LARGE TEAR OF THE PECTORALIS MAJOR MUSCLE IN AN ATHLETE. RESULTS AFTER TREATMENT WITH ELECTROLYSIS (USGET)
© 2014 Abat F, et al. J Sports Med Doping Stud 2014, 4:2
Injuries to the pectoral is major muscle are important because as they can result in functional and aesthetic deficiencies of the upper extremity. They typically arise through indirect means, with the muscle being in a state of maximum elongation and contraction at a point of sudden overload [1-3]. This type of injury has been observed in activities like weight lifting, wrestling, American football and water skiing [4,5].
A purely clinical assessment of the pectoralis major injury may be deficient, so additional tests with imaging are needed to refine the diagnosis. Magnetic resonance imaging has been successfully used to assess the characteristics of injuries to the pectoral is major . Similarly, ultrasound has been used to determine the extent and location of the lesion [7,8]. However, diagnosing with imaging is not without problems due to the anatomical complexity of the distal tendon of the pectoral is major as this has a 180° twist that comprises the sternal and clavicular portions [7,8]. The anatomical location of the muscle tear is very important because an avulsion of the tendon at its insertion into the humerus requires surgical repair, while myotendinous junction lesions are usually treated with conservative treatment [2,5,9].
Among the conservative treatment options, Ultrasound-guided Electrolysis (USGET) stands out. This is a minimally invasive medical and physiotherapeutic technique that involves the application of a high-intensity galvanic current through a conductive stylus that provokes a rapid and localized regenerative process in the target tissue [10,11]. This allows for phagocytosis and the subsequent repair of affected tissue while making it possible to aspirate the hematic content of the injury and reducing the production of a secondary fibrotic lesion . This is vitally important because it decreases the fibrous scar that occurs in muscle injuries and therefore the risk of re-rupture.
With this paper, the aim is to present the clinical and functional results in the treatment of an athlete affected by a large partial tear of the pectoralis major muscle treated with the USGET.
Materials and Methods
A 30 year-old male patient who came to our clinic with pain and a functional limitation in the upper left extremity. The pain appeared suddenly during his usual gymnastic practice when performing a pull- up on the horizontal bar. The patient had no relevant medical history or concomitant therapies and had never received injections to the affected area.
Clinical examination showed a clear indentation in the musculature of the left pectoralis major that became more pronounced when the patient pressed their palms together to contract the large pectoral muscles bilaterally. An obvious indentation was seen on the left upon comparing it to the right pectoral, which indicated a major tear of the muscle.
Ultrasound evaluation of the pectoral is major was performed longitudinally and transversally to the muscle fibers and the tendons were evaluated from origin to insertion. The distal pectoral tendon was identified and evaluated on the transverse plane at the level of the bicipital groove of the humerus, where the pectoral tendon and the tendon of the long head of biceps brachii cross. Equally, an evaluation of the flow was performed with high-resolution color Doppler. The images were compared to the contralateral side, placing the patient’s shoulder in abduction and external rotation for the examination.
The ultrasound study was performed by two specialists in musculoskeletal ultrasound using a color Doppler device and lineal probe of 5-16 Mhz and longitudinal and transverse views. At the same time, a radiographic study of the shoulder was performed with AP projection, an axillary «Y» view as well as in internal and external rotation.
The functional assessment was performed according to the criteria described by Bak et al.  in which results for patients without symptoms with normal range mobility without cosmetic changes, without adduction weakness and able to return to their sport activity were considered as excellent. Those results with almost normal range of mobility without cosmetic changes and less than a 20% deficit in peak torque in the isokinetic test were considered good. The poor results are those in which there is limited range of mobility, poor cosmetic results and the patient is unable to return to their sport activity. Finally, those results where the pain persists and revision surgery is needed were considered bad.
As a second item in the functional assessment, the test for assessing subjective outcomes described by Schepsis et al.  was used for the evaluation of lesions of the pectoral is major. Patient follow-up was conducted over a year while getting clinical and functional results before treatment, at one month as well as 2, 6 and 12 months. The Tegner scale was used to rate the level of activity of patients before and after the injury.
Treatment was consisted of the application of the ultrasound- guided USGET once a week and eccentric exercise twice a week. The USGET was performed with the patient supine.
A 40mm-long sterile 20G needles were used. The application was performed by means of stratified ultrasound-guided puncturing. In the first treatment session, a puncture was performed in the center of the hematic injury to do the first USGET pulse of 5 seconds duration, activating then the vacuum system of the device itself so as to get quick closure of the muscle injury.
Once the closure of the lesion was successful, USGET was continued at the edges of the lesion without removing the needle and applying 4 pulses of 10 seconds each in the geographical margins of the lesion. In 3 subsequent weekly sessions, 0.3×30 mm needles were used to apply the USGET to minimize the pain of the puncture, using 4 pulses of 10 seconds in the length of remnant muscle scar.
According to the classification of Tietjen , it was a pectoral is major muscle injury type II at the mid-portion of the muscle. Ultrasound examination detected a marked accumulation of fluid (hypoechoic) in the pectoral is major muscle. The diameter of the lesion was 30×7 millimeters with plenty of hematic content. The radiographic studies showed no abnormalities or bony avulsions.
In the functional evaluation, according to the criteria of Bak et al. , the good results that were seen at one month passed to excellent at 2 months and remained at the same level at 12 months.
The results obtained according to the criteria of Schepsis et al.  are shown in Table 1. Four weeks after the treatment starts, the patient had returned to their level of activity prior to the injury that was 8 points on the Tegner scale. These results were maintained in controls at 2, 6 and 12 months.
The ultrasound scan performed during follow-up showed a correct arrangement of muscle fibers without evidence of fibrous scarring or accumulations of hematic residuals. During the procedure, no medical complications related to treatment presented.
This paper shows that the treatment of injury in the pectoral is major of a gymnast treated with the Ultrasound-guided electrolysis (USGET) technique obtained excellent results and allowed for an early return to sports activity.
The pectoral is major muscle is a powerful internal rotator, flexor, and adductor of the arm and has its origin in the collarbone, sternum and the cartilages of the first six ribs. The pectoral is major muscle fibers converge in three bundles that rotate 180° that join to form a tendon which inserts into the lateral aspect of the humeral bicipital groove . Patients with lesions of the pectoral is major muscle are clinically characterized by pain, bruising, swelling, and decreased range of motion. Clinically speaking, it is difficult to assess the extent and location of this type of injury except through ultrasound or magnetic resonance imaging evaluation. It is possible that a small initial injury of the pectoral is major muscle associated with lifting weights is not identified by ultrasound, but the patient may have pain in the anterior region of the chest [7,8,16,17]. In these cases, the immediate suspension of strength training is important so as to avoid further muscle ruptures of a serious nature within the first 6 weeks [1,4].
Tears of this muscle occur more frequently in the myotendinous junction or the insertion of the humerus and partial tears are more frequent than complete tears. The most commonly used clinical classification of this lesion is described by Tietjen . It focuses on both the type of injury and the location of the lesion in relation to the origin or insertion. A type I injury refers to a concussion; a partial tear refers to type II, and type III to a complete rupture. On the other hand, it also stands out if the location of the lesion is in the sternal origin in the muscle, at the myotendinous junction or the humeral insertion.
The injuries of the pectoral is major muscle usually occurs during a high intensity eccentric action when the muscle is exposed to high tensile forces [4,5,7]. The main sports injury associated with the pectoral is major muscle are weightlifting, wrestling, gymnastics or wind-surfing.
Although MRI has been used to evaluate injuries of the pectoral is major muscle [6,7], ultrasound may also be useful in the assessment of this type of injury. Ahypoechoic image corresponding to hematic collection inside the rupture of the pectoral is major muscle can be seen .
Treatment options for an injury of the pectoral is major muscle are based on an accurate assessment of the extent and location of the lesion. Treatment is usually conservative in partial tears and sometimes in total ruptures in non-athletes. Surgical repair is used for complete tears and ruptures of the distal tendon in athlete patients [1-4]. The chosen method of treatment varies greatly depending on the literature consulted.
The Ultrasound-guided electrolysis (USGET) technique has proven effective in the treatment of soft tissue injuries [10,11] and experimental studies  have demonstrated that the early use of this technique reduces the fibrotic reactions secondary to these lesions. By using a high-intensity galvanic current, directed through a needle, rapid regeneration of damaged tissue is achieved. At the same time, the suction capacity provided by the USGET Medical Tissue Remover device during the application of the technique makes it possible to evacuate the hematic content of the lesion, thereby facilitating healing and preventing potential later complications.
In the case presented, the ultrasound findings showed a large partial tear of the pectoral is major muscle with a large collection of blood. After treatment with the eco-guided Ultrasound-guided electrolysis (USGET) technique, the hematic fluid significantly decreased and proper remodeling of injured tissue was obtained, allowing the athlete to return to sports competition at 4 weeks after injury. The study with ultrasonographic images showed a repair of the myotendinous junction of the pectoral is major muscle with no signs of the formation of fibrotic scar tissue and no signs of hypoechoic thickening of the tendon.
Treatment with USGET on pectoral is major muscle tear resulted in a high improvement in function and a rapid return to the previous level of activity after few sessions. The procedure has proven to be safe with no recurrences at one-year follow-up.
de Castro Pochini A, Andreoli CV, Belangero PS, Figueiredo EA, Terra BB, et al. (2014) Clinical considerations for the surgical treatment of pectoralis major muscle ruptures based on 60 cases: a prospective study and literature review. Am J Sports Med 42: 95-102.
Ziskoven C, Patzer T, Ritsch M, Krauspe R, Kircher J (2011) [Current treatment options for complete ruptures of the pectoralis major tendon]. Sportverletz Sportschaden 25: 147-152.
Garrigues GE, Kraeutler MJ, Gillespie RJ, O’Brien DF, Lazarus MD (2012) Repair of pectoralis major ruptures: single-surgeon case series. Orthopedics 35: e1184-1190.
de Castro Pochini A, Ejnisman B, Andreoli CV, Monteiro GC, Silva AC, et al. (2010) Pectoralis major muscle rupture in athletes: a prospective study. Am J Sports Med 38: 92-98.
ElMaraghy AW, Devereaux MW (2012) A systematic review and comprehensive classification of pectoralis major tears. J Shoulder Elbow Surg 21: 412-422.
El-Essawy MT, Al-Jassir FF, Al-Nakshabandi NA (2010) Magnetic resonance imaging assessment of the pectoralis major muscle rupture. Saudi Med J 31: 937-938.
Provencher MT, Handfield K, Boniquit NT, Reiff SN, Sekiya JK, et al. (2010) Injuries to the pectoralis major muscle: diagnosis and management. Am J Sports Med 38: 1693-1705.
Ball V, Maskell K, Pink J (2012) Case series of pectoralis major muscle tears in joint special operations task force-Philippines soldiers diagnosed by bedside ultrasound. J Spec Oper Med 12: 5-9.
Fleury AM, Silva AC, de Castro Pochini A, Ejnisman B, Lira CA, et al. (2011) Isokinetic muscle assessment after treatment of pectoralis major muscle rupture using surgical or non-surgical procedures. Clinics (Sao Paulo) 66: 313-320.
Abat F, Gelber PE, Polidori F, Monllau JC, Sanchez-Ibañez JM (2014) Clinical results after ultrasound-guided intratissue percutaneous electrolysis (EPI®) and eccentric exercise in the treatment of patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc.
Abat F, Diesel WJ, Gelber PE, Polidori F, Monllau JC, et al. (2014) Effectiveness of the Intratissue Percutaneous Electrolysis (EPI®) technique and isoinertial eccentric exercise in the treatment of patellar tendinopathy at two years follow-up. Muscles Ligaments Tendons J.
Abat F, Valles SL, Gelber PE, Polidori F, Stitik TP, et al. (2014) Molecular repair mechanisms using the Intratissue Percutaneous Electrolysis technique in patellar tendonitis. Rev Esp Cir Ortop Traumatol .
Bak K, Cameron EA, Henderson IJ (2000) Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 8: 113-119.
Schepsis AA, Grafe MW, Jones HP, Lemos MJ (2000) Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med 28: 9-15.
Tietjen R (1980) Closed injuries of the pectoralis major muscle. J Trauma 20: 262-264.
Hasegawa K, Schofer JM (2010) Rupture of the pectoralis major: a case report and review. J Emerg Med 38: 196-200.
Ho LC, Chiang CK, Huang JW, Hung KY, Wu KD (2009) Rupture of pectoralis major muscle in an elderly patient receiving long-term hemodialysis: case report and literature review. Clin Nephrol 71: 451-453.
Lee SJ, Jacobson JA, Kim SM, Fessell D, Jiang Y, et al. (2013) Distal pectoralis major tears: sonographic characterization and potential diagnostic pitfalls. J Ultrasound Med 32: 2075-2081.