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Pectoralis Major Repair

48 citationsUpdated Aug 2026

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Overview

Surgical repair of clinical pectoralis major tears yields superior functional outcomes compared to nonoperative management, including greater recovery of peak torque and work performed [1]. Operative treatment results in significantly superior outcomes with an associated 14.21% complication rate [7, 13]. Early surgical intervention by anatomic repair provides the best results for total and near-total ruptures [6]. Acute repair specifically leads to significantly superior functional outcomes and cosmesis satisfaction, with a trend toward a higher proportion of patients who are pain-free [21].

The procedure is an effective treatment that facilitates a high rate of return to work (97.8%) with a mean time to return of 1.6 months [2]. It also allows for an early return to sport and functional activity, alongside pain relief and improved cosmetic appearance [10, 12]. Unicortical button fixation and suture tape provide a reproducible and reliable anatomic repair with positive clinical outcomes [3]. Surgical repair can be performed safely with a low re-rupture rate and low risk of complications [20].

Patients treated operatively for acute or chronic ruptures fare significantly better than those treated nonoperatively, with no statistically significant difference in outcomes between acute and chronic operative groups [15]. As a salvage procedure, pectoralis major tendon transfer provides good results in most cases [5].

Anatomy & Pathophysiology

The majority of pectoralis major tears occur at the myotendinous junction [55]. The distal pectoralis major tendon exhibits a 'U' shape, comprised of an anterior layer (clavicular head and, to a lesser extent, sternal head) and a posterior layer (sternal head) [14]. These anterior and posterior layers fuse proximal (medial) to the distal tendon attachment on the humerus [14].

Diagnostic Assessment: The Pectoralis Major Index (PMI) technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears [9].

Clinical Significance: The pectoralis major muscle is not necessary for normal shoulder function but is required for athletics or strenuous activity [36]. In shoulders with massive rotator cuff tear, the pectoralis major and latissimus dorsi muscles have increased importance [52]. Specifically, in massive rotator cuff tear, these muscles improve glenohumeral kinematics and reduce acromiohumeral pressures [35]. Restoration of dynamic external and internal couple forces via pectoralis major transfer maintains the humeral head in the center of rotation [37].

Repair Outcomes: Early surgical repair of distal pectoralis major tendon ruptures provides reliable restoration of shoulder function and strength [12]. Patients undergoing repair of the pectoralis major muscle are expected to have significant improvements in shoulder function [41]. Isolated tears of the sternocostal head of the pectoralis major muscle can be treated with a biomechanically sound repair technique with favorable outcomes [17].

Biomechanics and Reconstruction: A locking whipstitch of the pectoralis major tendon over a length of 6 cm provides superior biomechanical properties at time zero compared to 2 cm or 4 cm lengths [45]. Transfer of the clavicular or sternocostal portion of the pectoralis major muscle under the coracoid process reduces pain and improves shoulder strength and function [47]. Although one-third of shoulders treated with pectoralis major transfer for irreparable subscapularis tears developed mildly symptomatic or asymptomatic osteoarthritis, the need for salvage with reverse total shoulder arthroplasty was rare [53].

Classification

Tietjen (1980): Proposed an early functional classification for pectoralis major injuries [24].

Bak Criteria: Classifies outcomes after pectoralis major tendon repair into Excellent, Good, Fair, and Poor categories based on pain, range of motion, cosmetic complaints, strength deficits, and return to activity [27].

Comprehensive Classification System: Categorizes injuries by Timing (Acute vs. Chronic), Location (Muscle Origin/Belly vs. Musculotendinous junction/Insertion vs. Bony avulsion), Extent thickness (Partial-Anterior, Partial-Posterior, Full), and Extent width (Incomplete, Complete) [50]. * Extent Thickness: Partial-thickness tears are subdivided into Partial-Anterior (Pa) and Partial-Posterior (Pp) based on the anterior-to-posterior direction of the tear [50]. * Extent Width: Defined as complete or incomplete, which is distinct from tear thickness [50]. * Clinical Utility: The distinction between tear depth (thickness) and width allows for the identification of ruptures affecting only one layer of the bilaminar pectoralis major tendon [50].

Alternate Classification: Proposed based on the crossing of tendon segments, suggesting that lesions classified as Pp-I cannot involve only the inferior part of the posterior layer [23]. Surgical recommendations for this system are yet to be established [23].

Sternocostal Head Classification: A new classification proposed specifically for isolated tears of the sternocostal head [17].

Clinical Presentation

Pectoralis major tears are diagnosed primarily through history and physical examination [26]. Rupture of the pectoralis major muscle likely occurs more frequently than reported in the literature [19], although full-thickness ruptures of the pectoralis major muscle belly are rare [18]. Discrepancies exist between intraoperative and radiographic assessments of pectoralis major tears [11].

Imaging: Magnetic resonance imaging (MRI) is the modality of choice when confirmatory imaging is required or graft reconstruction is being considered [26].

Anatomy: The distal pectoralis major tendon has a 'U' shape comprised of an anterior layer (clavicular head and, to a lesser extent, the sternal head) and a posterior layer (sternal head) that fuse proximal to the distal tendon attachment on the humerus [14].

Clinical Findings: Rupture of the pectoralis major muscle can result in ossification within the muscle, presenting as a tender lump [28]. Compartment syndrome secondary to acute pectoralis major tendon rupture is a potential complication requiring prompt recognition and decompression [25].

Management Rationale: Surgical repair of pectoralis major tears is important to restore complete function and contour, especially in young athletes [16]. Surgical repair allows for an early return to sports and functional activity in athletes [12].

Investigations

MRI: MRI is accurate for diagnosing the tear grade and location of pectoralis major tendon ruptures, particularly for acute, tendon-bone, and G3 tears [44].

Other Considerations: Surgical repair of a clinical pectoralis major tear results in greater recovery of peak torque and work performed than conservative management [1]. Surgical repair of the ruptured pectoralis major muscle is important to restore complete function and contour, especially in young athletes [16]. Full-thickness ruptures of the pectoralis major muscle belly are rare and have been treated surgically with good to excellent results [18]. Rupture of the pectoralis major muscle probably occurs much more frequently than reports would indicate [19]. Prompt recognition and decompression of pectoral/upper arm compartment syndrome, followed by delayed pectoralis major tendon repair, can result in a successful return to normal function [25].

Treatment

Non-Operative

Conservative management of pectoralis major rupture results in incomplete loss of strength [16]. However, total ruptures exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes [43].

Operative

Indications: Surgical repair is important to restore complete function and contour, especially in young athletes [16]. The authors recommend repair of complete pectoralis muscle ruptures in active patients who require maximum strength in vocational or avocational activities [40].

Surgical Approach / Technique: Repair of the pectoralis major tendon ruptures using intramedullary suture anchors yields high rates of return to duty, patient satisfaction, and patient-reported outcomes [22]. A biomechanically sound repair technique for isolated tears of the sternocostal head yields favorable outcomes [17]. Full-thickness ruptures of the pectoralis major muscle belly have been treated surgically with good to excellent results reported [18]. Unicortical button fixation and suture tape provides a reproducible and reliable anatomic repair with positive clinical outcomes [3]. Allograft reconstruction is a useful technique for chronic pectoralis major ruptures where direct repair is not possible, allowing patients to return to preinjury occupation levels [8]. Repair of a pectoralis major muscle rupture can be successfully performed 13 years after the initial injury [4].

Implant Selection: Augmentation of pectoralis major tendon repair with an acellular dermal matrix significantly increases the ultimate load to failure compared to standard repair and achieves biomechanical properties equivalent to the native tendon [46].

Other Considerations: Transfer of the pectoralis major has a much longer track record than other transfer options [32].

Complications

Overall Complication Rate: Pectoralis major tendon repair is associated with a 14.21% complication rate [7, 13]. Despite this baseline incidence, surgical repair of pectoralis major tendon ruptures can be performed with a low risk of complications [20], and patients undergoing pectoralis major tendon repair should expect a low complication rate [60].

Re-rupture: Re-rupture occurs in 5.8% of patients after primary pectoralis major repair [29].

Recovery

Light activity (weeks): Early surgical repair of distal pectoralis major tendon ruptures combined with an accelerated rehabilitation protocol facilitates an early return to sports and functional activity [12]. Patients are able to resume desk work, driving, and light activities of daily living within the timeframe supported by this accelerated protocol [12].

Full activity (months): Pectoralis major tendon repair results in a high rate of return to sport and work [10]. In military populations, 94% of patients are able to return to full military duty after primary pectoralis major repair [29]. Surgical repair of acute pectoralis major rupture results in complete recovery and restoration of full muscle strength [39].

Complete recovery / outcome plateau (months): Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction compared to other timings [21]. Acute repair also showed a trend toward a higher proportion of patients who were pain-free [21]. Repair of a pectoralis major muscle rupture was successfully performed 13 years after the initial injury, indicating that late reconstruction remains a viable option for chronic cases [4].

Rehabilitation protocol: Early surgical repair of distal pectoralis major tendon ruptures and an accelerated rehabilitation protocol provide reliable restoration of shoulder function and strength [12]. This protocol supports the early return to sports and functional activity noted above [12].

Functional milestones: Pectoralis major tendon repair results in a high rate of return to sport and work, pain relief, and improved cosmetic appearance [10]. Loss of strength is not complete in conservative treatment of pectoralis major rupture, highlighting the functional advantage of surgical intervention [16].

Other Considerations: Pectoralis major tendon repair is associated with a significant rate of complication [10]. Re-rupture occurs in 5.8% of patients after primary pectoralis major repair [29]. Pectoralis major transfer results in improvement for patients with an irreparable subscapularis tear with or without an associated reparable supraspinatus tear [38].

Key Evidence

  • [L3] Objective strength testing shows that surgical repair of a clinical tear of the pectoralis major results in greater recovery of peak torque and work performed than conservative management. [1] (10.1136/bjsm.35.3.202)
  • [L4] Pectoralis major repair results in a high rate of return to work (97.8%) with a mean time to return of 1.6 months. [2] (10.1177/23259671211045635)
  • [Paper] The authors recommend their preferred technique for pectoralis major repair as it provides a reproducible and reliable anatomic repair with positive clinical outcomes. [3] (10.1016/j.eats.2017.02.002)
  • [L4] Repair of a pectoralis major muscle rupture was successfully performed 13 years after the initial injury. [4] (10.1177/03635465000280021901)
  • [L3] As a salvage procedure, the pectoralis major tendon transfer provides good results in most cases. [5] (10.1016/j.jse.2011.01.023)
  • [L4] Early surgical treatment by anatomic repair gives the best results in the treatment of total and near-total ruptures of the pectoralis major muscle. [6] (10.1177/0363546503261137)
  • [L1] Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. [7] (10.1177/2325967119900813)
  • [L4] Allograft reconstruction is a useful technique for chronic pectoralis major ruptures where direct repair is not possible, allowing patients to return to preinjury occupation levels. [8] (10.1177/1758573217741319)
  • [L2] The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. [9] (10.1177/2325967113516729)
  • [L4] Pectoralis major tendon repair is an effective treatment that results in a high rate of return to sport and work, pain relief, and improved cosmetic appearance, albeit with a significant rate of complication. [10] (10.1177/1941738118818060)
  • [L4] The majority of pectoralis major tears occurred at the myotendinous junction. [11] (10.1016/j.jseint.2023.06.019)
  • [L4] Early surgical repair of distal pectoralis major tendon ruptures and an accelerated rehabilitation protocol provide reliable restoration of shoulder function and strength, allowing an early return to sports and functional activity. [12] (10.1007/s00264-006-0171-2)
  • [L1] Pectoralis major tendon repair resulted in significantly superior outcomes as compared to nonoperative treatment with an associated 14.21% complication rate. [13] (10.1177/2325967120s00411)
  • [L5] New anatomic descriptions of the distal pectoralis major tendon detail a ' U ' shape of the distal tendon comprised of anterior layer (the clavicular head and, to a lesser extent, the sternal head) and posterior layer (the sternal head), which fuse proximal (i.e., medial) to the distal tendon attachment on the humerus. [14] (10.1007/s00256-014-1990-7)
  • [L3] Patients treated operatively for acute or chronic pectoralis major ruptures fared significantly better than those treated nonoperatively, with no statistically significant difference in outcomes between acute and chronic operative groups. [15] (10.1177/03635465000280012701)
  • [L4] The authors propose a new classification of pectoralis major injury and present a biomechanically sound repair technique for isolated tears of the sternocostal head with favorable outcomes. [17] (10.1016/j.jse.2019.11.024)
  • [L4] Full-thickness ruptures of the pectoralis major muscle belly are rare and have been treated surgically with good to excellent results reported. [18] (10.1016/j.jses.2019.10.006)
  • [L4] Surgical repair of pectoralis major tendon ruptures can be performed safely with a low re-rupture rate and low risk of complications. [20] (10.1177/2325967117s00242)
  • [L1] Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. [21] (10.1177/0363546520904402)
  • [L4] Repair of the pectoralis major tendon ruptures using intramedullary suture anchors has high rates of return to duty, patient satisfaction, and patient-reported outcomes. [22] (10.1016/j.jse.2024.04.029)
  • [Letter] The authors propose an alternate classification of pectoralis major tears based on the crossing of tendon segments, suggesting that lesions Pp-I cannot involve only the inferior part of the posterior layer and that surgical recommendations for this classification are yet to be established. [23] (10.1016/j.jse.2012.10.030)
  • [L4] [24] (10.1177/0363546505279573)
  • [L4] Our case demonstrates that prompt recognition and decompression of pectoral/upper arm compartment syndrome, followed by delayed pectoralis major tendon repair, can result in a successful return to normal function. [25] (10.1016/j.jse.2014.10.023)
  • [L5] [26] (10.5435/jaaos-d-21-00541)
  • [L4] [27] (10.1016/j.jse.2016.07.018)
  • [L5] Rupture of the pectoralis major muscle can result in ossification within the muscle, presenting as a tender lump. [28] (10.1016/0020-1383(88)90050-2)
  • [L3] In the largest study to date, 94% of patients are able to return to full military duty after primary pectoralis major repair and 5.8% experience re-rupture. [29] (10.1016/j.arthro.2016.03.068)
  • [L4] Transfer of the pectoralis major has a much longer track record. [32] (10.1007/s12178-020-09674-4)
  • [L5] Bone trough repair of the pectoralis major tendon was stronger than suture anchor repair. [33] (10.1177/0363546512449291)
  • [L5] In massive rotator cuff tear, the pectoralis major and latissimus dorsi muscles are effective in improving glenohumeral kinematics and reducing acromiohumeral pressures. [35] (10.1016/j.jse.2013.11.030)
  • [Paper] Restoration of the dynamic external and internal couple forces maintains the humeral head in the center of rotation. [37] (10.1007/s00064-021-00760-5)
  • [L2] Pectoralis major transfer results in improvement for patients with an irreparable subscapularis tear with or without an associated reparable supraspinatus tear. [38] (10.2106/00004623-200310000-00012)
  • [L4] Surgical repair of acute pectoralis major rupture results in complete recovery and restoration of full muscle strength, which is essential for active athletes. [39] (10.1007/s001670050085)
  • [L4] The authors recommend repair of complete pectoralis muscle ruptures in active patients who require maximum strength in vocational or avocational activities. [40] (10.1177/036354659202000517)
  • [L3] Patients undergoing repair of the PMM are expected to have significant improvements in function of the shoulder. [41] (10.1177/2325967119s00252)
  • [L2] Total ruptures of the pectoralis major muscle exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes. [43] (10.1177/0363546513506556)
  • [L3] MRI is accurate for diagnosing the tear grade and location of pectoralis major tendon ruptures, particularly for acute, tendon-bone, and G3 tears. [44] (10.1016/j.jse.2015.08.037)
  • [L5] A locking whipstitch of the PM tendon over a length of 6 cm provides superior biomechanical properties at time zero compared to 2 cm or 4 cm lengths. [45] (10.1016/j.jse.2025.01.045)
  • [L5] Augmentation of pectoralis major tendon repair with an acellular dermal matrix significantly increases the ultimate load to failure compared to standard repair and achieves biomechanical properties equivalent to the native tendon. [46] (10.1016/j.jse.2019.09.020)
  • [L4] A clavicular or a sternocostal head transfer of the pectoralis major under the coracoid process reduced pain, and improved the strength and function of the shoulder. [47] (10.1007/s00264-014-2566-9)
  • [L4] [50] (10.1016/j.jse.2011.04.035)
  • [L5] The findings from this study suggest the increased importance of PM and LD in shoulders with massive rotator cuff tear. [52] (10.1016/j.jse.2007.02.036)
  • [L4] Although one-third of the shoulders developed mildly symptomatic or asymptomatic osteoarthritis, the need for salvage with use of reverse total shoulder arthroplasty was rare. [53] (10.2106/jbjs.19.00172)
  • [L4] The majority of pectoralis major tears occurred at the myotendinous junction, potentially reflecting changes in population-wide physical activities. [55] (10.1177/2325967123s00348)
  • [L4] Patients undergoing PMT repair should expect significant functional improvements and a low complication rate. [60] (10.1177/0363546519851506)

See Also

References

[1] Pectoralis major tears: comparison of surgical and conservative treatment. British Journal of Sports Medicine. 2001. DOI: 10.1136/bjsm.35.3.202

[2] Return to Work After Pectoralis Major Repair. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211045635

[3] Pectoralis Major Repair With Unicortical Button Fixation And Suture Tape. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2017.02.002

[4] Delayed Repair of a Ruptured Pectoralis Major Muscle. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280021901

[5] Magnetic resonance imaging-controlled results of the pectoralis major tendon transfer for irreparable anterosuperior rotator cuff tears performed with standard and modified fixation techniques. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.01.023

[6] Rupture of the Pectoralis Major Muscle. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503261137

[7] Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967119900813

[8] Surgical reconstruction of unrepairable pectoralis major rupture using tendo-achilles allograft. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217741319

[9] Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113516729

[10] Outcomes and Return to Sport After Pectoralis Major Tendon Repair: A Systematic Review. Sports Health: A Multidisciplinary Approach. 2018. DOI: 10.1177/1941738118818060

[11] Myotendinous junction tears of the pectoralis major are occurring more frequently and discrepancies exist between intraoperative and radiographic assessments. JSES International. 2023. DOI: 10.1016/j.jseint.2023.06.019

[12] Rupture of the pectoralis major muscle: Surgical treatment in athletes. International Orthopaedics. 2006. DOI: 10.1007/s00264-006-0171-2

[13] Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-Analysis of Operative and Nonoperative Treatment. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00411

[14] Pectoralis major tears: anatomy, classification, and diagnosis with ultrasound and MR imaging. Skeletal Radiology. 2014. DOI: 10.1007/s00256-014-1990-7

[15] Rupture of the Pectoralis Major Muscle. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280012701

[16] Rupture of Pectoralis Major Muscle: A CASE REPORT AND REVIEW OF LITERATURE.. The Journal of Bone and Joint Surgery. American Volume. 1970.

[17] Isolated tears of the sternocostal head of the pectoralis major muscle: surgical technique, clinical outcomes, and a modification of the Tietjen and Bak classification. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.024

[18] Successful surgical repair of a full-thickness intramuscular muscle belly rupture of pectoralis major. JSES International. 2020. DOI: 10.1016/j.jses.2019.10.006

[19] Rupture of the Pectoralis Major Muscle: A REPORT OF ELEVEN INJURIES AND REVIEW OF FIFTY-SIX.. The Journal of Bone and Joint Surgery. American Volume. 1972.

[20] Surgical Treatment of Pectoralis Major Tendon Ruptures: A Retrospective Review of 134 Patients Tendon Ruptures. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00242

[21] Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520904402

[22] Pectoralis major tendon rupture repairs using intramedullary suture anchors shows high patient-reported outcomes in military service members. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.04.029

[23] Regarding “A systematic review and comprehensive classification of pectoralis major tears”. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.10.030

[24] Pectoralis Major Tears. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546505279573

[25] Compartment syndrome secondary to acute pectoralis major tendon rupture. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.10.023

[26] Pectoralis Major Rupture: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-00541

[27] Pectoralis major tendon tears: functional outcomes and return to sport in a consecutive series of 40 athletes. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.07.018

[28] Rupture of the pectoralis major muscle: a complication. Injury. 1988. DOI: 10.1016/0020-1383(88)90050-2

[29] Mid‐Term Complications and Re‐operation Rates Following Pectoralis Major Tendon Repair in the Young Active Population. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.068

[32] Pectoralis Major and Anterior Latissimus Dorsi Transfer for Subscapularis Tears. Current Reviews in Musculoskeletal Medicine. 2020. DOI: 10.1007/s12178-020-09674-4

[33] Biomechanical Comparison of 3 Methods to Repair Pectoralis Major Ruptures. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512449291

[35] The role of pectoralis major and latissimus dorsi muscles in a biomechanical model of massive rotator cuff tear. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.11.030

[36] Pectoralis Major Muscle: Function of Sternal Portion and Mechanism of Rupture of Normal Muscle: Case Reports.. The Journal of Bone and Joint Surgery. American Volume. 1961.

[37] Pectoralis major and pectoralis minor transfer for irreparable subscapularis tendon tears. Operative Orthopädie und Traumatologie. 2022. DOI: 10.1007/s00064-021-00760-5

[38] OUTCOME OF PECTORALIS MAJOR TRANSFER FOR THE TREATMENT OF IRREPARABLE SUBSCAPULARIS TEARS. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200310000-00012

[39] Surgical treatment of pectoralis major rupture in athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050085

[40] Ruptures of the pectoralis major muscle. The American Journal of Sports Medicine. 2020. DOI: 10.1177/036354659202000517

[41] Return to Sport and Exercise Following Repair of the Pectoralis Major Tendon. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00252

[43] Clinical Considerations for the Surgical Treatment of Pectoralis Major Muscle Ruptures Based on 60 Cases. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513506556

[44] Accuracy of magnetic resonance imaging in predicting the intraoperative tear characteristics of pectoralis major ruptures. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.08.037

[45] Pectoralis major tendon tears: a biomechanical study to analyze the influence of intratendinous suture distance on repair stability. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.045

[46] Acellular dermal matrix augmentation significantly increases ultimate load to failure of pectoralis major tendon repair: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.09.020

[47] Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results. International Orthopaedics. 2014. DOI: 10.1007/s00264-014-2566-9

[50] A systematic review and comprehensive classification of pectoralis major tears. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.04.035

[52] The Role Of Pectoralis Major And Latissimus Dorsi Muscles In A Biomechanical Model Of Massive Rotator Cuff Tear. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.036

[53] Long-Term Outcomes of Pectoralis Major Transfer for the Treatment of Irreparable Subscapularis Tears. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00172

[55] Poster 385: Discrepancies Exist Between Intraoperative and Magnetic Resonance Imaging Assessments of Partial Pectoralis Major Tears. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00348

[60] Analysis of Return to Sport and Weight Training After Repair of the Pectoralis Major Tendon. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519851506

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a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.