John-Paul Rue, MD, Orthopedic Surgeon at Mercy Medical Center talks about pec tears and how they are fixed.
Interview conducted by Ivanhoe Broadcast News in February 2019.
I want to talk about pec tears, today. It’s the first time I’ve come across it and heard about a couple of cases. Is this something that happens with more frequency?
JOHN-PAUL RUE: Well so the pec tear means the pectoralis major, a very large muscle that starts from the chest wall and goes through the arm. It’s a large muscle in weightlifters, particularly with people who bench press, and when it tears it’s a very dramatic injury. It tears. Often they feel a pop and have severe bruising and swelling, and then they have a deformity because the muscle tendon unit has pulled off. It’s quite dramatic. In terms of increasing frequency, we probably hear about it more because of a trend towards fitness and some of the explosive type of sports that people are doing nowadays.
So tell me how it happens. It’s one particular move? Is it too much weight? Not enough stretching? What leads to this kind of injury?
JOHN-PAUL RUE: This is an injury that occurs when the muscle is elongating under force; So it’s under tension. Particularly in a bench press move when they’re coming down with a heavy weight. It often happens in wrestlers or fighters. When the arm is placed in an abducted, external rotated position with a great force, it typically causes the muscle tendon unit to rupture.
You had mentioned when we’d spoken earlier that this is also an injury we’re seeing in our in our armed forces. Can you explain why?
JOHN-PAUL RUE: It’s a very infrequently seen injury in the general population. When we see it, it usually follows a pattern; it’s typically a male, in the age category of 25 to 40 something, and it’s typically in someone who’s doing those high competitive-level of working out or activities. We see it a lot in our military personnel particularly overseas because when they’re not in their battle situation, they’re often working out and getting strong. It’s in fact still one of the top three or four types of non-battle injuries that require a serviceman or woman to come back to the United States for surgery. It typically happens in male and very infrequently in females.
So what is the solution when you have this kind of injury? Is surgery the only solution?
JOHN-PAUL RUE: For the type of person that we described; high demand, very active, very physically fit and strong, typically a non-operative approach without surgery is not going to result in the outcomes that they want from a strength, appearance, and functionality standpoint. We typically recommend surgery to repair that tendon back to the bone where it pulled off from.
Could you describe to me what it is that you have to do? The patient had mentioned something about stretching and anchoring.
JOHN-PAUL RUE: When the tendon tears it typically pulls back and retracts, so they develop a deformity of that muscle and if you ask them to push their hands together you can see the pec muscle on the other side. On this side it typically caves in. We typically diagnose it based on the exam. But we often do get imaging such as an MRI to confirm. That helps give us a road map of where to see it and how much retraction. We make an incision in the skin, we find the tendon, and basically pull it back over to the bone and anchor it securely to the bone. There’s a variety of techniques that we’d use and basically it’s about an evolution of our technology to improve those types of techniques.
What is the surgery like? Is it a long surgery? Tell me about the recovery.
JOHN-PAUL RUE: Surgery itself takes about an hour to an hour and a half. It is a long recovery particularly in these high-demand patients. One of the hardest things we have is ensuring compliance because that’s the nature of the people who get this type of injury. So we like to protect our repair with a sling and protected motion for about six weeks. Then we start a graduated progression with physical therapy for motion and strength. By about three months out from this surgery, most patients have full motion of strength, symmetric to the other side, but they’re not ready to hit the gym heavily. It takes about six months for the whole reparative process to happen and for us to clear them to go back to 100 percent.
You had mentioned that you’re able to diagnose sometimes just by taking a look. We noticed a lot of bruising still weeks later. Can you tell me why we’re seeing all of that bruising still?
JOHN-PAUL RUE: A lot of the bruising deposits some of the blood products into the skin so you may see that kind of staining appearance for some time. It is not necessarily indicative of ongoing injury.
Can you tell me a little bit about that? Has Triple H’s put this injury a little bit more in the spotlight?
JOHN-PAUL RUE: I think that’s pretty common. When a celebrity or someone of their stature has an injury; it brings light to that particular type of injury. It’s fairly uncommon as I said in the general population, but it is not uncommon in mixed martial arts, high level wrestlers, the military, and then in folks who do a lot of bench press.
Will Oscar be able to get full function? Do your patients get full function eventually from that muscle?
JOHN-PAUL RUE: Yes. The expected course is that they return to their full functionality back to 100 percent in essentially six months. In reality, it will probably take a full year to get back to the level because you have six months of not going hard at the lifting specifically and to rebuild that muscle strength is going to take some time.
For people in this sport, is there any kind of preventive? Or is this a cautionary tale for people they want to get fit, they’re very competitive so they’re pushing as hard as they can. So where do you draw the line?
JOHN-PAUL RUE: It’s hard because the person that gets this injury is the person that’s motivated to push through pain so one of the things that we often say is you have to listen to your body. Oftentimes people have a little bit of prodromal, or meaning before injury, kind of hinting that something was going on. But it is also just one of those injuries where it’s the tendon is holding on, holding on, holding on. Pop. And it’s just enough force to do it so it happens.
Do you get any warning sign before it goes?
JOHN-PAUL RUE: Usually about the same time that you’re feeling the pop.
How rare is something like this and how often is this happening?
JOHN-PAUL RUE: It’s hard to get an exact number or handle on the exact number of incidents, but it’s a fairly uncommon injury to have. That being said in that particular population, if I hear someone tell me, Doc I was doing a bench press. I was on the way down. I felt a pop. My arm gave out. I almost dropped the bar. I looked down. I had a lot of pain right there and my chest looked like it caved in. You know exactly what it was. It was the pec tendon tearing. Similarly I’ll have a history of someone you know with having had that a couple weeks ago and they had some bruising and I see them. It is a fairly simple clinical diagnosis. Unfortunately it’s a long process to recover from.
You gave me a statistic on the frequency or injury for military personnel and non-battle injury, can you tell me a little bit about that?
JOHN-PAUL RUE: When we differentiate a wartime injury, we have a service man or woman deployed overseas and they have an injury that causes them to be medevacked or brought back to United States for definitive treatment, we classify that typically as non battle-related or battle-related. Non battle-related would be car accidents, motor vehicle accidents, sports-type injuries, or weightlifting-type injuries. And unfortunately this is one of the top injuries that we see for a non battle-related injury that requires medevac back to the states to definitively treat.
So they’re not set up overseas to handle this particular?
JOHN-PAUL RUE: Not set up to do the surgery, not set up to do the rehab and so they’re not set up to have that person not doing their job. They need someone to tag them out.
How many of these cases do you think you’ve treated over the years?
JOHN-PAUL RUE: I find these kind of have gone in waves. In my time in the military we would see two or three in a matter of a couple of weeks, and then you may go a couple of months without seeing them. It just seems to go in that pattern.
Is there anything I didn’t ask that you would want people to know?
JOHN-PAUL RUE: I think that one of the key things to know about this is it’s a very dramatic-type of injury meaning it often frightens the person who is injured because they know something happened. It can be missed initially because they either move their arms around; they feel I think I’m OK. And sometimes they may have a delayed presentation, getting it fixed. It’s one of those things where a timely diagnosis, meaning getting the diagnosis done within a couple of weeks and getting to surgery within a couple of weeks, makes the surgery technically less demanding because the muscle tendon hasn’t pulled back. The longer a tendon has been torn off of where it’s supposed to go, the harder it is to get it there and the harder it is to keep it there.
END OF INTERVIEW
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