Breaking: Huselius tears pectoral, grosses me out.

After Kristian Huselius injured himself, I reached out to Jo Innes of the "Puck That Hurts!" blog to take a look at the injury from a medical standpoint. Please take a look and give her site a visit - it's a great resource! -Matt

I have to admit I don't follow the Blue Jackets. I do follow hockey injuries, however, and when I got an email to the effect of "Hey, Huselius blew out a pec" from Matt at The Cannon, this post practically wrote itself. A pectoral tear is a pretty intense injury, and unfortunately it's one that takes a long time to rehab. Here's a look at the injury, the treatment, and what's ahead for Huselius.

Want to know what it takes to gross me out? This:

Gross.

That’s Scott Howson, GM of the Columbus Blue Jackets. I could easily fill a post on the subject of how kickass it is that there’s a GM on Twitter (solid PR move, Columbus), but let’s talk about the pectoralis major and what happens when you tear it (other then me getting grossed out).

Pectoralis Major (aka the pec, pec major, moobs, etc.)

Pectoralis major

Pectoralis major is the muscle that makes up the bulk of what your personal trainer calls your pec. You’ve got one on each side, and if you’ve ever benched too much, then you know exactly where they are.

The pec originates at the sternum, clavicle and aponeurosis of the external abdominal oblique, and inserts on the bicipital groove of the humerus.

Huh?

The pec is connected to the sternum, collarbone, top of the abs, and the upper arm.

That’s better.

It has several jobs, mostly involving shoulder movement (and holding your arm on), and the NCAA guide to "Ice Hockey Officials’ Signals" will illustrate them nicely:

Arm flexion

Arm flexion: In order to get your hands up in front of you to signal cross-checking, you’d first have to raise them up in front of your body. That’s arm flexion.

Arm adduction

Arm adduction: To signal kneeing, you reach across your body and slap the opposite knee. To do this you have to adduct your arm (the opposite of raising it away from your body to the side).

Medial rotation of the humerus

Medial rotation: Delay of game? Well, actually this isn’t really close. Imagine your arm is bent at the elbow with your hand pointed straight in front of you. Rotate your arm so that it’s across your chest (like you’ve got it in a sling). That’s medial rotation.

Deep inspiration: The NCAA can’t help me here. If you take a really deep breath, the pectoralis helps expand your chest.

Assorted scapula (shoulder blade) jobs: Flex your pec and you’ll have a better idea of what it does to the shoulder blade than I could possibly explain.

Holding your arm on: Obviously your arm is connected to the rest of your body by a lot more than your pec, but it definitely contributes. The tendon that attaches the pec to the humerus (upper arm) is about 2 inches wide – that’s not insignificant where tendons are concerned.

The Injury

Pectoralis tears aren’t exactly common, which just as well because they’re painful and take a long time to heal. The tear generally happens during the bench press, and results in sudden pain, swelling, bruising, and a dimple above the armpit (from the missing muscle). This is a gross injury on a lot of levels – there’s horrible pain, your arm stops working properly, and many patients who’ve had this injury say they actually heard their muscle tearing when it happened.

Two thirds of pec tears involve pulling the tendon off the humerus. The rest are scattered amongst pulling off one of the other attachments, or rupture of the pectoral muscle itself (which is thankfully uncommon).  Since rupture of the tendon that holds the pec to the arm is the most common, that’s what we’ll be looking at.

The Repair

The best results are achieved with a quick repair. Older or sedentary patients can be managed conservatively and non-operatively, but since the majority of these injuries occur in athletes, they’re almost always repaired surgically. The repair involves opening the shoulder, scraping what’s left of the tendon off the bone, and re-attaching the severed end of the pectoralis tendon. Traditionally the repair was done by drilling holes through the humerus and threading suture through the holes and the end of the tendon.  Recent research has shown that you can get as good a result using absorbable sutures threaded onto an anchor that’s screwed into the bone (which is a far easier surgical technique).

Anchor suture

The suture takes years to be absorbed, and maintains full strength for 5 months – plenty of time for the tendon to heal to the bone.

The Recovery

The ugly part of this injury (other than hearing your own muscle ripping) is the recovery. After surgical repair, it can take four (more likely six) months to get back to pre-injury activity:

• The first four weeks: The patient has to stay in a sling and isn’t allowed to bear weight or move their arm in any of the ways the NCAA refs are showing us above.
• Weeks four to six:  Simple range of motion exercises start – they’re allowed to move the arm, but not to lift it up or twist it away from the body, as these movements put too much stress on the tendon.
• Six weeks post-op: The sling comes off and all range of motion is permitted.
• Eight weeks post-op: Isometric training begins – no weights, just contraction of the muscles by pushing or pulling a fixed object. I’m bored just thinking about it.
• Three months post-op: Light resistance training begins.
• Four months: Heavy training begins.
• Six months: Full activity resumes.

As with any major injury, it can take a long time to feel good again. The same study that looked at absorbable sutures found that at fourteen months post-op all patients were happy with their result.

What this means for Kristian Huselius

He’s in for a long, long rehab. He could be back mid-November at the earliest, more likely early January. He may not feel right or play to his fullest for a year. On the other hand, he could heal quickly and be fine. This is one of those injuries that would be a bad idea to rush back with (honestly, there’s no good injury to rush).

Things I didn’t mention, and will spend very little time discussing

Steroids: Yes, steroids can weaken tendons. No, this in no way means Huselius was using them. Tendon rupture with steroid use is frequently seen in older patients taking steroids for other reasons (like respiratory problems), and the rupture is usually atraumatic (i.e. it just happens out of nowhere). Jumping right to a steroid conclusion here would be stupid. Don’t do it.

Pectoralis minor: Pec minor is a tiny version of pec major that lives directly underneath it. It attaches to the underside of the scapula (shoulder blade) and the top few ribs. Its job is to hunch the shoulders forward. Boooooooring. That’s why I didn’t bother discussing it.

Many thanks to the NCAA refs for beautifully demonstrating the actions of pec major.

- Jo

You can find me blogging about hockey injuries and equipment at Puck, That Hurts! and on Twitter at @JoNana.