Pec INjury

A few days later, I went to visit Dr. Richard Diana, a premiere orthopedist (and former NFL Miami Dolphin) in New Haven, Connecticut. He concluded that I had a pectoral tear and wanted me to be examined by a doctor who specialized in pectoral tears. He stated that not too many cases of pectoral tears were recorded in literature and that a specific doctor at Yale Hospital (also in New Haven, Connecticut), Dr. Scott Wolf, had conducted studies and presentations on tears of the pectoralis in New England. I visited Dr. Wolf two weeks later. By this time, the bruising had started to subside, and my arm was looking more yellowish. The tightening feeling had subsided, too. However, I was left with a very visible concaving on the axillary line of the chest cavity (basically my armpit).

Dr. Wolf conducted various tests with me, which concluded that I had a pectoral tear. He desired an MRI to confirm his findings. A week later, I had an MRI, and four days later, I was back in Dr. Wolf's office. He confirmed that I had ruptured the pectoralis tendon. He knew it was a tear because the concave along the chest wall was excessively evident to the naked eye. He stated it was a common symptom in previous findings. I knew something “bad” had happened because the pain was overwhelming and the weakness that I felt in that arm was pretty evident to me.

Dr. Wolf explained to me the surgical procedure to repair the torn muscle. It sounded quite terrifying and pretty evasive to my 20-year-old ears. He said that I could elect not to have the procedure done and simply modify my exercise program. He warned that I would have a noted weakness in the left side and that I should stay away from activities that would overstress the right side. He also mentioned that although I couldn’t tear the left side anymore than it already was, I could place the right side (good side) at risk.

Troubleshooting my pec tear

1. I was lifting a lot of weight a lot of the time. I don’t think that I knew what the concept of “deloading” meant. I sure didn’t like the word “rest.” At the time, I figured that if I could lift heavy weights, I needed to keep lifting heavy weights so that I could continue to lift heavy weights. Does that make sense? The amount of volume every week, and sometimes twice a week, called for 50–100 repetitions of flat bench pressing. Talk about overtraining.

What I know today: Deloading and continuously changing the volume amount is critical to keep tissue healthy and muscles fully recovered. Today, I change up muscle groups, have light days/heavy days, and follow more compounded movements to take the stress away from muscles that participate in single joint actions.

2. I wasn’t just performing chest pressing. At the time, it was about getting bigger and stronger. So I accompanied the bench pressing with incline pressing, decline work, cable crossovers, flyes, peck decks, pull-overs, and tons and tons of other upper body exercises. I included tons of shoulder work such as military presses, behind the neck presses, upright rows, front raises, lateral raises, and shrugs. Over time, the repetitive stress on these joints caused an enormous imbalance in my anterior musculature versus the rear antagonists, which simply tore muscle fibers without letting them heal fully.

What I know today: As I’ve gotten older, my goals have obviously changed. At times, I still want to walk into any gym and “punk” out a lifter, but I know that I’m not as strong as I was simply because I’ve had injuries that have prohibited me from maxing all the time. Therefore, my goals have changed and so has my exercise program. Instead of workouts consisting of five days, I’ve scaled back to just three lifting days and two days of cardio.

3. With the amount of shoulder work that I did with my chest work, I exhibited a terribly protracted shoulder girdle that portrayed me as a walking ape and also spelled disaster for my shoulders and surrounding muscles. At the time, I wasn’t overly concerned with my posterior chain muscles, and the amount of “mirror” muscle work always outweighed the amount of back exercises in my programs.

What I know today: I understand the repercussions of a tight anterior shoulder capsule and how the movement pattern is affected by the condition of the surrounding joint structure. Today, I make it a point to give equal attention to antagonist muscle groups and concentrate on eccentric actions during lifts. I tend to pay close attention to the rotator cuff and scapular muscles as well as the core.

4. Back then, I only used machines. If I wasn’t up to bench pressing, you’d find me on a Cybex chest press machine or a plate loaded Hammer Strength. Machines that were staples in my upper body workouts included the peck deck, incline or seated chest press, Nautilus pull-over, side raise machine, and shoulder press machine. I thought that these pieces were godsends at the gym, and for years, I always looked for these dinosaurs whenever I joined a facility. It was obvious that the loading pattern had taken its toll on the joint structure, and the pattern of load had weakened the fibers of the pectoralis muscle. The barbell (bench press) is just as guilty here because the bar’s bilateral property causes a fixed plane that the shoulder joint has to follow.

What I know today: I understand that joints must be able to work in the range of motion that is allowed. I understand that injuries cause scar tissue and that will affect the range of motion in my muscles and/or that of my clients. Therefore, it is imperative that I utilize movements that allow my joints to move in the strongest plane and make corrections where needed. There’s no need to apply tons of balance boards and other tools. Simple free weights and body weight exercises will satisfy this. A word to the wise—if it shakes and quivers, it’s weak.

5. Neither stretching nor mobility was in my repertoire. Mobility? Huh? I didn’t even know what that was. Stretching...hmmm... I knew what stretching was, but no one cared to do it. It was all about getting big. We didn’t want to be flexible. We wanted to be strong.

What I know today: Injuries develop scar tissue. I know that because my left pectoral is filled with scar tissue. Scar tissue doesn’t carry the same tensile properties that muscle fibers do, and therefore, is inherently weaker and less pliable. Mobility work, especially in the scapular region, is important, and stretching (both static and dynamic) is detrimental to overall tissue quality. When I learned the importance of foam rolling back in 2003, I put myofascial release on my menu of exercise preparation drills. The kinesthetic “ball shaped knot” in my left chest wall has lessened, and the entire range of motion in my left side has improved dramatically.

Tearing the pectoralis major occurs mostly in bodybuilders performing the bench press exercise. When this unfortunate incident occurs, the athlete is often unsure of the correct way to treat this injury. That is, should they have surgery or treat it simply with inflammatory medication, ice and rehabilitation. With a partial tear, the later is defiantly an option, however, a full pec tear (where the tendon is torn off the bone) is a more serious matter.

A recent study completed by Finnish scientists suggests that the best treatment for a full pec tear is immediate surgery. To arrive at this conclusion, the researchers analyzed 33 cases of pec tears. Early surgical repair provided the best chance for complete recovery. Conversely, the worst results occurred when there was a long delay between injury and surgery.

This new study contradicts earlier reports that suggested a delay between injury and surgery did not provide an unsatisfactory outcome. Nevertheless, if you do suffer this unfortunate incident, get your injury diagnosed quickly. If your physician does recommend surgery then don’t delay. Maximize your chance of a full recovery, get your pec tear diagnosed and treated as done as soon as possible.

Source: American Journal of Sports Medicine, 32; 1256-62, 2005.

How to treat pec tears is something orthopedic specialists have also been debating for years. At last a study has been completed on the subject* regarding whether to treat the injury immediately, let it heal naturally or adopt the "wait and see, then operate" approach. Dr. A. A. Schepsis examined 17 cases of pec tear injuries, most produced by lifting weights.

For a start, surgical repair worked far better than no operation. Ninety-six percent of the patients were happy with the outcome of their procedure, while only fifty-one percent of the patients that opted for no operation were happy with their outcome.

One interesting and reassuring fact was that it did not appear crucial when the operation was performed. It made little difference whether the surgeon operated immediately or the patient opted for a wait and see approach.

*American Journal of Sports Med. 28:9-15,2000

Emphasis on the bench causes many people to push the training envelope in an effort to increase their poundages, often resulting in injury. The most common mistake is benching too often, which doesn't allow the muscles and ligaments to heal properly. With this overtraining syndrome, many areas of the shoulder are affected, causing injury and decreasing overall performance.

An Ounce of Prevention

When bench pressing, it's extremely important that the weight is controlled by the lifter for the duration of the repetition. If the bar is descended too quickly, it can hit the chest in the wrong spot, causing improper ascension toward the abdominals, resulting in compensation by raising the hips. This automatically forces the bar to go back over the chest, improving the chances of completing the lift.

The correct way to do the bench press is to lower the weight to the chest in a controlled motion. Note that the motion is described as controlled, not slow. The bar can still descend at a rapid pace, but at a controlled rapid pace. Too much energy may be expended if the descent time is overly long. (In hypertrophy training, a slower negative can be beneficial; however, we're focusing on maximal lifts here.) For beginners, a slower pace is preferable to one that's too fast. Once the ability to control the lift at a slow speed is mastered, speed can be increased.

One of the best cues to learn how to maintain control is in grip strength. The harder the bar is squeezed, the more control is gained over the bar. Visualize making dents in the bar with your fingers, and the bar will become easier to control. For this reason, the false — or "thumbless" — grip (whereby the thumb is positioned on the same side as the fingers) isn't recommended.

Research has shown that bench numbers can be increased by up to 10% simply by improving grip strength. In addition, the thumbless grip increases the potential for injury.

The second area of discussion involves the relationship between elbow angle and body position. The question is whether the arms should be held close to the body or at 90 degrees from the body. The answer depends on the motivation for doing the bench press in the first place. If the goal is to increase bench press poundage, keep the arms closer to the body, usually at a 45-degree angle:

This technique allows a backward push at the very bottom of the bench press and utilizes the anterior deltoids, along with the chest.

Tell Me Where It Hurts

Pain felt during the bench can be caused by many different variables. To properly identify the factors involved, distinguish at which point in the range of motion the pain is felt. Feeling pain at the top of the bench is different than feeling it at the bottom. This holds true even when the pain is felt in one isolated area.

Pain Patterns — The Evolution of Ouch

The first step in correction of pain and injury is a complete and thorough examination by a sports medicine physician, chiropractor, or physiotherapist. The examination should include an assessment of the shoulder, arm, pecs, and cervical and thoracic spine to determine if one or more of these areas is involved. All shoulder muscles must be checked with orthopedic muscle testing to determine if the pain is being caused by the muscles, joints, or nerves.

If the muscles are found to be weak in the shoulder joint, the pattern usually involves just the muscles and joint. If the muscles are weak all the way down the arm and into the wrist, the whole arm, upper back, and cervical spine may be influencing the weakness pattern. If this is the case, then all three must be treated simultaneously. The muscles, joint, and nerves must be treated first in order to restore strength prior to rehabilitation.

Too often, rehabilitation exercises are recommended for shoulder injuries which involve a dysfunctional shoulder joint due to muscles with excessive scar tissue and compromised muscular nerve supply. Once these problems have been corrected, rehabilitation is extremely effective. If the dysfunctional areas aren't treated, rehabilitation can have minimal to moderate results.

A dysfunctional muscle with excessive scar tissue due to years of heavy benching can't be strengthened properly. The same holds true for an unstable AC joint, or for compromised nerve supply to the pec due to a nerve entrapment in the neurovascular bundle under the collarbone.

Treatments That Work

* The typical pain and injury pattern involves an excessively scarred anterior deltoid, causing improper function, especially when stressed with a lot of weight.

* The other muscle that's usually dysfunctional due to scar tissue is the subscapularis, located on the front of the scapula in the armpit. This muscle stabilizes the shoulder joint when pushing heavy iron.

* The infraspinatus muscle in the back is an external rotator of the arm and usually becomes weak, creating more internal rotation than necessary. This pattern sets up altered biomechanics, leading to abnormal movement patterns which impinge on tissue, creating wear and tear in the shoulder joint. For strengthening the infraspinatus muscle, treatment incorporating rehabilitation tubing or dumbbell exercises are best.

- This exercise for the infraspinatus is an external rotation of the arm in an abducted position. In English, the person does a double biceps pose and brings his forearm down while leaving his upper arm in the same place until the palm faces the floor and the forearm is horizontal. This is like doing a double biceps pose toward the floor. Then you rotate the arm back into a double biceps position again.
- The best way to do this with resistance is to use a piece of rubber tubing or a cable machine that has an adjustable pulley height. Set the height of the pulley or tubing at shoulder level. Grab the handle in the position of a double biceps toward the floor, then rotate the arm until it's in a double biceps position. This works the external rotation, or infraspinatus:

- In the shoulder joint, the AC joint absorbs a lot of force when benching, and it's easy to traumatize and create an instability in this area. Muscles that cross an unstable joint won't work properly and might cause pain. The instability may be caused by a weakness in the subclavius, the small muscle located directly under the collarbone.

Myofascial Release with Movement (MRM). This is a soft-tissue therapy which breaks down scar tissue in muscle, allowing the muscle to heal and function properly. Treatment incorporating MRM and rehabilitation exercises can usually help stabilize the collarbone. If the AC joint is overstressed, certain taping techniques can allow it to heal and rehabilitate by strengthening the muscles that cross the joint.

The upper thoracic region is greatly affected by benching, as all of your bodyweight plus the weight of the bar is placed on the upper back. This can lead to excessive pressure in the spinal column and cause what's known as a T4 syndrome. This syndrome is recognized by a misalignment of the fourth thoracic vertebrae (T4), which can cause the whole arm to decrease in strength. T4 syndrome is often overlooked. However, once that area is fixed, strength can be restored and pain decreased dramatically.