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Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears.

ElMaraghy AW, Rehsia SS, Pennings AL - Orthop J Sports Med (2013)

Bottom Line: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears.The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears.Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, St. Joseph's Health Centre, Toronto, Ontario, Canada. ; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

ABSTRACT

Background: Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment.

Purpose: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears.

Study design: Cohort study (diagnosis); Level of evidence, 2.

Methods: A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the "military press" starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique.

Results: Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76).

Conclusion: The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

No MeSH data available.


Related in: MedlinePlus

Preoperative photograph of a chronic right pectoralis major rupture 84 days after injury. Alteration due to a structurally significant rupture is apparent in the visual appearance of the anterior axillary fold on the injured side (arrow).
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fig1-2325967113516729: Preoperative photograph of a chronic right pectoralis major rupture 84 days after injury. Alteration due to a structurally significant rupture is apparent in the visual appearance of the anterior axillary fold on the injured side (arrow).

Mentions: Participants completed a short questionnaire containing demographics, activity level, and history of PM injury or surgery. A high-definition digital photograph of each participant was obtained in a standardized position (subject standing 6 feet away, with the camera at chest level). Participants were asked to maintain a standardized testing position, referred to as the “military press” starting position: 90° of shoulder abduction and 90° of shoulder external rotation for both upper extremities (Figure 1). The choice of this testing position is seen by us as critically important to the utility of the test, since we are attempting to maximize the distance between the origin and insertion of the PM to passively reveal a significant structural disconnect. We feel the medial surface anatomy location should be low and medial, if not central (and could just as easily have been the xiphoid process), since not only are the lower sternal head segments (that contribute to the posterior tendon layer of the PM) most commonly torn, they also contribute the most to the normally bulky and curved prominence of the anterior axillary fold contour of the PM, which is enhanced in the “military press” starting position. Numerous reports of PM diagnosis and treatment show clinical images of the chest with the arm adducted if not internally rotated. This position hides any scars, closes up and covers the anterior axillary fold, and allows the origin to be much closer to the insertion of the PM muscle, thereby masking any traumatic deformity and/or quality of its postoperative restoration.


Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears.

ElMaraghy AW, Rehsia SS, Pennings AL - Orthop J Sports Med (2013)

Preoperative photograph of a chronic right pectoralis major rupture 84 days after injury. Alteration due to a structurally significant rupture is apparent in the visual appearance of the anterior axillary fold on the injured side (arrow).
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4555516&req=5

fig1-2325967113516729: Preoperative photograph of a chronic right pectoralis major rupture 84 days after injury. Alteration due to a structurally significant rupture is apparent in the visual appearance of the anterior axillary fold on the injured side (arrow).
Mentions: Participants completed a short questionnaire containing demographics, activity level, and history of PM injury or surgery. A high-definition digital photograph of each participant was obtained in a standardized position (subject standing 6 feet away, with the camera at chest level). Participants were asked to maintain a standardized testing position, referred to as the “military press” starting position: 90° of shoulder abduction and 90° of shoulder external rotation for both upper extremities (Figure 1). The choice of this testing position is seen by us as critically important to the utility of the test, since we are attempting to maximize the distance between the origin and insertion of the PM to passively reveal a significant structural disconnect. We feel the medial surface anatomy location should be low and medial, if not central (and could just as easily have been the xiphoid process), since not only are the lower sternal head segments (that contribute to the posterior tendon layer of the PM) most commonly torn, they also contribute the most to the normally bulky and curved prominence of the anterior axillary fold contour of the PM, which is enhanced in the “military press” starting position. Numerous reports of PM diagnosis and treatment show clinical images of the chest with the arm adducted if not internally rotated. This position hides any scars, closes up and covers the anterior axillary fold, and allows the origin to be much closer to the insertion of the PM muscle, thereby masking any traumatic deformity and/or quality of its postoperative restoration.

Bottom Line: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears.The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears.Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, St. Joseph's Health Centre, Toronto, Ontario, Canada. ; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

ABSTRACT

Background: Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment.

Purpose: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears.

Study design: Cohort study (diagnosis); Level of evidence, 2.

Methods: A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the "military press" starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique.

Results: Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76).

Conclusion: The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

No MeSH data available.


Related in: MedlinePlus