerical support. Dr Ross provided data analysis.
A poster presentation of this work was given at the Eastern Athletic Trainers' Association 61st Annual Meeting; January 9–12, 2009; Boston, Massachusetts.
- Received March 29, 2012.
- Accepted October 10, 2012.
- © 2013 American Physical Therapy Association
References
Issue highlights
