Shoulder injuries during weightlifting I: rupture of the pectoralis major tendon

Weightlifting is undoubtedly one of the oldest sports practiced. In recent years, the health benefits of weightlifting have become evident, such as lower blood pressure, improved blood glucose control, maintenance of bone mineral density, and resistance to fat accumulation. Its benefits have also been demonstrated in older adults and adolescents, groups in which there has always been reluctance to practice this sport. In adolescents, weightlifting improves motor skills and promotes a healthier body composition. In older adults, it helps control osteoarthritis.

Both weightlifting (Olympic weightlifting) and powerlifting are disciplines that focus primarily on maximal strength in a single attempt. Weightlifting has two events: the snatch and the clean and jerk, while powerlifting consists of three events: the squat, the bench press, and the deadlift.

Musculoskeletal Injuries in Weightlifting
Imbalances between training load and recovery have been postulated as determining factors in the development of musculoskeletal injuries in this sport, as has lifting heavy loads in extreme joint positions.

While acute injuries such as tears, sprains, lacerations, or bruises are common and often lead to discontinuation of sports practice, there are overuse injuries that develop gradually and with which the athlete lives and trains regularly.

According to various studies, the injury incidence in weightlifting is between 2.4 and 3.3 injuries per 1,000 hours of training. Acute injuries are the most common, accounting for 60–75% of injuries. Chronic injuries are usually associated with overuse and constitute the remaining 25-40%. In the literature, they are associated with older athletes, with higher rates of tendinopathy, previous tendon ruptures, and degenerative joint problems. The shoulders, knees, lower back, and wrists account for the majority of injuries, most frequently affecting tendons and muscles.

Some determining factors in the onset of these injuries are technical errors (present in 30% of injuries), fatigue or overload (present in 82% of injuries), and accidentally dropping weights (the most common injury mechanism in acute injuries).

Regarding the most common injuries in the upper extremities, we frequently find:

• muscle strains and ligament sprains
• pectoralis major tendon ruptures
• distal biceps brachii tendon ruptures
• chronic shoulder pain
• capsular and labral injuries

Pectoralis Major Tendon Rupture

Pectoralis major tendon rupture is an injury that has been on the rise in recent years. This increased incidence is likely due to increased resistance training and concentrated efforts to increase the volume of this muscle for functional or aesthetic purposes, as it is an important source of energy for upper extremity exercises.

The literature links up to 70% of pectoralis major injuries to bench pressing, an exercise frequently performed by this type of athlete. Forced abduction or elevation of the arm in this exercise causes an eccentric contraction that exceeds the tendon's resistance.

The diagnosis is clinical. Sudden pain, ecchymosis (hematoma), a palpable hollow or defect in the anterior part of the axilla, and decreased height of the nipple on the side of the injury. The diagnosis is usually confirmed with the support of magnetic resonance imaging or ultrasound.

The typical location of this injury is controversial in the literature. Some studies most frequently locate the injury at the tendon-to-bone junction. Other studies report a more common injury location at the muscle-tendon junction. The latter usually receive conservative treatment in most cases, while tendon avulsions (tendon avulsions from the bone) usually require surgical treatment.

Conservative or non-surgical treatment is usually recommended for partial tendon tears or injuries at the muscle-tendon junction in the absence of weakness. It involves immobilization with a sling in an internally rotated position for 3 weeks. Active and passive mobility exercises are then introduced, with a gradual increase in strengthening exercises over the following weeks. Surgical treatment is indicated in cases of complete avulsion of the tendon from its insertion on the humerus. Various techniques are used to reanchor the tendon at the bone insertion site. Ruptures that have lasted more than three months, with tendon retraction and shortening, require surgical intervention with tendon reconstruction.

Several studies have compared the results of conservative treatment with surgical treatment for complete ruptures. In this regard, it is worth noting that nonsurgical treatment is associated with a 50% reduction in strength in these studies, compared to a 15% reduction in strength in athletes who underwent surgery. In general, the literature reports better functional outcomes with surgical treatment for complete ruptures of the pectoralis major tendon.