The pectoralis major is the large muscle across the front of the chest. It attaches to the humerus, the upper arm bone, by a broad tendon, and it drives movements that pull the arm across the body, such as pushing, bench pressing and throwing. The tendon can tear or rupture under sudden heavy load.
Pec major repair is an operation to reattach the torn tendon to the humerus using sutures, anchors or screws. The aim is to restore the function and strength of the muscle and of the shoulder.
The procedure
The torn tendon is identified, brought back to its attachment on the humerus and secured there with sutures, anchors or screws while it heals back onto the bone. The operation can be performed arthroscopically or open, depending on the pattern of the tear. About two hours of operating theatre time is booked.
Risks and complications
All surgery carries risk. The risks that are relevant to you are discussed with you in consultation before any decision about surgery is made.
General surgical risks
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Bruising and haematoma. The amount of bruising varies from patient to patient and is a normal part of healing. It usually settles quickly. A haematoma, which is a collection of blood under the wound, occasionally needs to be drained in theatre.
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Infection. Infection is uncommon but possible, and is usually treated with antibiotics.
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Deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots can form in the veins of the leg and can travel to the lungs. These are serious conditions, but the risk of lasting harm is significantly reduced when they are recognised and treated promptly.
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Anaesthetic risks. These are discussed with your anaesthetist before surgery. In Australia the risk of death from a general anaesthetic is around 1 in 100,000.
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Wound problems. Superficial wound problems can occur. Most are minor and settle with a small intervention.
Risks specific to this procedure
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Nerve injury. Nerves run close to the surgical field, including the axillary nerve. Injury can cause numbness or weakness in the shoulder and upper arm.
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Stiffness or frozen shoulder. Loss of shoulder movement. Frozen shoulder resolves with time, but if it is severe, rehabilitation can be prolonged and difficult.
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Hardware problems. The anchors or screws used to hold the repair can cause problems and may need to be addressed with further surgery.
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Re-tear or rupture. The repair can fail, particularly in early recovery, and some patients need further surgery as a result.
Before surgery
There are a number of things to work through while you are waiting for your surgery date. You will be given detailed written instructions covering all of this.
- Confirm with your health fund that the hospital fee is covered.
- Confirm your anaesthetist’s fees.
- Register your details with the hospital.
- Read, complete and return your paperwork to the rooms.
- Plan your transport to and from hospital. You cannot drive yourself home.
- Attend any pre-operative physiotherapy that has been recommended.
- Complete any pre-operative pathology, such as blood tests, if it has been requested.
- Wash the shoulder with benzoyl peroxide 5% wash, twice daily for two days, and then once more on the morning of surgery, five applications in total. This reduces the risk of infection with Cutibacterium acnes, a bacterium that lives in the skin.
- Pack your hospital bag: your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. Bring your CPAP machine if you have sleep apnoea.
- If you take blood thinners, phone the rooms to confirm when to stop them.
- If you take tablets for diabetes, phone your anaesthetist to confirm whether to stop them.
- Confirm your admission details with the rooms one to two business days before surgery.
The day of surgery
- Your admission details are confirmed one to two business days beforehand. Make a note of your admission time, which may be as early as 6am, and the time from which you must fast.
- If you do not live in Brisbane, staying in the city the night before is usually recommended.
- After the admissions process you wait in the surgical waiting area. Your anaesthetist will see you for a brief consultation before you go through to theatre.
- Dr Cutbush will greet you in the anaesthetic bay and mark the operation site. You are then given the general anaesthetic.
- The usual stay is one night. Discharge is generally around 10am, after Dr Cutbush has reviewed you.
- You will be given a folder containing your post-operative pack: a letter describing what was found and what was done, together with your rehabilitation and aftercare information.
- Arrange for someone to take you home.
Recovery and healing
The shoulder is immobilised in a sling, worn full time for six weeks. Activity has to be limited well beyond that point, particularly for the first three months, because the repair is vulnerable to re-tear or rupture while the tendon is healing onto the bone.
Physiotherapy progresses once the sling is no longer required, working first on range of motion and then on building strength. Full recovery usually takes between six and twelve months, and physical activity should be limited for the first six months.
Rehabilitation
Rehabilitation after pec major repair works on range of motion first and strength second. Early exercises emphasise movement with very limited strengthening; later exercises build strength and work towards a return to full activity. The tendon takes at least twelve weeks to heal, which is why care is needed from day one.
Day one
Before you leave hospital the physiotherapist will fit your sling and show you how to put it on and take it off, and how to manage eating, showering and dressing while wearing it. You will also be taken through the precautions below.
Phase one: early healing, protective phase
Exercises in this phase are strictly passive. The arm stays in the sling except for washing and for doing the exercises.
Restrictions:
- No active shoulder movement.
- No external rotation and no abduction.
- No load through the arm and no weight bearing.
- No tucking in shirts and no reaching the hand behind your back.
- The pectoralis major must not be activated: no movement of the arm across the body, no pushing and no stretching of the muscle.
- A pillow under the elbow can be used for sleeping.
Pain management relies on a correctly fitted sling and on ice.
Phase one exercises
- Pendulum exercises to 90 degrees, without swinging the body.
- Passive elevation to 90 degrees, with the arm in internal rotation.
- Passive external rotation to neutral only, with the arm at the side.
- Active-assisted elbow flexion and extension, four times daily.
- Wrist and hand range of motion, avoiding any forceful grip.
- Cervical spine range of motion.
- Gentle scapular exercises and postural work.
Follow-up
A local physiotherapist will see you at around week two to check your understanding of the programme and your range of motion. Rehabilitation is not progressed beyond phase one until after about six weeks and a review with Dr Cutbush.
Results after surgery
Most people who have a pec major repair experience lasting improvement in pain and range of motion and return to their normal activities. A small number are left with reduced strength or ongoing discomfort, and some need further surgery after a re-tear or rupture of the repair. How closely the recovery protocol and the activity restrictions are followed has a real bearing on the result. Individual results vary.
Next steps
This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.
