Anatomy

The pectoralis major (PM) arises in a broad triangular sheet as primarily two distinct heads, an upper clavicular head and a lower sternocostal head, that combine to form a complex bilaminar insertion along the lateral edge of the intertubercular sulcus. The clavicular head originates from the medial and middle thirds of the clavicle and courses from proximal to distal, forming the anterior portion of the tendon lamina that inserts distally. The sternocostal head originates from the sternum and the costochondral junction of the first six ribs as six or seven segments. The inferior segments attach to the fascia of the external oblique muscle and insert proximally through the posterior tendon lamina. ^, A portion of the sternocostal head spirals on itself to produce the round appearance of the anterior axillary fold, with the result that the inferior sternocostal fibers insert posterosuperiorly to the clavicular head fibers. The two laminae of the tendons fuse immediately before insertion on the humerus ( Fig. 10.1 ).

Pectoralis major anatomy, clavicular head (CH) , sternocostal head segments 1–7 (s1–s7) . H, Humerus.

(From Arciero RA, Cordasco FA, Provencher MT. Shoulder and Elbow Injuries in Athletes: Prevention, Treatment and Return to Sport . Philadelphia: Elsevier; 2017.)

Cadaver studies have described the tendon footprint of both the anterior and posterior layers to average a mean proximal to distal length of 5.4 to 7.2 cm. ^{, ,} The mean distance from the medial aspect of the greater tuberosity to the proximal aspect of the PM footprint has been reported to be 4.2 cm. The distance from the muscle tendon junction to the humeral insertion has been reported to range from 5 to 15 mm. ^, The total tendon fiber length, including the intramuscular portion, can measure 5 to 6 cm in length. ^,

The innervation of the PM is from the C5 to T1 nerve roots via the medial and lateral pectoral nerves. The lateral pectoral nerve emanating from the lateral cord of the brachial plexus provides the predominant innervation. It courses anterior to the axillary artery and medial to the pectoralis minor and pierces the deep surface of the proximal PM 12.5 cm medial to the humeral insertion. The medial pectoral nerve innervates the lower sternocostal segments and arises from C8 to T1 via the medial cord of the brachial plexus. It pierces the pectoralis minor and then the inferior components of the sternocostal head 11.9 cm medial to the humeral insertion. ^,

The vascular supply is delivered primarily from the pectoral branch of the thoracoacromial artery with a contribution from the clavicular branch of the internal mammary artery. Venous drainage occurs through the axillary vein and the internal mammary venous complex.

The PM serves as a strong adductor, forward elevator (clavicular head), and internal rotator of the shoulder joint. ^{, ,} Depending upon arm position, the PM can function as either a shoulder flexor or extensor. With a flexed shoulder the inferior fibers function as shoulder extensors, whereas with an extended shoulder the superior fibers function as shoulder flexors. Muscle fiber length varies considerably within the PM muscle. ^{, ,} Wolfe et al. demonstrated that this variability produces a greater fiber excursion in the inferior sternocostal segments at 0 to 30 degrees of shoulder extension. When maximal force is applied in shoulder abduction and extension, as in the terminal stages of eccentric contraction during the bench press or when a slalom water skier’s hand hits the water, the inferior segments of the sternocostal head are at risk of tearing. ^,

Epidemiology

Rupture of the PM, first described by Patissier in 1822, was generally described as a rare injury associated with horse-related and workplace accidents. In 1972 a comprehensive review of the literature by McEntire and colleagues revealed only 45 cases, to which they added 11 more. However, only 22 of the 56 patients had undergone surgical exploration, and 1 case of rupture was confirmed at autopsy. Between 1972 and 2012, a number of relatively small case series were published with short-term clinical results following repair of PM tears. ^,

In 2012, ElMaraghy and Devereaux reported a total of 365 cases in a systematic review of PM injury between 1822 and 2010, of which the majority were published after 1990. The incidence of PM tendon tears has been steadily increasing in incidence. This has been attributed to the widespread increase in contact sports and collision activities in young athletes and to weight training in older adults. ^{, ,}

Two large military database studies added a total of 548 patients with PM tears to the literature. ^, These reports bring the total number of published cases in the literature to approximately 1000.

The injury has been reported almost exclusively in male patients between 20 and 40 years. ^{, , , ,} Despite the increasing participation of women in sports such as power lifting and competitive body building, PM tears have remained essentially a male injury. There does not appear to be a clear reason for this sex-specific injury pattern. It has been speculated that females may have larger tendon to muscle diameter ratios, better elasticity, or less energetic injuries.

Anabolic steroid use has been implicated in the etiology of PM tears by some authors. ^{, , ,} Animal studies using a rat model have demonstrated that anabolic steroids increase the stiffness of tendons thereby diminishing the ability to absorb energy. Wolfe et al. reported that 4 of 12 patients in their cohort admitted to anabolic steroid use. In a series of 33 patients, Aarimaa et al. reported that anabolic steroid use was the only factor that correlated with a statistically significant better outcome (cumulative odds ratio, 5.1; 95% confidence interval, 1.1–23.3; P = .033). de Castro Pochini et al. noted that 46 of 48 patients (95.8%) in their series from Brazil admitted to anabolic steroid use. Cordasco et al. reported that of 40 patients in their consecutive series of PM repairs, no patient admitted to anabolic steroid use, and the authors suspected that this was due to underreporting. Bak et al. speculated that anabolic steroids may increase muscle strength disproportionate to the strength of the tendon, of the muscle tendon junction, and of the insertional site, making these tendons more susceptible to injury. The role of anabolic steroid use in predisposing athletes to PM tears is not clear.

Rupture of the PM tendon has been described following two basic mechanisms of injury, direct and indirect trauma. ^{, , ,} Direct trauma usually occurs as a result of collision and contact sports or falls. ^, Indirect trauma occurs from weight training. ^{, , , , , ,} In particular, the bench press has been implicated and is the result of the eccentric contraction of the sternocostal head as described by Wolfe et al. In addition, Elliot and colleagues showed by electromyographic studies that the PM muscle is maximally activated at the initiation of the lift with the humerus in the extended position. Most series have reported that a majority of PM tears occur as a result of weight training. ^{, ,}

Tears of the PM can occur in two forms, combined tears involving both the clavicular and sternocostal heads and isolated tears, usually involving only the sternocostal head. The majority of the series reported in the literature did not distinguish between these two types of tears. ^{, ,} More recent studies have differentiated between combined and isolated sternocostal head tears. ^{, , , ,} Cordasco et al. reported that 23 of 40 tears (57.5%) in their consecutive series were isolated sternocostal head tears predominantly the result of indirect trauma.

Classification

Ronald Tietjen described the original classification system for PM injuries, which included three types. Type III consisting of complete tears, was further subdivided into four subcategories based upon location of the tear ( Box 10.1 ). Bak modified the Tietjen Classification by adding type IIIE (bony avulsion) ( Fig. 10.2 ) and type IIIF (tendon substance rupture) (see Box 10.1 ).

Axillary radiograph demonstrating a pectoralis major tear with bony avulsion (Cordasco type IIIE).

As the incidence of PM injuries has increased, the differentiation between combined tears of both the clavicular and sternocostal heads and so-called partial tears involving an isolated head has been recognized. ^{, ,} In their systematic review, ElMaraghy and Devereaux recognized that the published literature regarding the description of PM injuries was inconsistent and lacked a classification system that was consistently applied and that accurately reflected the surgically relevant anatomic tear patterns. The authors proposed a comprehensive approach to the classification system ( Table 10.1 ). The senior author (F.A.C.) has found that the Tietjen Classification (see Box 10.1 ) is limited and leads to confusion regarding the concept of the type II injury. Does this represent a partial-thickness tear of both the clavicular and sternocostal heads, a partial-thickness tear of an isolated single head, or a complete tear of an isolated single head? The senior author believes that the ElMaraghy and Devereaux Classification (see Table 10.1 ), although comprehensive, is unwieldy and not practical for clinical or research purposes. As a result, a new classification was developed based upon the improved understanding of the clinical relevance of these injuries ( Table 10.2 ). The Cordasco Classification renames the type I injury as a contusion or strain, redefines the type II injury to be a tear of an isolated single head (most often the sternocostal head), redefines the type III injury to be a combined tear of both sternocostal and clavicular heads, and removes the Bak type IIIF tendon substance rupture modification because it is not clinically useful because all tendon tears are managed in a similar manner whether they are myotendinous, intratendinous, or tendon avulsions. The authors recommended surgery for athletes with Cordasco types IIC, IID, IIIC, IIID, and the rare type IIIE injury and nonoperative treatment for types I, IIA, IIB, IIIA, and IIIB.

The correct classification of these injuries is important because it has been found that the indirect mechanism of injury often involves only the sternocostal head. Cordasco et al. noted that the majority of sternocostal head injuries (19/23 = 83%) in their consecutive series were located at the myotendinous junction ( Fig. 10.3 ) . Several of these patients were initially managed nonoperatively prior to referral because of confusion regarding the significance of the “partial” injury. In their series they also found that of the combined tears involving both the clavicular and sternocostal heads, the majority of patients (12/17 = 71%) were tendon avulsions. Overall, 24 of the 40 consecutive patients (60%) had myotendinous junction injuries.

Intraoperative findings of a left pectoralis major tear at the myotendinous junction of the sternocostal head (Cordasco type IIC).

Clinical assessment

As with any traumatic injury, a complete and thorough history and physical exam are of paramount importance. This should include a cervical spine and distal upper extremity evaluation and a neurovascular assessment.

A history of an acute weightlifting injury, a direct blow while engaged in a contact sport, or a crush injury in the shoulder region is often the mechanism of injury. The most common indirect mechanism of injury occurs during the eccentric contraction of a bench press maneuver. A common direct mechanism of injury in football occurs when outside linebackers and defensive ends are attempting a tackle. The athlete will often complain of severe, sharp, and often burning pain; a tearing sensation; and spasm within the pectoralis muscle during attempted shoulder motion. The athlete will note significant swelling and subsequent ecchymosis in the axilla and proximal biceps region. Immediate shoulder dysfunction is apparent. When presenting either in the subacute or chronic setting, patients will report noting a deformity.

The physical exam assessment should include observation, palpation, a range-of-motion analysis, strength testing, and provocative maneuvers. Observation in the acute setting will often demonstrate ecchymosis overlying the anterior chest, axilla, and proximal biceps. An asymmetry of the PM compared with the contralateral side can be obvious in the setting of a complete tear of both heads but may be more subtle when an isolated sternocostal head tear has occurred ( Fig. 10.4 ). With an isolated sternocostal head injury, the intact clavicular head can provide the impression that the combined insertion is intact. In cases of chronic tears, a prominent skin fold, axillary webbing, and a pronounced insertion of the anterior deltoid have been described. ^{, ,} de Castro Pochini and colleagues have described the “triangle sign” in patients with isolated sternocostal head tears and the “S sign” formed by the retracted stump within the axillary fold during active elevation. Palpation of the humeral insertion and the anterior axillary skin fold will often demonstrate tenderness. The senior author has found it useful to palpate the posterior aspect of the clavicular head while the athlete is supine with the humerus abducted and elevated; as in cases of isolated sternocostal head injuries, the stump of the myotendinous junction can be identified. In the acute setting, shoulder range of motion will be diminished secondary to pain, whereas in the chronic setting, motion may be near complete. Strength of horizontal adduction and internal rotation will be diminished in both the acute and chronic cases. Haley and Zacchilli described a provocative maneuver by having the athlete rest his or her palms on the iliac crest while attempting to abduct the shoulder with an isometric contraction which will demonstrate an asymmetry at the insertion site. Additional provocative maneuvers include having the seated athlete resist bilateral horizontal adduction with the shoulder in 90 degrees of scapular elevation and bilateral resisted internal rotation with the shoulder in adduction.

Right pectoralis major tear in a Division 1 Collegiate Hockey Defenseman demonstrating complete tear of both sternocostal and clavicular heads (Cordasco type IIID confirmed at surgery).

Imaging evaluation

Radiographs are usually obtained in the setting of a traumatic injury to an athlete. In the setting of suspected PM injury, radiographs can assess for the rare avulsion fractures (see Fig. 10.2 ). ^, The loss of the normal PM soft tissue shadow has been reported by some investigators but is an inconsistent sign of tear.

Ultrasonography is a quick, ubiquitous, and accurate modality in experienced hands but is extremely operator dependent. ^, It was originally described for use in diagnosing PM tears by Pavlik et al.

Standard shoulder magnetic resonance imaging (MRI) does not contain sufficient sequences extending caudally to identify a PM tear at the tendinous insertion. Dedicated chest sequences extending superiorly from the quadrilateral space and inferiorly to the deltoid tuberosity are required. MRI is the imaging modality of choice for assessment of PM injury in the acute setting. It can be very useful to determine tear injury location, whether a complete tear of the clavicular and sternocostal heads or an isolated sternocostal head tear ( Fig. 10.5 ), as well as the degree of retraction. In our experience the majority of tears are either myotendinous or intratendinous injuries; tears cleanly avulsed from bone are infrequently noted. Chang and colleagues demonstrated a sensitivity of 1.00 for MRI detecting acute tears of the sternocostal and clavicular head. The sensitivity for detecting tendon-bone tears is 0.93 for sternal head tears and 0.90 for clavicular head tears. The sensitivity diminishes for chronic tears, myotendinous tears, or incomplete high-grade partial tears.

Coronal magnetic resonance image demonstrating a left pectoralis major tear at the myotendinous junction of the sternocostal head (Cordasco type IIC).

Surgical treatment

We believe that surgical treatment for Cordasco types IIC, IID, IIIC, IIID, and IIIE is the treatment of choice in the collegiate, professional, and elite athlete, as well as the recreational healthy adult and heavy laborer. ^,

Surgical repair yields the best outcomes regarding strength, return to sports, functional improvement, cosmesis, and patient satisfaction with low postoperative complication rates. ^{, ,} Many techniques for repair of the PM tendon tear have been described. ^{, , ,} In general, the beach chair or modified Fowler position may be used and the repair is performed via an anterior axillary or deltopectoral approach. ^{, , ,} Careful dissection and retraction is required to avoid injury to the pectoralis nerves, particularly inferomedial to the coracoid. The long head of the biceps is located medial to the PM insertion. The surgeon should remain cognizant of this during surgical fixation because there have been reports regarding the potential for long head biceps scar and contracture necessitating subsequent subpectoral biceps tenodesis.

Multiple repair techniques to reattach the tendon to the footprint have been described in the literature. These repairs have included tendon to tendon and tendon to bone using a bone trough, suture anchors, or cortical button fixation techniques ( Fig. 10.6 ). For the vast majority of repairs, sutures are passed through the ruptured tendon using either a modified Krakow or modified-Mason Allen technique and then securely repaired to bone with either a transosseous method or more commonly with suture anchors or cortical buttons. ^{, , , , , ,} Although direct suture repair has been described in the literature in the event that enough healthy tissue remains attached to the insertion site, ^{, ,} this is quite atypical, and if present using current techniques, it would likely be supplemented with sutures or tapes to bone.

Three types of footprint fixation techniques for pectoralis major repairs: (A) bone trough technique, (B) suture anchor technique, (C) unicortical button technique.

(From Haley CA, Zacchilli MA. Pectoralis major injuries: evaluation and treatment. Clin Sports Med. 2014;33[4]:739–756.)

The bone trough technique has been described in which a 5-cm vertical trough is created at the PM footprint lateral to the bicipital groove. Four 2-mm drill holes are placed 1 cm lateral to the trough. Nonabsorbable sutures, fixed to the ruptured tendon, are then shuttled into the trough, and drill holes are then tied over the bone bridge. ^, Currently, the suture anchor and the cortical button methods are preferred because they provide excellent outcomes, efficiency, technical ease, and less dissection to prepare the humerus compared with the transosseous bone trough technique. ^{, ,} The PM footprint is identified and debrided of mechanically nonviable tissue. The suture anchor technique will generally use two to four anchors preloaded with high-strength suture, depending on whether the tear involves a single tendon or combined tendon injury. The anchors are deployed and tested to confirm secure fixation. One of the suture limbs of each anchor is secured to the tendon using the aforementioned constructs and then is tied to the other limb. ^, The cortical button technique uses 3.2-mm unicortical drill holes within the footprint with an adequate (4 to 5 mm) bone bridge between sites. The button is designed to flip in the intramedullary canal, which allows unicortical engagement on the near cortex. The titanium buttons are preloaded with one or two high-strength nonabsorbable sutures. One limb of each suture is secured to the tendon. Some buttons serve as suture anchors and the limbs are simply tied to one another pushing the tendon to the footprint; other buttons are of the tensioning variety and may be used to pull the tendon to the footprint. ^{, ,}

A number of biomechanical cadaver studies have been performed to evaluate the different techniques of PM tendon repair. Hart et al. compared bone trough and suture anchor techniques and found no difference on ultimate load to failure. Sherman et al. compared the three repair techniques and found no differences in load to failure, elongation, linear stiffness, initial excursion, cyclic elongation, or footprint restoration. All three techniques failed at the suture tendon interface. They reported a significantly greater stiffness and maximal load (1455 N) in the intact tendon specimens. Rabuck et al. compared the three techniques (bone trough, suture anchor, and button techniques) and found a slightly higher load to failure on the bone trough group (596 N) when compared with suture anchor group (383 N). These time zero studies are in general agreement that all three repair techniques described earlier are adequate to repair a PM tendon rupture.

The definition of acute versus chronic in PM injuries is not clearly defined. Flint et al., in their systematic review, defined chronic injuries as those beyond 6 weeks. The longer the interval of time before injury and surgical repair, the greater the risk of surgical morbidity associated with the need for increased surgical exposure and dissection of scar tissue to mobilize the retracted muscle. ^{, ,} Delayed treatment of acute tears and chronic injuries with retracted or involuted tears may lead to circumstances in which the tendon length is insufficient to allow for primary repair with minimal tension. The military population has been particularly at risk for this due to frequent field training and deployments. In these situations, reconstruction or augmentation with either autograft or allograft may be required. ^, Extended chronicity of the injury and/or the need for allograft or autograft reconstruction should not preclude surgical intervention, given that good outcomes can still be achieved. ^{, , , , ,} For chronic involuted and retracted tears and those subacute injuries with inadequate or poor quality tissue available for repair, Achilles allograft has been an ideal graft reconstruction choice.

Postoperative rehabilitation

Following surgical repair, patients are instructed to remain in a sling for 4 to 6 weeks, with the arm in internal rotation and adducted. By the 6-week postoperative period, active-assisted range of motion in all planes is permitted, and at 8 weeks, periscapular and isometric strengthening exercises are added. After week 12, the patient should have near full range of motion and light resistance and strengthening are started. Additional strengthening and sport-specific rehabilitation progress for the next 12 weeks with a goal of unrestricted activity by 4.5 to 5.5 months postoperatively, assuming the athlete has achieved all the benchmarks. ^{, , , , ,} Although there have been some notable professional athletes who have achieved full return to sport in 7 to 10 weeks following surgery, this approach is not the standard of care at this time.

Outcomes and return to sport

As noted earlier, the data are compelling with respect to athletes in that the outcomes are significantly better with surgical treatment of PM tears in this cohort. Surgery is the standard of care for tears at the myotendinous junction and tendon of isolated sternocostal head and in those involving combined tears of the sternocostal and clavicular head. Surgical repair reliably returns strength and provides for the return to preinjury level of activity with excellent patient satisfaction and improved cosmesis. ^{, , ,} The following review will focus on the published literature after 2015 with the exception of one single surgeon series published in 2012.

Two large military database studies added 548 patients following PM repair to the literature. Balazs et al. identified 291 males, all active-duty military personnel, who underwent surgical repair of PM tendon ruptures by reviewing the Military Health System Data Repository. The majority, 187 of 291 (64%) were injured via an indirect mechanism while weight lifting. Ruptures occurred at the myotendinous junction in 39.9%, at the tendinous insertion in 39.9%, and unspecified in the remainder. The differentiation between an isolated sternocostal head tear and a tear involving combined heads was unavailable. The majority, 280 (96%), underwent primary repair, with the remaining 11 (4%) requiring allograft reconstruction. One-year follow-up was available for 214 of the 291 patients (74%). Of these 214 patients, 204 (95%) were able to return to military duty. There were 29 complications, which are discussed in the complications section later. Nute et al. reviewed 257 patients, also active-duty military personnel, surgically treated for PM tendon rupture. The surgical procedures were performed by 152 different surgeons at 57 medical centers. Complete tears of both sternocostal and clavicular heads were noted in 120 patients (47%); 83 patients (32%) had isolated sternocostal head tears, 3 patients (1.2%) had isolated clavicular head tears, and in the remaining 28 patients (11%), tear site was unspecified. Tear site location was noted at the myotendinous junction in 109 patients (42%), while in 72 patients (28%) the tear was noted at the insertion and in 26 patients (10%) the tear was intratendinous. A total of 242 patients (94%) were able to return to full preoperative level of military function. Complications were significant, 42 minor and 41 major, and are reported later in the complications section.

Liu et al. reviewed a series of patients from an institutional database with respect to return to sport and weight training following PM repair. Forty-four patients (73.3%) were available for follow-up. Weightlifting was the mechanism of injury in 59%. Sternocostal head tears were found in the majority, present in 32 patients (72.7%). A myotendinous junction tear was present in 28 patients (64%). Forty-three of 44 patients (97.7%) were able to return to sport at any level, whereas only 22 of 44 patients (50%) reported returning to the same level of activity after surgery. On average, there was a 23.3% decrease in one-repetition maximum barbell bench press, and 17 patients (38.6%) reported a degree of apprehension that affected their ability to lift weights. Three patients (6.8%) required a second surgery, and these complications are reviewed later in the complication section.

Chan et al. reviewed a series of 19 PM repairs that were performed as a result of injury at the US Military Academy and the US Naval Academy over a 12-year period. The bench press was implicated in 10 athletes (53%). The most common type occurred at the myotendinous junction in 10 athletes (53%). They noted a decrease in push-up performance on physical fitness testing despite surgical repair. Nevertheless, none of the cadets had Military Examination Board or Physical Examination Board reviews as a result of the injury.

There are three single-surgeon series published in the literature: two since 2017 and the aforementioned one published in 2012. ^{, ,} Cordasco et al. have reported the largest single surgeon continuous series published to date, which included 40 athletes (several D1 collegiate football and hockey players and four NFL American football players among them). They were treated with the same surgical repair technique. The average Single Assessment Numeric Evaluation score was 93.6 ± 9.6 and all returned to preinjury level of function at an average of 5.5 months (range 4.5 to 6.5 months) postoperatively. All collegiate and professional athletes returned to sport at their previous level. Isokinetic assessment revealed 90% return in strength, compared with the uninjured side. Average preinjury bench press of 396 lb (range, 170 to 500 lb) was restored to 241 lb postoperatively (range, 150 to 550 lb). Garrigues et al. reviewed 19 patients following surgical repair of PM rupture and reported good to excellent outcome in 96% of patients. Preinjury bench press compared with postsurgical bench press demonstrated a 23% decrease ( P < .001). Marsh et al. reviewed the largest single surgeon series of consecutive isolated sternocostal head tears (Cordasco type IIC and IID) published in the literature to date. There were 21 athletes, including 2 NFL football players. The majority (57%) had been injured during an indirect mechanism of injury, and all of these occurred during the bench press. Of these injuries, 17 athletes (81%) had myotendinous injuries and 4 athletes (19%) had tendon injuries. Postoperative Single Assessment Numeric Evaluation scores averaged 90.1 (standard deviation, 8.4). Return to sport averaged 5.5 months. Isokinetic strength evaluation revealed an average decrease of 8%. Average preinjury bench press of 295 lb (range, 195 to 500 lb) decreased to 259 lb (range, 135 to 550 lb). Complications regarding these three series are listed later in the complications section.

Complications

The complications associated with nonoperative treatment are primarily related to functional deficits, PM muscle spasm, and concerns regarding chest wall asymmetry and cosmesis. ^{, , , ,} Additional complications associated with nonoperative treatment include myositis ossificans, hematoma, and abscess formation. ^,

Surgical repair of PM injuries allows the patient to return to their preinjury activity level and complications are relatively uncommon but include infection, wound complications, hypertrophic scar, stiffness, pulmonary embolus, heterotopic ossification, and rerupture. ^,

The two largest studies, using military health care management databases regarding active-duty military personnel surgically treated for PM injuries reported relatively high complication rates. ^, Balazs et al. reviewed 291 patients and reported a 10% complication rate (29 complications occurred), with surgical site infection (12 superficial and 6 deep) notably the most common (8%). Reoperation was needed in 3% of the patients (four patients for infection and three patients for repair failure). Nute et al. reviewed 257 patients and reported 42 minor complications in 36 patients (14%) and 41 major complications in 31 patients (12%) that required second surgery (5.8% to revise retears and 5.1% for wound complications). Overall, 59 patients (23%) experienced either a major or minor complication after PM repair. Altogether, 15 reruptures occurred in 14 patients, for a 5.4% rate.

Liu et al. reviewed an institutional database from multiple surgeons and reported a second surgery rate of 6.8% (3 of 44). There was one rerupture requiring revision and two infections requiring return to the operating room.

Cordasco et al., in their consecutive series of 40 athletes, reported that no athlete developed a surgical site infection and three athletes required a second surgery. Two patients had repair failure due to recurrent trauma and noncompliance within 3 weeks of surgery (one was arrested and handcuffed during a pool party brawl, and one was intoxicated and dancing without his sling). The third patient (a firefighter) developed refractory biceps tendon symptoms that required long head biceps tenodesis several months after repair. Excluding the two noncompliant patients, there were no reruptures and the second surgery rate was 2.5%. One patient developed a pulmonary embolus 10 days postoperatively. Dopplers were negative, and there were no predisposing factors (hematologic, recent flights, etc.). He eventually returned to full activities. Two NFL athletes (5%) developed asymptomatic heterotopic ossification, which was incidentally noted on routine 1-year postoperative radiographs ( Fig. 10.7 ).

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