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Isolated insertional ruptures of the pectoralis minor tendon at the coracoid process are a rare condition. Hitherto, very few cases have been reported in the literature. A precise diagnosis is often difficult to obtain and commonly requires advanced imaging to confirm the suspicion and rule out concomitant injuries. All cases reported in the literature to date have been treated conservatively, with excellent results and no further complications. Here, however, we present the case of a patient who had developed a subclavian vein thrombosis. Furthermore, we provide an overview over and draw comparisons to the cases described in the literature. Despite the effectiveness of the conservative treatment, physicians should be aware that adverse events may occur.

This is a rare case of an isolated pectoralis minor partial-thickness tendon tear in a 24-year-old man who was involved in a major trauma. The purpose of this paper is to report the clinical signs, symptoms, cross-sectional imaging findings, and management of an isolated pectoralis minor tendon tear. Furthermore, this case represents a novel traumatic mechanism of injury, as opposed to the classic sports-related pectoralis minor tendon tear injury. The current limited body of literature on isolated pectoralis minor tendon tears is reviewed. Keywords: Pectoralis minor, Trauma, MVA, MRI, CT

We present a case of ectopic insertion of the whole tendon of the pectoralis minor muscle associated with impingement syndrome. Based on this case, we performed a review of the literature focused on the association between this ectopic tendon insertion and anterior shoulder pain.

Background: Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space. Purpose: To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population. Study Design: Case series; Level of evidence, 4. Methods: Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores. Results: Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities. Conclusion: In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Case A 27-year-old right-hand-dominant National Football League (NFL) quarterback injured his right shoulder after falling with the elbow flexed and the shoulder flexed and slightly abducted. He noted an immediate onset of right anterior shoulder pain, but was able to continue playing and throwing without notable deficit. Magnetic resonance imaging of the chest revealed an isolated tear of the pectoralis minor tendon. The patient received nonoperative local treatment and was able to start as quarterback at the next game. Conclusion An isolated pectoralis minor tear in the dominant arm of a professional throwing athlete may be successfully treated with nonoperative local treatment and shoulder strengthening and stabilization exercises, allowing an early return to competition.

OjectiveClinical consequences of ectopic tendons of the pectoralis minor muscle (PMM) for shoulder pain and range-of-motion limitation have been demonstrated. For better understanding the existence of such ectopic tendons, a phylogenetic hypothesis is proposed.MethodsForty-five shoulders of anatomical specimens were dissected and examined. Insertions areas of PMM were measured and occurring aberrant tendons were identified. Their relationship with the coracohumeral ligament (CHL) described and samples of the ligament were collected and histologically stained.ResultsThe prevalence of PMM variations was 37.84%. Shoulders with variations showed a statistically significant smaller coracopectoral distance (pConclusionsThe presented results prompted the conclusion that the CHL may be in fact the remnant of the pectoralis minor tendon (PMT), which migrated from the humerus to the coracoid process through the process of phylogenetic evolution. Variations of PMTs are significantly more common than in previous studies. Imaging techniques appear to be insufficiently sensitive for reliably detecting ectopic tendons. Especially in patients experiencing shoulder pain and stiffness in whom the commoner pathologies have been ruled out the possibility of ectopic PMT should be kept in mind and ruled out.

Tightness or contracture of the pectoralis minor muscle can cause significant scapular dysfunction and is typically seen in patients with scapular dyskinesis and abnormal scapular protraction. When nonoperative treatment in these patients has failed, pectoralis tenotomy aims to resect the pectoralis minor tendon from the medial aspect of the coracoid process in order to decrease the force on the scapula, thereby improving scapular dynamics.

Isolated rupture of the pectoralis minor tendon is extremely rare and has been reported 3 times in 4 pa-tients. This article describes the first case of an isolated spontaneous pectoralis minor tendon tear in an end-stage renal disease (ESRD) patient undergoing long-term hemodialysis and with a previous history of bilat-eral rupture of the quadriceps tendons.He presented with left anterior shoulderand chest wall pain with direct tenderness on palpation over the coracoid. Magnetic resonance imaging revealed an isolated tear of the pectoralis minor tendon with an intact pectoralis major tendon. The patient returned to full activities after conservative management. Although rare, the diagnosis of pectoralis minor tendon rupture should be considered in ESRD patients who present with anterior shoulder pain in the absence of an antecendent trauma.

In the last 10 years we have found impingement of the coracoid process on the rotator interval in 12 patients (14 shoulders). Seven of these patients were women and 5 were men; the average patient age was 48.5 years. One patient had a calcified coracohumeral ligament, another patient had an anterior tear of a repaired deltoid flap, and a third had an aberrant pectoralis minor tendon inserted into the rotator interval. Eleven patients had a weak rotator interval, and in 4 cases the rotator interval had a small tear. We closed the rotator interval in all 12 patients. We also performed a coracoidoplasty in 5 of the patients. The condition of all shoulders improved clinically after operation; the average follow-up was 4.2 years. Three patients (4 shoulders) still had moderate pain, and 7 patients (9 shoulders) lacked strength. Internal rotation was the only shoulder movement that remained limited. Although impingement seemed obvious during surgery, experimental studies have reported contradictory findings.

Introducao: O musculo peitoral menor e um musculo delgado, que se origina do terceiro, quarto e quinto arcos costais e se insere proximalmente na superficie supero-medial do processo coracoide. Sua variacao anatomica pode estar correlacionada com diversas patologias do ombro e estar implicada ate mesmo na falha dos tratamentos de capsulite adesiva. Le Double em seu classico trabalho descreveu tres tipos de variacoes anatomicas e relatou uma incidencia em torno de 15% desta variacao. O objetivo deste trabalho foi analisar a insercao proximal do peitoral menor e relatar suas variacoes anatomicas. Metodos: Foram dissecados 12 cadaveres (24 ombros), onde foi realizada uma via deltopeitoral ampliada, isolada a insercao do tendao do peitoral menor e estudado sua insercao proximal. Foram excluidos os cadaveres com cicatrizes na regiao do ombro ou limitacao importante do arco de movimento passivo. Resultados: Entre os 12 cadaveres dissecados, 8 eram homens e 4 mulheres, com idade media de 53,9 anos. Dos 24 ombros dissecados, 21 (87,5%) apresentaram a insercao do musculo totalmente na porcao superior e medial do terco distal do processo coracoide. Em 3 ombros (12,5%), observou-se as variacoes anatomicas descritas por Le Double: um caso bilateral, com variacao do tipo I e um caso unilateral direito, com variacao do tipo II. Conclusao: Conhecer a anatomia do peitoral menor e suas possiveis variacoes anatomicas e importante para o manejo e entendimento das patologias do ombro. Introduction: The pectoralis minor is a thin muscle that originates from the third, fourth and fifth ribs and inserts proximally on the upper surface of the coracoid process and medial. Its action pull ventral and caudal the scapula, lowering his side angle in adduction of the arm. It also participates in the elevation of the third, fourth and fifth ribs during inspiration. His anatomical variation may be correlated with various pathologies of the shoulder and even be implicated in the failure of treatment of adhesive capsulitis. Le Double in his classic paper described three types of anatomical variations and reported an incidence of around 15% of this variation. Our goal was to analyze the proximal attachment of the pectoralis minor and report their anatomical variations. Methods: We dissected 12 cadavers (24 shoulders), 8 men and 4 women, mean age of 53.9 years. Was performed an extended deltopectoral approach, isolated insertion of the pectoralis minor tendon and studied the proximal attachment of the muscle. We excluded the bodies with scars on the shoulder or important limitation of passive range of motion. Results: Of the 24 shoulders dissected in 21 (87.5%) the insertion of the muscle occurred entirely in the upper medial and distal third of the coracoid process. In three shoulders (12.5%), we observed the anatomical variations described by Le Double. A bilateral case, with change of type I and one case with unilateral right variation of type II. Conclusion: Knowledge of the anatomy of the pectoralis minor and the possible anatomical variations is important for the understanding and management of pathologies of the shoulder, especially in techniques involving the coracoid process, or even the understanding of pathologies that can possibly have as the genesis of this anatomic variation of muscle.

To evaluate the anomalous insertion of the pectoralis minor tendon with absence of the coracohumeral ligament on MR arthrography and to demonstrate the associated findings seen with this anatomical variation.We retrospectively reviewed the 335 MR arthrograms of the shoulder joint (mean age 37.8 years) performed from March 2000 to February 2008. Images were evaluated with attention to anomalous insertion of the pectoralis minor tendon and the coracohumeral ligament.Anomalous insertion of the pectoralis minor tendon was demonstrated in 5 out of 335 shoulders (1.5%). The pectoralis minor tendons crossed over the coracoid process and attached directly to a glenohumeral joint capsule, and the coracohumeral ligament was absent in these 5 patients. In these patients, injected contrast material was noted to extend over the coracoid process along the course of the pectoralis minor tendon. Among 5 patients, 3 patients (60%) were diagnosed with SLAP (superior labrum anterior to posterior) lesions.Anomalous insertion of the pectoralis minor tendon to the glenohumeral joint capsule and associated absence of the coracohumeral ligament is well demonstrated on MR arthrography. It is an unusual variant of the pectoralis minor muscle insertion, and may be a possible contributing factor in the development of a SLAP lesion.

Objective: To evaluate magnetic resonance imaging (MRI) observer variability to detect ectopic insertion of the pectoralis minor tendon (EIPMT) and to investigate changes in the rotator interval in patients with EIPMT using MRI. Materials and Methods: A total of 507 shoulder MRIs (male:female = 259:248; mean age, 55.4 years) were classified into 1) normal type insertion of the pectoralis minor tendon, 2) complete type EIPMT, and 3) partial type EIPMT independently by two radiologists. Inter-observer agreement was calculated using the kappa coefficient. Thickness of the fibrotic scar tissue in the subcoracoid triangle and humeral side axillary recess was measured. MRIs were reviewed by consensus with regard to the grade of fibrotic scar tissue proliferation in the rotator interval. Comparisons were made between normal and EIPMT and between partial and complete type EIPMT. Results: The incidence of EIPMT was 13.4% (complete type, 7.7%; partial type, 5.7%). Inter-observer agreement was substantial (κ = 0.775). Fibrotic scar tissue in the subcoracoid triangle was thicker, and the grade of fibrotic scar tissue proliferation in the rotator interval was higher in the EIPMT group than those in the control group. No significant difference was observed in the thickness of humeral side axillary recess. The thicknesses of fibrotic scar tissue in the subcoracoid triangle and humeral side axillary recess as well as the grade of fibrotic scar tissue in the rotator interval were not significantly different between complete and partial type EIPMT. Conclusion: MRI enabled detection of EIPMT with substantial observer agreement. Patients with EIPMT show a high tendency for fibrotic scar tissue proliferation in the rotator interval. Index terms: Ectopic insertion of the pectoralis minor tendon; Rotator interval; MR