Muscle Injury of the Chest Wall and Upper

Extremity
Melanie A. Hopper, M.B.Ch.B., M.R.C.S., F.R.C.R.,1 Phillip Tirman, M.D.,2
and Philip Robinson, M.B.Ch.B., M.R.C.P., F.R.C.R.3

ABSTRACT

Most muscle trauma more commonly involves the lower extremity, but injury to
the chest wall, particularly the pectoralis major, is well recognized. Trauma to the upper
limb muscle-tendon unit is preserved. Development of complications from muscle injury is
also discussed. This article systematically reviews the clinical features, pathogenesis,
imaging findings, and management for upper limb and chest wall muscle injuries. Imaging
modalities focus on magnetic resonance imaging and ultrasound, highlighting their
advantages and disadvantages in specific situations.

KEYWORDS: Muscle, athletic injury, MRI, ultrasound

M uscle injury is an important cause of pain and
impaired function. Although most muscle injuries are
minor and do not require imaging, muscle tears are a
significant cause of time away from sports in the athletic
population.1 Most muscle trauma involves the lower
extremity, but injury to the chest wall, particularly the
pectoralis major and oblique musculature, is well recog-
nized. Trauma to the upper limb muscle-tendon unit
typically involves the tendon or musculotendinous junc-
tion, but injury to the muscle belly is also reported and is
important to appreciate and understand.
PECTORALIS MAJOR MUSCLE
Significant chest wall muscle injuries are rare, most
involve the pectoralis major, and, as elsewhere in the
body, injuries predominantly occur at sites of anatomical
and functional transition where the greatest forces are
experienced.2
Anatomy and Function
The pectoralis major consists of a complex anatomical
arrangement. It is a large fan-shaped muscle with a
trilaminar tendon sheath (Fig. 1). The anterior lamina
is formed by the clavicular head, which originates from
the anterior aspect of the medial two thirds of the
clavicle and extends to the lateral humerus insertion
blending with the deltoid insertion. The larger sternal
head forms the middle lamina, which comes to lie
immediately deep to the clavicular head. The sternal
head fibers originate from the anterior manubrium and
sternal body with fibers also coming from the upper
costal cartilages. The abdominal head makes up the

1
Department of Radiology, Cambridge University Hospitals NHS
Trust, Cambridge, United Kingdom; 2MRI, Northern California
Division, Radnet, Inc., San Francisco, California; 3Department of
Radiology, Leeds Teaching Hospitals, Chapel Allerton Hospital,
Leeds, United Kingdom.
Address for correspondence and reprint requests: Philip Robinson,
M.B.Ch.B., Department of Radiology, Leeds Teaching Hospitals,
Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA UK
122
(e-mail: P.Robinson@leedsth.nhs.uk).
Imaging of Muscle; Guest Editor, David A. Connell, F.R.A.C.R.,
F.F.S.E.M.(UK).
Semin Musculoskelet Radiol 2010;14:122–130. Copyright # 2010
Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY
10001, USA. Tel: + 1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0030-1253156.
ISSN 1089-7860.
 MUSCLE INJURY OF THE CHEST WALL AND UPPER EXTREMITY/HOPPER ET AL
Figure 1 Normal pectoralis major anatomy. (A) Drawing
of pectoralis major shows clavicular (C), sternal (S), and
abdominal (A) heads converging to form trilaminar tendon
(asterisk). (B) Longitudinal extended field of view sonogram
shows normal abdominal head of pectoralis major (asterisks).
Arrows denote origin from fifth and sixth ribs and intervening
fascia.
posterior lamina receiving fibers from the fascia of
external oblique and transversus abdominus as well as
taking slips from the costal cartilages of the fifth and
sixth ribs (Fig. 1B).
There is a 90-degree twist to the tendons so that
uppermost fibers insert more caudally onto the humerus
with the abdominal head inserting cranially onto the
humeral shaft where it blends with the biceps tendon
fascial sheath.
Nerve supply is via branches of the lateral and
medial anterior thoracic nerves (C5, 6, 7, and T1), which
penetrate the midportion of the sternal head.
The main function of pectoralis major is in
adduction, flexion, and internal rotation of the arm
when the thoracic cage is fixed. The clavicular head
assists in arm flexion, and the sternal fibers extend the
arm against resistance. When the shoulders are elevated
and fixed, the muscle acts as an accessory muscle of
respiration.
Injury to the Pectoralis Major Muscle
Tears to the pectoralis muscle have been reported
following a direct blow,3 but typically injuries occur
123
indirectly during eccentric muscular contraction.4,5
High-grade injury occurs predominantly in male athletes
participating in weight lifting, waterskiing, and contact
sports such as American football, rugby, or wrestling6
where the muscle under full tension is subjected to
additional stresses. The most often cited mechanism of
injury is in weightlifters performing the bench-press
maneuver.7 Nonsports injuries have been reported; in
this group the most common mechanism of injury was
forced abduction with extension and/or external rotation
during a fall or while lifting.8 Interestingly, tears due to
nonsports injuries, both complete and partial, predom-
inate at the myotendinous junction. In comparison, most
sports-related complete tears occur at the enthesis,
whereas partial tears in this group of patients typically
involve the myotendinous junction.9,10 It should be
considered that most mild strains and partial tears likely
go unreported.11 Tears of the muscle belly, in contrast,
are most commonly seen associated with direct trauma
from crush injuries and road traffic accidents.12
Clinically, patients describe a sudden pain in the
arm or shoulder that may be accompanied by an audible
pop and is generally followed by swelling and ecchymo-
sis. It may be possible to palpate a defect, and on
inspection loss of the anterior axillary fold and/or asym-
metry on comparison with the other side may be clini-
cally apparent.
Loss of strength in adduction is often subtle but
becomes important in athletes such as weight lifters. The
cosmetic abnormality may also be of consequence, for
example in body builders, and may influence manage-
ment decisions.
Differentiation between injury to the musculo-
tendinous junction and avulsion at the humeral attach-
ment has a significant bearing on management, with
the former generally responding well to conservative
measures, humeral avulsion typically requiring surgical
repair.6,8,9,11 Acutely, clinical assessment is hampered by
muscle spasm and hematoma, and so accurate diagnostic
imaging is essential. A significant proportion of patients
are initially misdiagnosed or present late, a consideration
when interpreting imaging findings.
Tears are described by location (i.e., at the origin,
muscle belly, musculotendinous junction, or insertion).
Grading, as in other muscle groups, can be divided into
grades 1 to 3; however, subdividing pectoralis major
injuries into complete or incomplete in relation to the
clavicular and sternal heads is generally of more clinical
use in this instance.
Imaging
In the acute presentation, plain radiographic assessment
is usually warranted. Soft tissue swelling and absence of
the pectoralis major shadow are the classic findings. A
bone fragment may be appreciated at the humerus in the
124 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2 2010

Figure 2 Subacute tear of the pectoralis major sternal head myotendinous junction following forced abduction and external
rotation caused by falling into a manhole. (A) Extended field of view sonogram shows complete tear with retraction of the
sternal head muscle belly, which has fatty infiltration (P). Linear echogenic structure (arrowheads) extending from retracted
muscle belly to humerus (H) did not contract on dynamic scanning and represents scar tissue. Chronic hematoma is seen deep
to scar and deltoid (D). (B) Axial T1 image at same level as (A) shows retracted sternal head (P) with fatty infiltration. Chronic
hematoma deep to deltoid (D) is more difficult to appreciate than on the corresponding ultrasound image, but scar tissue is seen
(arrowheads).

case of humeral avulsion of the pectoralis insertion.
However, ultrasound (US) and magnetic resonance
(MR) imaging are the modalities of choice providing
full evaluation of the muscle and surrounding structures
and allowing informed management decisions.
High-resolution US interrogation of pectoralis
major injury is not well reported in the literature, but
in experienced hands it has been shown to provide rapid
targeted assessment of the pectoralis major as well as
surrounding anatomical structures.8,13 Sonographic eval-
uation has been shown to correlate well both with MR
imaging (Fig. 2) and with operative findings.8,13
Static and dynamic evaluation is advocated with
interrogation of the pectoralis muscles with the arm
abducted and in an externally rotated position).8 This
provides stress to the musculotendinous junction, a
common site of injury. Extended field of view images
are useful in demonstrating surrounding anatomy, par-
ticularly when reviewing cases with the clinical team.
Dynamic evaluation allows interrogation of muscle-ten-
don unit integrity. A systematic approach will provide
identification of the three heads of pectoralis major,
which blend laterally before inserting onto the humerus.
US has been shown to effectively demonstrate
acute partial and complete tears at the enthesis, muscu-
lotendinous junction, and origin of pectoralis major,
including injury to the investing aponeurosis.8With
acute presentation of a tear, hematoma and perifascial
fluid can be appreciated. In higher-grade injuries, fiber
separation and retraction will be evident; care should be
taken not to misinterpret echogenic hematoma and
debris at the tear site for muscle continuity. Gentle
dynamic evaluation is essential when there is doubt
(Fig. 3). In more chronic cases, scar tissue and adhesion
formation can be identified. Muscle fibers may be
retracted and the muscle itself may have undergone
atrophic change with decreased muscle bulk and fatty
infiltration (Fig. 2A).
MRI is considered to be the gold standard, and
imaging of the pectoralis major is well described in the
literature.9,10,14 MR allows accurate assessment of the
site and severity of pectoral injury, helping to identify
those patients who will benefit most from surgical
intervention. This is important because clinical evalua-
tion alone has been shown to overestimate injury
severity.15 MR imaging also allows assessment of bony
structures not well demonstrated at US. Reports show
that MR findings correlate well with operative findings.
Due to its position within the chest, respiratory
artifact can be problematic when imaging the pectoralis
major. Patients should be encouraged to breathe gently
and, if possible, use diaphragmatic excursions to mini-
mize chest wall movement. Some authors advocate the
use of an oblique coronal sequence along the long axis of
the pectoralis major tendon and report this as the most
useful in grading a tear.9 Other authors report the
usefulness of the axial plane, recommending T2-
weighted sequences in an acute and subacute presenta-
tion to show a hematoma and hemorrhage with more
reliance. In chronic cases they recommend T1 axial
images to demonstrate scarring and atrophy14 (Fig. 2B).
Hematoma and edema are seen in cases of acute
injury. When the distal tendon is avulsed, periosteal
stripping at the insertion may be noted, and this finding
has been confirmed at surgery. A variable degree of
tendon retraction may be appreciated.9 Chronic tears
demonstrate scarring and fibrotic change, and atrophy
should be commented on (Figs. 2B, 4). MR imaging
Figure 3 Patient with acute complete tear of pectoralis
major sternal head from abduction and external rotation
injury. Longitudinal extended field of view sonogram taken
in active contraction shows retraction of the sternal head (P).
Hyperechoic but intact tendon (arrowheads) is seen distally
attaching to the humerus (H) deep to deltoid (D).Fluid and
isoechoic hematoma (double-headed arrow) fill the tear at the
myotendinous junction.
 MUSCLE INJURY OF THE CHEST WALL AND UPPER EXTREMITY/HOPPER ET AL
Figure 4 Coronal oblique T1 magnetic resonance image in
abducted and externally rotated position shows chronic
complete tear of the pectoralis major sternal head with
muscle retraction and fibrotic scarring (arrow). There is fatty
infiltration of sternal muscle belly (arrowheads). Clavicular
head (C) is intact.
may be used to monitor healing and hematoma resolu-
tion and in the case of athletes provides guidance on
when to return to sports.
Management
Early surgical intervention is recommended in patients
with complete pectoralis major tendon avulsion from the
humerus. Anatomical repair has been shown to give
excellent functional and cosmetic results with restoration
of strength and timely return to sporting activity in
athletes.4,9,11 Delayed repair of complete tears, although
reported as being more technically difficult, has been
shown to provide similar results.7 Follow-up in patients
with complete tears suggests that both acute and delayed
surgical repair is significantly more successful than con-
servative management in this group.6 Nonoperative
treatment is advocated for muscular or musculotendi-
nous tears, low-grade partial tears, and in older or more
sedentary patients in whom loss of strength may not
cause significant symptoms.6,10
CHEST WALL MUSCLE INJURY
Injuries to the other chest wall muscles are significantly
less common than those affecting the pectoralis major.
Isolated tears of the pectoralis minor can be demon-
strated with similar imaging protocols for US and for
MR as those used for evaluation of pectoralis major with
similar efficacy reported.8,16 US can be used successfully
for targeted evaluation (Fig. 5) but when symptoms are
more vague, MR imaging generally provides a better
overall assessment of this anatomically complex area.
125
Figure 5 Ultrasound image of latissimus dorsi muscle.
Arrow shows grade 2 tear with hypoechoic fluid and discon-
tinuity of muscle fibers.
SIDE STRAIN
The term side strain is used to describe injury to the
internal oblique muscle, or less commonly external
oblique, at the rib or costal cartilage insertion.17
Although an uncommon injury, there is a predilection
for certain sporting groups, particularly throwing athle-
tes such as bowlers (cricket) and javelin throwers. Tears
of the same region have been described in athletes who
undergo violent rotation such as rowers, swimmers, and
ice hockey players. The described mechanism of injury is
muscle lengthening followed by sudden eccentric con-
traction as is seen in the non-bowling arm of pace
bowlers in cricket.17,18
Clinical presentation occurs with acute pain and
tenderness over the lower four ribs costal cartilages that
can be exacerbated by resisted side flexion to the affected
side.17 There is a high proportion of recurrent injury.17
Imaging
Although the diagnosis is generally a clinical one,
imaging can assist in evaluation of injury severity to
help guide rehabilitation. Sonographic assessment of
side strain will show loss of normal architecture and a
hypoechoic gap at the insertion of internal oblique onto
the costal cartilage and rib (Fig. 6). Hematoma can be
seen at the injury site, and fluid may be traced between
the muscle layers. Associated bone injury is typically
better evaluated at MRI, but bone avulsion can be seen.18
US becomes less sensitive when the injury is not acute
and/or the muscle tear is small.18
MR imaging is complicated by respiration
movement artifact but has been shown to be of use in
injury assessment. Positive findings include hematoma at
the injury site, periosteal stripping has been demon-
strated,17 and chronic stress injury to the underlying rib
may be seen (Fig. 7). MR is especially useful in the
assessment of concomitant injury to the external oblique
muscle acutely,19 and more long term it can be used in
follow-up of patients who fail to respond to conserva-
tive measures.
126 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2
Figure 6 Sonogram of the chest wall of a rugby league
player following an acute twisting injury. Focal hypoecho-
genicity is seen at the site of the internal oblique tear (arrow).
EO, external oblique; TA, transversalis abdominus.
UPPER LIMB MUSCLE INJURY
Injuries to the upper extremity muscle units typically
involve the musculotendinous junction in younger, more
athletic patients and the tendon at its osseous insertion
in the elderly (Fig. 8). In any age group, muscle belly
injuries are rare. In contrast to tendon injuries, which are
increasingly seen in conjunction with anabolic steroid
use and with various disease processes such as hyper-
parathyroidism,20 there does not appear to be such a link
with muscle belly rupture.21
Figure 7 T2-weighted fat-suppressed coronal oblique im-
age of the chest wall in an elite cricketer with side strain.
White arrows denote the tear in internal oblique (IO) between
transversalis abdominis (TA) and external oblique (EO). The
adjacent rib is hypertrophied due to chronic stress (arrow-
head); compare with normal rib (asterisk).
2010
Pain on muscle activation and localized tender-
ness are usually evident with acute presentation. In
higher-grade tears, deformity is typically apparent and
is exacerbated by attempted muscle activation; a mass
may be palpable. Clinical evaluation may be sufficient,
but when there is doubt as to the underlying diagnosis or
extent of injury, evaluation with MR imaging or US has
been shown to provide valuable additional informa-
tion.22–24 Care must be taken to correctly diagnose
muscle belly tears. The rarity of such injury in the upper
extremity may predispose to misdiagnosis as more sinis-
ter pathology such as malignancy.24
Most muscle belly injuries occur due to indirect
trauma, but they should also be considered following
direct trauma, particularly upper limb laceration where
there is a significant incidence of injury to multiple
structures including adjacent neurovascular bundles.
The deep extent of injury due to laceration in the upper
limb is often initially underestimated.25 More unusual
mechanisms of injury to muscle fibers include joint
dislocation; again the muscle disruption may not be
appreciated at presentation because clinical evaluation
is complicated by associated injury (Fig. 9). Muscle
contusion is typically seen following a significant direct
blow; however, in patients with an underlying bleeding
disorder, seemingly insignificant trauma can result in
extensive intramuscular hemorrhage with risk of com-
partment syndrome (Fig. 10). Focal myonecrosis may
Figure 8 Sagittal proton-density fat-suppressed image
shows typical triceps tendon tear at the distal insertion.
White arrow shows proximal stump, which has increased
signal compared with more normal adjacent tendon. Fluid is
shown at the tear (asterisk).
 MUSCLE INJURY OF THE CHEST WALL AND UPPER EXTREMITY/HOPPER ET AL
Figure 9 Postreduction sagittal T2-weighted fat-sup-
pressed image in an American football player whose elbow
was dislocated during a game. There is a high-grade tear of
brachialis, and hematoma formation is evident (white ar-
rows). Biceps tendon (black arrow), median nerve (arrow-
heads), ulnar (U), trochlea (T).
have a similar appearance to an intramuscular hematoma
but should be considered, particularly with a history of a
penetrating wound such as an injection or stab injury
(Fig. 11).
The largest series of indirect muscle injury of the
biceps brachii is reported in military static line para-
chuting. Problems with the line during the jump may
cause violent forced arm abduction. In this group of
patients, early anatomical operative repair is advocated
with good functional and cosmetic results. Associated
symptoms from the musculocutaneous nerve has been
described following biceps brachii tears, perhaps not
surprising considering the close proximity of the nerve
to the deep aspect of the biceps brachii muscle26
(Figs. 12 and 13).
Figure 10 Patient with hemophilia. Ultrasound images of hemorrhage into biceps brachii caused by inflation of a blood
pressure cuff. (A) Transverse, (B) longitudinal extended field of view arrowheads denote focal hypoechoic hematoma. Note the
entire muscle is swollen and hyperechoic with loss of normal fascicular architecture.
127
Figure 11 Longitudinal extended field of view sonogram
shows focal hypoechoic focus (asterisk) surrounded by dif-
fuse increased echogenicity (arrowheads) representing myo-
necrosis and muscle edema, respectively, within deltoid
following intramuscular anabolic steroid injection. Note nor-
mal adjacent triceps brachii (T).
To our knowledge there are no other large series
of specific upper extremity muscle tears. Individual case
reports in the literature describe complete and partial
ruptures of a variety of muscles. Triceps brachii muscle
tears have been reported secondary to direct trauma and
to forced elbow flexion in triceps contraction.27,28 From
this small number of cases it seems that nonoperative
management is effective in individuals who do not
require significant endurance strength in elbow exten-
sion.28
Isolated rupture of other muscles, such as infra-
spinatus, subscapularis, brachialis, and supinator, have
been reported in athletes and the general popula-
tion.22,29–31 It may be that minor strains and tears simply
go unreported or unrecognized.
Imaging
US and MR imaging have been used to diagnose and
grade upper limb muscle belly injury successfully,24,29
although false-negative imaging studies have been re-
ported.21
US demonstrates the expected findings, de-
pendent on the time since injury. Muscle contusion
is acutely hyperechoic and characteristically crosses
fascial boundaries (Fig. 10). Low-grade injuries may
be normal on US with positive findings including
perifascial fluid and focal or generalized hyperecho-
genicity. As severity of injury increases, so does the
US abnormality. However, by 48 hours postinjury,
128 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2
Figure 12 Complete rupture long head biceps brachii. T2
fat-suppressed coronal image shows hematoma surrounding
the tear (black arrow). Tendon (white arrow) is ruptured
proximally. B, biceps brachii muscle belly; D, deltoid.
hematoma becomes isoechoic with surrounding
muscle, making assessment more difficult. Complete
tears show discontinuity of muscle fibers; the proximal
and distal stumps can frequently be appreciated
(Fig. 14). US can also be used successfully to follow
up tears, ensuring complete healing and evaluating the
Figure 13 Axial T2 fat-suppressed image of ruptured
biceps brachii muscle at the level of the distal stump (aster-
isk), which is surrounded by fluid. Note musculocutaneous
nerve deep to biceps (black arrow). Long white arrow, intact
brachialis; short white arrow, short head biceps brachii.
2010
Figure 14 Longitudinal ultrasound image of high grade
triceps muscle belly tear. Long arrow shows hematoma;
arrowheads show retracted muscle stump. Note posterior
acoustic shadowing (short arrows) deep to stump end.
development of possible complications such as scar-
ring or myositis ossificans (Figs. 15 and 16).
With respect to MRI, the use of a correctly sized
surface coil greatly enhances image quality, allowing
higher resolution targeted imaging. T2-weighted fat-
suppressed sequences show hemorrhage and edema
acutely. The appearance of the tear can vary from linear
to globular and mass-like.32 The entire muscle may be
swollen and edematous, and the appearance may be
similar to acute neuropathy or myositis, but the clinical
scenario should help differentiate. T1 images show
disruption of the normal muscle fiber architecture and,
in more chronic tears, scarring and muscle atrophy
(Fig. 17).
Management
Little is reported about the management of upper limb
muscle trauma. Some authors advocate early anatomical
operative repair for complete tears; others suggest con-
servative treatment.26 Generally nonoperative repair is
recommended for partial tears;22,24,28 however, the num-
ber of reported cases is small.
Figure 15 Extended field of view sonogram shows devel-
opment of myositis ossificans following triceps brachii injury.
Persistent intramuscular hematoma (asterisk). Arrowheads
denote sheet-like calcification within triceps with posterior
acoustic enhancement. H, humerus.
 MUSCLE INJURY OF THE CHEST WALL AND UPPER EXTREMITY/HOPPER ET AL 129

Figure 16 Myositis ossificans. (A) Radiograph shows soft tissue mass (black arrowheads) with classical peripheral
calcification (white arrowheads). (B) Longitudinal sonogram confirms calcification (arrowheads) with posterior acoustic
shadowing. (C) Sagittal T2-weighted magnetic resonance image. Note the aggressive-looking heterogeneous and edematous
mass (asterisk). Peripheral calcification is difficult to appreciate; arrowheads show extensive surrounding edema.

Figure 17 Sagittal shoulder magnetic resonance images. (A) T1 and (B) T2 fat-suppressed images show chronic dehiscence
of proximal deltoid with fibrous scar tissue (arrowheads). D, deltoid. There is also a supraspinatus tendon tear with atrophy of
the supraspinatus muscle belly (arrows).

CONCLUSION 3. Kretzler HH Jr, Richardson AB. Rupture of the pectoralis

Tendon injuries around the shoulder and involving the
upper extremity are frequently encountered. Although
muscle tears in this region and in the chest wall are rare,
an awareness of their clinical features and potential
sequelae is important. MR imaging and US can provide
accurate diagnosis and information regarding severity
and possible injury to other structures and so are helpful
in the management decision-making process.
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