Have you experienced a pec muscle strain or complete rupture from bench pressing, playing sports, or falling?
In this blog, I’m going to tell you everything you need to know, including a detailed discussion about surgical vs non-operative management.
Be sure to also check out our Shoulder Resilience Program!
Pectoralis Major Anatomy & Function
The pectoralis major is a broad, fan-shaped muscle that consists of two parts: a clavicular head and a sternal head. The clavicular portion originates from the clavicle, or collarbone, while the sternal portion originates from the sternum, the costal cartilage of ribs 2-6, and part of the abdominal aponeurosis. The sternal portion accounts for 80% of the total muscle volume.
The tendons of both the sternal and clavicular heads come together to create a common, U-shaped tendon that attaches to the humerus, or arm bone.
Their primary muscle actions include internal rotation (rotating your arm inward), adduction (bringing your arm down toward your side), and horizontal adduction (bringing your arm toward midline). They also contribute to shoulder flexion and extension.
Pectoralis Major Muscle Injury
Although injuries to the pectoralis major can occur in women and older individuals, the vast majority of injuries occur in men between the ages of 20 and 40. The most common mechanism of injury is during the eccentric, or lowering portion, of the bench press.
This is followed by injuries from a variety of sporting activities, such as rugby, football, wrestling, and gymnastics, which may involve forceful abduction and external rotation of the shoulder.
Individuals often report hearing or feeling a popping or tearing sensation at the time of injury. Other common signs and symptoms include pain, bruising, swelling, and a loss of strength. Depending on the severity of the injury, there may be observable or palpable changes in the arm and chest wall.
Surgery vs Non-Operative Management
Ultrasound imaging may be used initially to assess a pectoralis major injury, but an MRI is considered the gold standard and is preferred prior to surgical considerations. Thompson 2020, Magone 2021
Tears are typically described using a classification system developed by ElMaraghy et al in 2012 that details the timing, location, and extent of the injury.
For timing, injuries are classified as either acute or chronic. Acute refers to the tear occurring within the past 6 weeks. This is an important consideration because when surgery is indicated, most surgeons suggest operating within 3-6 weeks of the initial injury for optimal outcomes.
The timing may also affect the type of surgery that can be performed. For example, acute injuries are usually repaired, which involves reattaching the injured tissues. On the other hand, if the tissue is not repairable, which may occur in chronic cases, a reconstruction using a graft may be performed.
With regards to location, tears can be found at the muscle origin, muscle belly, musculotendinous junction (where the muscle and tendon meet), intra-tendinous region, and at the tendinous insertion, including possible detachment of bone (known as an avulsion). Tears of the muscle are usually managed nonoperatively, whereas tears involving the tendon or bone are managed surgically. The tendinous and bony injuries occur most commonly.
The extent of the injury refers to its severity by describing the width and thickness of the tear. For simplicity and the purpose of this blog, the majority of injuries described in the research are complete tears.
As written by Thompson et al in 2020, “Nonoperative treatment is indicated for patients with certain incomplete tears, irreparable damage (e.g. muscle belly tears), low demand patients accepting of the cosmetic defect or those who are unable or unwilling due to medical comorbidities, age, or the ability to comply with a post-operative rehabilitation protocol.”
On the flip side of that, a paper by Magone et al in 2021 recommends that, “Early surgical repair should be offered to young, active patients with a complete pectoralis major tear.” “Nonsurgical treatment of a complete pectoralis major tear is an option but will result in a cosmetic deformity and deficit in adduction strength of the injured arm.”
Post-Surgical Rehabilitation Overview
There are 4 overlapping phases that occur during post-surgical rehabilitation.
The first phase focuses on protecting the newly repaired or reconstructed tissues. Although timelines vary between surgeons based on the extent of the injury and surgery, as well as their experience and preference, individuals can expect to use a sling in some capacity for at least 3-4 weeks.
The second component of rehab focuses on restoring range of motion. Once again, timelines will vary, but passive range of motion is initiated around the 2 week mark while the sling is still being used on a day-to-day basis. Protecting the integrity of the surgery remains the priority, so restrictions or precautions are provided by limiting the degree of allowable shoulder flexion, external rotation, etc.
Over time, active-assisted and active range of motion are initiated, and full range of motion is expected around the 3 month period.
The third element of rehab is regaining strength and control of the shoulder and arm. Isometrics of the shoulder, which are muscle contractions that involve no movement, are started around 3 weeks post-surgery.
However, contractions of the pectoralis major are purposely avoided until 6 weeks or so as protection of the surgical tissues is still important. Strengthening is gradually progressed beyond that, and return to most daily activities can be expected around 3-4 months after surgery.
The last phase of rehab focuses on returning to unrestricted activity. This is getting back to playing sports, benching your 1-rep max, etc. Although some limitations may persist, full function is expected between 6-12 months after surgery.
Non-Operative Rehabilitation Guidelines
With regards to non-operative management in more severe cases, rehab will follow a similar framework, including temporary use of a sling to allow healing of the recently injured tissues.
However, as I mentioned earlier, deficits in strength may persist, so long-term resistance training should be a priority. Restoring range of motion will likely be less of a problem.
What if you don’t fall into either one of these categories? For instance, what if you experienced a low grade strain of your pectoralis major while working out that doesn’t require surgery or use of a sling prior to initiating non-operative rehabilitation?
Load Management & Activity Modifications (Recommended)
Well, the primary focus revolves around load management and activity modifications. Whether you’ve strained your pectoralis major bench pressing, sprained your ankle playing sports, or hurt your low back deadlifting, an injured body part is going to have a decreased load-bearing capacity.
What this means is that you will have to temporarily scale back movements, exercises, and activities that load the aggravated area.
In the case of a strained pectoralis major from bench pressing, you might have to take 1-2 weeks off from most chest-specific strengthening exercises. Maybe a little less, maybe slightly more.
When you do eventually resume push-ups, flat dumbbell presses, etc., it is vital that you carefully manage and adjust the volume, frequency, and intensity of loading. If you strained your pectoralis major from a new training program that had you benching 85-100% of your 1-rep max for multiple sets, 4 times per week, that is NOT going to be your starting point for rehab. Instead, you’ll probably reduce the frequency, you’ll definitely reduce the intensity (the total weight on the bar), and you’ll likely reduce the overall volume. Additionally, you’ll decrease your effort – meaning that you won’t take each set as close to failure.
It’s also very possible that you don’t start your rehab with bench press, dips, and dumbbell flyes. Rather, you might test the waters with push-ups or flat dumbbell presses.
Aside from adjusting your frequency, intensity, and volume of loading, there are other components of exercise that can be modified to predictably lower the demand on your chest and shoulder. Here are 4 examples:
1. Exercise Selection – I already alluded to this, but you wouldn’t try dips prior to doing push-ups. You want to start with exercises that are easier and more controllable. Even if you started with push-ups, you might have to do them with your hands elevated initially.
2. Range of Motion – All else being equal, a deeper stretch is going to increase the load on the pectoralis major. If you’re doing push-ups, you can place a foam roller underneath you to decrease the total range of motion. Similarly, for a barbell bench press or a flat dumbbell press, you can consciously reduce the range of motion, use a physical block to reduce the range of motion, or do something like a floor press.
3. Technique – This ties in with range of motion. Using a narrower hand placement during push-ups, bench press, etc. will decrease the total demand on your chest and shoulder.
4. Tempo – It can be helpful to slow things down. You can try a slow tempo, particularly during the eccentric portion of an exercise, or use pauses at the bottom of a movement.
This part of rehab is a careful dance as opposed to a perfect science. The dose is and was the poison, but it’s also the antidote. You can’t completely rest for an extended period of time and expect your body to suddenly tolerate the same amount of loads as prior to your injury. Likewise, there’s no way of forcing the body to heal faster by doing more than what it’s ready for. There’s a fine balance between doing too much and doing too little, which we refer to as the Goldilocks Principle.
Monitoring Pain (Recommended)
Pain can be a helpful guide during rehab. It’s often believed that rehab needs to be completely pain-free, but that’s actually rarely the case. A better rule of thumb is to keep your symptoms tolerable during exercise, after exercise, and the following day.
If you have a significant increase in symptoms the day after a training session, it just means you did a little too much and need to scale back as I discussed earlier.
Your comfort or confidence can also play a role. If you’re unsure if you’re ready to add another 5 or 10 pounds to the bar, you might be better off repeating a past performance instead of striving for a new record.
Other than directly loading the pectoralis major with chest-specific exercises, is it worthwhile incorporating accessory exercises that train the rest of the shoulder? It might not always be necessary, but it probably doesn’t hurt to be as comprehensive as possible. That is exactly what’s done during post-surgical rehab.
Shoulder External Rotation Strength (Optional)
One optional category of exercises that can be performed involves shoulder external rotation strengthening, which is often associated with the rotator cuff. Examples include side lying external rotation, standing external rotation with a cable or band, and external rotation with your elbow on your knee.
Option 1: Side Lying External Rotation – Place your top arm at your side with your elbow bent to 90° while holding a weight in your hand. Rotate your arm outward while keeping your arm at your side. Lower back to your stomach and repeat.
Option 2: Standing External Rotation with a Cable or Band – With your elbow bent to 90° and pinned at your side, rotate your arm outward. Slowly control the motion back to the start and repeat.
Option 3: External Rotation with Elbow on Knee – Sit with your elbow supported on your knee and a weight in your hand. Slowly lower the weight, rotating your arm inward as far as possible without letting your shoulder roll forward. Then, rotate back to the starting position.
If you want to progress these exercises, you can perform them in what’s known as the “90/90 position”, in which the shoulder and elbow are bent to 90 degree angles.
If you’re standing, use a cable or band. If you’re lying on your stomach, use a weight.
You’d pick one option to perform slowly within tolerable symptoms for 2-3 sets of 10-15 repetitions, 2-3 times per week.
Posterior Shoulder Strength (Optional)
Another optional category is posterior shoulder strengthening in the form of As, Ts, and Ys, with or without resistance. These can be done isometrically on the floor, or through a full range of motion on an elevated surface or using a cable column.
Once again, you’d pick one option for 2-3 sets of 10-15 repetitions or 30-45 second holds, 2-3 times per week.
Shoulder Internal Rotation Strength (Optional)
A third optional category is shoulder internal rotation strengthening. Keep in mind that this directly loads the pectoralis major and therefore may not be suitable to start.
The primary option is standing internal rotation with a cable or band. With your elbow bent to 90° and pinned at your side, rotate your arm inward. Slowly control the motion back to the start and repeat.
If you want to make it more challenging, perform the movement in the 90/90 position.
Like the previous two categories, either exercise can be done for 2-3 sets of 10-15 repetitions, 2-3 times per week.
Shoulder Flexion Range of Motion
Depending on your symptoms and goals, you may also want to improve your tolerance to different ranges of motion.
To work on your overhead range of motion, the best choice is supine shoulder flexion with a dowel. Lie on your back with your knees bent and slowly move your arms overhead as far as comfortable while holding onto a stick, PVC pipe, or broom with both hands. Use as much assistance from your uninvolved side as needed.
To increase the intensity, add a light weight to help move the shoulder further overhead.
To decrease the intensity, move through less range of motion.
To reinforce this range of motion, you could pair this with something like a downward dog or prone shoulder flexion with a dowel. This combination can make for a great warm-up prior to an upper body workout.
The number of repetitions may vary based on the speed at which you perform a particular movement. Therefore, it might be helpful to think about accumulating 30-60 seconds total per set for 2-3 sets, 2-3 times per week.
Guidelines, Not Rules
Please understand that all of this information is a generalized framework that needs to be individualized based on your symptoms, function, goals, etc. These exercises may also be applicable to post-surgical cases, as well as more severe non-operative cases, but how, when, and why they are applied will vary depending on your doctor’s precautions, healing timelines, and other factors.
This blog is also not all-inclusive. Many individuals will need to work on their shoulder external rotation range of motion, starting at their side and working overhead, as well as improving their ability to reach back into shoulder extension.
As always, rehab takes time, so be patient and consistent!
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Shoulder Resilience Program!
Want to learn more? Check out some of our other similar blogs:
Biceps Tendinopathy, How to Improve Shoulder Range of Motion, SLAP Tear Rehab
Thanks for reading. Check out the video and please leave any questions or comments below.
