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Re: Bench-presser’s shoulder – a question of neovascularisation

Dear Editor

We read with great interest the case series from Bhatia and coworkers describing the “Bench-presser’s shoulder” as an overuse insertional tendinopathy of the pectoralis minor muscle. We fully agree with the authors that tendinopathy is often times underdiagnosed as it is at the pectoralis minor muscle. However, we would like to comment on some issues.

Body-building athletes seem to be the predominant athletes’ entity suffering pectoralis tendinopathy and pectoralis tendon ruptures [6]. About 25% to 30% of all elite weight and power lifters report an injury sufficiently severe to seek medical attention [5]. Power lifting injuries most often involve shoulder injuries with an injury rate of 0.57 to 0.71/1000 hours of power lifting. Upper limb injuries account for ¼ of all power lifting injuries. Often two contributing factors causing wrist injuries are encountered: (a) loss of balance causing the barbell to drift back behind the head of the power lifter, which hyperextends the wrist and (b) the maximal weight.

Songraphic evaluation was performed including the assessment of the rotator cuff, the biceps tendon and the bicipital groove. Furthermore the integrity of the muscle-tendon-unit was examined. However, unfortunately only conventional grey scale Sonography has been performed by the authors. Neovascularisation, which is often times encountered in tendinopathy all over the body might be detected by colour Doppler, which is not addressed in the current study. However, currently no published evidence regarding the potential neovascularisation in pectoralis tendinopathy is given. Therefore, we advocate using the colour Doppler on the future patients encountered with this tendinopathy and report on that.

In analogy to the Achilles tendon, one might speculate that at the pectoralis level a continuum from the healthy tendon via the painful, tendinopathic tendon towards the pectoralis tendon rupture is evident. As shown by Maffulli [2], only degenerated tendons rupture, which might be the same for the pectoralis muscle rupture [4].

MRI might add evidence to the colour Doppler Sonography results as stated by Carrino using thin (3-4mm) axial sections with a variety of sequences combined for anatomical delineation (T1-weighted SE or PD SE) and fluid detection (T2-weighted SE, T2-weighted FSE with fat suppression, or STIR). Zvijac and coworkers stated in 2006 that clinical impression often times appeared to be overestimate the severity, location and the grade of the pectoralis injury [8]. Magnetic resonance imaging provided in their view a more accurate assessment. However, the current report on the seven patients with pectoralis minor tendinopathy did not comment on MRI findings, which might be of interest at least in our view.

Regarding the therapy used – a single ultrasound-guided injection of a corticosteroid to the enthesis - we have reasonable concerns, since evidence is accumulating that a single dose of a corticosteroid does not alter the acute phase response in tendinopathy at all [7, 3]. We rather recommend to implement – in analogy to the patellar and the Achilles tendon – an eccentric training in case of pectoralis minor tendinopathy, which hypothetically might decrease the suspected neovascularisation in analogy to the Achilles and patellar tendon.

References

(1) Carrino JA, Chandnanni VP, Mitchell DB, Choi-Chinn K, DeBerardino TM, Miller MD. Pectoralis major muscle and tendon tears: diagnosis and grading using magnetic resonance imaging. Skeletal Radiol 2000;29(6):305- 13.

(2) Maffulli N, Testa V, Capasso G, Ewen SW, Sullo A, Benazzo F, King JB. Similar histopathological picture in males with Achilles and patellar tendinopathy. Med Sci Sports Exerc 2004;36(9):1470-5.

(3) Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sports Med 2005;15(5):370-5.

(4) Potter BK, Lehman RA Jr, Doukas WC. Pectoralis major ruptures. Am J Orthop 2006;35(4):189-95.

(5) Powell KE, Heath GW, Kresnow MJ, Sacks JJ, Branche CK. Injury rates from walking, gardening, weightlifting, outdoor bicycling, and aerobics. Med Sci Sports Exerc 1998;30: 1246-1249.

(6) Roller A, Becker U, Bauer G. Rupture of the pectoralis major muscle: classification of injuries and results of operative treatment. Z Orthop Ihre Grenzgeb 2006;144(3):316-21.

(7) Wei AS, Callaci JJ, Juknelis D, Marra G, Tonino P, Freedman KB, Wezeman FH. The effect of corticosteroid on collagen expression in injured rotator cuff tendon. J Bone Joint Surg Am 2006;88(6):1331-8.