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Sport-Specific Illness and Injury: Case Reports

A Case Series of Pectoralis Major Injuries on One Collegiate Football Team

Baker, Hayden P. BA1; Tjong, Vehniah K. MD2; Varelas, Antonios BA1; Wonais, Matt BS1; Terry, Michael A. MD2

Author Information
Current Sports Medicine Reports: 9/10 2017 - Volume 16 - Issue 5 - p 346-350
doi: 10.1249/JSR.0000000000000400
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Introduction

Pectoralis major muscle (PMM) ruptures are an uncommon shoulder injury, but are often reported in football players (1,4,9,13,14,22). Injury to the PMM can result in pain, weakness, and deformity of the upper extremity (31). PMM ruptures are significant injuries for collision athletes because this muscle functions to stabilize the shoulder joint and also rotate, flex, and adduct the arm (9,16). The injury pattern of PMM ruptures reported in the literature is likely due to the muscle’s unique anatomy (30,31).

The PMM has two origins, the clavicular and sternal head, which join to insert at the lateral lip of the bicipital groove of the humerus (16). The superior muscle fibers that originate from the clavicular head insert more anteriorly and distal than the inferior segment fibers. The inferior segment fibers originate from the sternal head, and rotate 180° to insert more posteriorly and proximal on the humerus (24,31). The inferior segment of the PMM tendon is predisposed to rupture first (13,31). Most commonly, the musculotendinous junction of the PMM is torn from indirect trauma due to eccentric overload (9,16).

Excessive eccentric overload leading to PMM rupture has been associated with bench pressing when the arm is extended and externally rotated (31). The rigorous strength training required to play collegiate varsity football potentially puts players at risk to suffer PMM ruptures (31). In addition, football players also are subject to eccentric overload when attempting to block a charging opponent, usually with 90° flexion of the elbow and elbows locked (19). The resulting collision directs a posterior force on the player's upper extremity which is translated into an eccentric force on the PMM (4,9,13,16,31).

Over the last decade, the number of individuals suffering from pectoralis major tears has increased; two recent studies attributed this phenomena to an increase in the number of individuals participating in high impact sports like football (3,14). Each year, at the NFL Combine, football players compete in a bench press competition (21). The popularity of bench pressing may be a contributing factor to the rising number of pectoralis major tears within the athletic population (4).

A recent case control study reviewed all pectoralis major injuries in NFL players from 2000 to 2010 (31). Tarity et al. (31) found the incidence of grade III pectoralis major tears in NFL athletes over a 10-yr period to be 0.004 per year (about 1 NFL athlete each year), and the average days lost to injury was 111 d. The results of Tarity et al. show that pectoralis major tears are an uncommon, but significant injury for NFL athletes.

During the years 2014 to 2015, five members of the varsity football team involved in this study suffered pectoralis major injuries. The incidence rate of pectoralis major injury on this team during 2014 to 2015 was 0.025, almost 10 times the incidence rate reported by Tarity et al. of pectoralis major tears in NFL athletes. There is a gap in current literature on the incidence rate of PMM injuries in varsity collegiate football players (31). An incidence rate of 0.025 for pectoralis major injuries on a single football team over 2 yr has never been recorded before and thus warrants further investigation. This study will investigate factors that may have attributed to an excessive number of pectoralis major injuries on a single football team.

Case Presentations

The following cases were treated by the institution in this study’s athletic training staff over a 5-yr period (2011–2015 inclusive). All reported cases of pectoralis major injuries in members of the varsity football team were reviewed. The information in chart review is based on the diagnosis of the team’s medical and training room staff. Magnetic resonance imaging (MRI) also was used for radiographic confirmation. Injury severity was assessed and recorded using a three-point classification system described by Tietjen (32) — grade I, sprain or contusion; grade II, partial rupture; and grade III, complete rupture. Treatment method (conservative vs. surgical) and days lost to injury and period when the injury was sustained (i.e., preseason, off-season, regular season, or postseason) also were recorded.

The grades I and II PMM ruptures were managed nonoperatively. Nonoperative management included resting the affected limb in a sling (arm in adduction and internal rotation), which was supplemented with cryotherapy and analgesia treatment as needed. Passive exercises were resumed immediately, as tolerated, followed by a 6-wk progression from active assisted to active exercises. Unrestricted activity was resumed 6 wk after the initial injury. The team involved in this study does not provide supplements for their athletes. The athletes have access to Gatorade brand whey protein shakes and protein bars before and after all team activities. The athletes included in this study have never tested positive for performance enhancing drugs.

Classic physical examination findings of a patient with a suspected PMM injury include swelling and ecchymosis of the affected limb, a palpable defect and deformity of the anterior axillary fold, and weakness with adduction and internal rotation.

Case 1

A 22-yr-old male defensive lineman presented with acute pain and weakness on adduction and internal rotation of the right upper extremity after a personal record bench press lift attempt during an off-season workout. The patient's medical history was significant for a right fifth metatarsal fracture suffered 2 wk before this incident; at the time of injury, his activity level was limited to upper body lifting only. He was not on any prescription medications at the time of his PMM injury. Physical examination demonstrated swelling, ecchymosis, and deformity of the PMM. MRI confirmed a grade II PMM tear. The patient was managed nonoperatively with cessation from activity for 6 wk, supplemented with cryotherapy and analgesic treatment as needed. The patient successfully returned to his preinjury level of competition and did not miss any contact practices or games.

Case 2

A 20-yr-old male defensive back presented with acute right upper extremity pain after a bench press workout during a spring off-season workout. The patient's medical history was significant for a L groin strain suffered during practice earlier that week. At the time of injury, the patient’s activity level was restricted secondary to his groin strain. The patient was not on any prescription medications at the time of his PMM injury. Physical examination demonstrated swelling and weakness on adduction of the right upper extremity. MRI confirmed a grade II PMM tear. The patient was managed nonoperatively, passive exercises were resumed immediately, as tolerated, followed by an 11-wk progression from active assisted to active exercises. The patient missed 15 contact practices and one game but was able to successfully return to his preinjury level of competition.

Case 3

A 23-yr-old male defensive lineman presented with acute pain and weakness of the right upper extremity after a postspring practice weightlifting workout. The patient had no significant medical history and was not on any prescription medications at the time of his injury. Physical examination demonstrated weakness on adduction and internal rotation of the right upper extremity. A grade II PMM tear was confirmed with MR imaging. The patient was managed conservatively with cessation from activity for 6 and a half weeks. On completion of the rehabilitation protocol the patient was able to return to his preinjury level of competition but missed 15 contact practices.

Case 4

A 23-yr-old male defensive back presented with acute pain, weakness, and deformity of the left upper extremity after a personal record bench press lift attempt during an off-season workout. The patient's medical history was significant for a ruptured anterior cruciate ligament (ACL) which was surgically repaired 20 wk before this incident. The patient was not on any prescription medication at the time of his PMM injury. Physical examination demonstrated swelling, ecchymosis, deformity, and weakness on adduction and internal rotation of the right upper extremity. MRI confirmed a grade III PMM tear. The patient was managed surgically, and the player did not return to play after completion of his rehabilitation protocol. The decision to medically retire was made by this player after considering a number of factors including a history of previous injury to his ACL and potential playing opportunities.

Case 5

A 21-yr-old male offensive lineman presented with acute pain of the right upper extremity after an off-season weight-lifting workout. The patient's medical history was significant for a hamstring strain suffered during a conditioning workout earlier that week. At the time of injury, the patient’s activity level was restricted secondary to his hamstring strain, and he was not on any prescription medications. The patient was diagnosed with a grade I PMM tear and was managed conservatively. After cessation from activity for 3 wk, the patient was able to successfully return to his preinjury level of competition. The patient missed seven contact practices.

Case 6

A 22-yr-old male defensive lineman presented with acute pain and weakness of the left upper extremity after a personal record bench press attempt during a preseason workout. The patient's medical history was significant for a ruptured ACL which was surgically repaired 22 wk before this incident. The patient was not on any prescription medications at the time of his PMM injury. Physical examination demonstrated weakness on adduction and internal rotation of the left upper extremity. A grade II PMM tear was confirmed with MRI. Passive exercises were resumed immediately, as tolerated, followed by an 8-wk progression from active assisted to active exercises. After missing one game and 20 contact practices, the patient was able to successfully return to his preinjury level of competition.

Case 7

A 23-yr-old male offensive lineman presented with acute pain and weakness of the right upper extremity after an off-season workout. The patient's medical history was significant for ankle surgery 3 wk before this incident. At the time of injury, the patient’s activity level was restricted secondary to his ankle surgery rehabilitation protocol. The patient also was taking NSAIDs for management of his ankle pain at the time of his PMM injury. Physical examination demonstrated weakness on adduction and mild deformity of the left upper extremity. MRI confirmed a grade II PMM tear. The patient was managed nonoperatively with cessation from activity for 6 wk and was successfully able to return to his preinjury level of competition. The patient did not miss any contact practices or games.

Table summarizes the results of PMM injuries suffered by the athletes in this study.

Table
Table:
Demographics and summary of PMM injuries.

Discussion

Injury to the PMM is rarely reported in the general population (6). Between the years 1822 and 2016, there have been 656 cases of PMM injury reported in the literature (2,6). Thus, PMM injury is increasingly being recognized as solely a sports-related injury (26,27), primarily associated with football, but also has been described in the literature resulting from parallel bar dips, wrestling, and skiing (1,26). As of the year 2000, there have been about 150 cases of PMM injury in the athletic population reported in the literature (1,25,28). PMM injury typically occurs in young men (25,31), and has been observed in a range of sports activities. The most common mechanism of injury reported in the literature is overloaded eccentric contraction associated with bench pressing (4,10,33). A case control study on PMM injuries in NFL athletes by Tarity et al. (31) found that PMM ruptures rarely occur among NFL players; they reported 11 grade 3 cases over a 10-yr retrospective study. It can be concluded from the published incidence rates of PMM tears in athletes (1,25,28,31) that having five players on a single team injure their PMM over 2 yr is uncommon. This rare occurrence of numerous PMM injuries on the same team may be indicative of a compounding factor that predisposed these players to PMM injury. There is a gap in current literature on the incidence rate and mechanism of PMM injuries in varsity collegiate football players (31).

One would expect the incidence of PMM rupture to be greater in football players who participate in the highest level of competition when compared with the general population, due to the rigorous nature of their training. In theory, bench pressing and overtraining should predispose NFL athletes to PMM rupture (31). However, surprisingly, Tarity et al. (31) found that PMM ruptures in the NFL are not primarily an injury of training. In fact, Tarity et al. (31) concluded that the most common mechanism of PMM injury in NFL athletes is when players collide during a kickoff, punt, or tackling play. Tarity et al. (31) reported no evidence of off-season pectoralis major ruptures in NFL athletes. These findings are not consistent with the literature, which reports the primary mechanism of PMM injury to be the eccentric contraction that occurs during bench pressing (4,10).

The authors of this article speculate that the findings of Tarity et al. may not, in fact, be inconsistent with expectations; we hypothesize that elite football players undergo the majority of their physical development in college, which would predispose them to PMM injuries secondary to weight training, and thus NFL players would be expected to suffer PMM injury secondary to in-game collisions. A recent systematic review of anthropometric and athletic performance variables during the playing career of varsity college football players found that players in their fourth and fifth (red-shirt year) seasons of competition were significantly (P <0.05) heavier than first-year players (11). Significant increases in strength (31.0% improvement in bench press one repetition max and 36.0% increase in squat strength) also were observed during the course of each athlete’s collegiate career (11). More importantly, a recent study on the longitudinal effects of a collegiate strength and conditioning program in American football found that the greatest number of significant improvements among test parameters (body mass, percent body fat, lean body mass, pro-agility shuttle, 40-yard dash, bench press, chin-ups, vertical jump, and back squat) occurred during the first year of training (29); years 2 to 4 showed inconsistent improvement among test parameters (29). Thus, one can speculate that this trend of inconsistent improvement in strength and conditioning parameters would continue for the duration of a player’s career into the NFL. No study currently exists that directly compares the morphological profiles of first year varsity collegiate football players to NFL athletes. However, it can be concluded that college football players significantly increase in size, strength, and performance throughout their collegiate football careers, and that the first year of training in college is potentially the most important developmental period during a football player’s career (11,29).

The speculation that football players make significantly more strength improvements in college than in the NFL is in keeping with competition schedules of the NFL and NCAA. Excluding postseason play, NFL teams participate in 20 games per year (15) compared with just 12 games per year for varsity college football teams (5). Previous reports indicate that the majority of injuries in the NFL and NCAA occur during games compared with practice (5,15,18,20). The injury rate per game reported for NFL players (64.7 per 1000 athletic exposures) (7) is higher than the injury rate per game reported for college football players (35.9 injuries per 1000 athletic exposures) (5). The NFL season is approximately 2 months longer than the college football season. NFL training camp begins in July and the season can end as late as mid-February, whereas college football teams begin training camp in mid-August and the season ends in early January. According to a recent study published in The Journal of Strength and Conditioning Research, the goal of off-season football strength and conditioning programs is to maximize muscular fitness before the competitive season (12). The literature reports significant decreases in strength past the mid-season point for football players (12). Thus, in-season football strength and conditioning programs usually intend to maintain off-season strength gains (12). Due to the fact that NFL players participate in at least eight more games per year than college football players, with a higher injury rate per game, and a shorter off-season, we speculate that college football players weight train more frequently and make more significant strength improvements than NFL players. In addition, no study currently exists that directly compares the protocol and results of college vs. professional football strength and conditioning programs because they are unique to each team’s program and are not uniform across each level of competition.

The authors of this article believe that the key predisposing factor to six of the seven PMM injuries on this single football team was concurrent upper body strength and endurance training. A review article by Leveritt et al. (17) concluded that concurrent strength and endurance training of the same muscle group inhibits strength development when compared with strength training alone. In the case of the six athletes in this study, each athlete, at the time of their PMM injury, had a preexisting lower body injury. Given their preexisting lower body injuries, the players' activity was restricted to upper body work only. The off-season strength and conditioning protocol for injured players at the institution in this study is modified to accommodate injury limitations. The six players were asked to complete upper body cardio workouts to accommodate their lower body injuries. We believe that the concurrent upper body endurance/strength training observed in these athletes, which has been proven to inhibit strength development (17), on top of the fact that muscle weakness has been associated with increased risk of muscle injury (23), as well as the speculation that playing college football predisposes athletes to PMM injury, were compounding factors that predisposed this population of football players to PMM injury. The fact that these players were attempting to break their personal bench press record biweekly was another confounding factor in this situation. A review article published in the American Journal of Sports Medicine by Fees et al. (8) found that absolute intensity one-repetition maximum bench press can significantly contribute to shoulder lesions and should be avoided. Fees et al. (8) recommend that athletes of all ages limit their one-repetition maximum bench press attempts to 2 to 3 times per year to avoid upper extremity injury. It can be concluded from the results of Fees et al. (8) that the players in this study were testing their personal record bench press at a higher frequency than recommended, which may have predisposed them to PMM injury.

There are some limitations to this study. Only one collegiate institution was investigated. This restricts results and perhaps applicability to the college level football player. The retrospective nature of this study is uncontrollably confounded by factors such as nonrandomization and design. Injury prevention level also may have been variable depending on each athlete’s position, age, and skill level. Further investigation must be performed to determine the incidence rate of PMM injury in collegiate football players, the most common mechanism of injury, and whether isolated upper body training is a useful way to maintain athletic potential during a lower-extremity injury.

Conclusions

PMM ruptures are an uncommon, but significant shoulder injury reported in football players (1,6,31). The authors of this article speculate that a number of factors contributed to the high incidence of PMM injury on the football team in this study from 2014 to 2015. We hypothesize that football players undergo the majority of their physical development in college, which predisposes them to PMM injuries related to weight training. We also speculate that concurrent upper body strength and endurance training may have inhibited strength development in these athletes; muscle weakness has been associated with increased risk of muscle injury (23), thus we speculate that inhibited strength development secondary to concurrent upper body strength and endurance training in these athletes may have predisposed them to PMM injury. There is a gap in current literature on the incidence rate and mechanism of PMM injuries in varsity collegiate football players (31). It is the belief of the authors of this article that these findings hold clinical significance and thus warrant further investigation.

The authors declare no conflict of interest and do not have any financial disclosures. The opinions contained herein are those of the authors.

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