• Carrie W Hoppes, Michael D Ross, and Josef H Moore.
• Doctoral Program in Physical Therapy, US Army-Baylor University, Fort Sam Houston, Texas, USA. carrie.witherel@us.army.mil
• Phys Ther. 2013 Sep 1;93(9):1225-33.

Background And PurposeThis case report describes a patient who was referred to a physical therapist for treatment of a shoulder strain and was eventually diagnosed with a rupture of the pectoralis major tendon that required surgical repair. The purpose of this case report is to highlight the management of this injury within the unique constraints of a combat environment.Case DescriptionA 29-year-old man, currently serving as an active duty soldier in the U.S. Army in Iraq, had a sudden onset of right shoulder pain during the concentric portion of a bench press. He was seen by a physician immediately after the injury, diagnosed with a shoulder strain, and referred to a physical therapist for a sling and exercise instruction. On the basis of the history and physical examination findings, which were consistent with a pectoralis major tendon rupture, the physical therapist placed a consult to an orthopedic surgeon in the United States through teleconsultation because orthopedic surgeons were not easily accessible in Iraq for nonemergency musculoskeletal referrals. Subsequently, the orthopedic surgeon advised evacuating the patient out of Iraq for surgical treatment.OutcomesBy means of magnetic resonance imaging, the patient was diagnosed as having a rupture of the pectoralis major tendon at the musculotendinous junction near its insertion into the greater tubercle of the humerus that required surgical repair. At 3 months after surgery, the patient had full pain-free shoulder active range of motion and had progressed well through his strengthening program in a manner that allowed return to full duty. At 6 months after surgery, the patient maintained full duty status, was performing a routine of strength training 3 times per week, and had met all of his rehabilitation and personal goals.DiscussionSuccessful treatment of this patient depended on analysis of the history and physical examination findings by the physical therapist to form an accurate diagnosis. In addition, timely medical evacuation and referral to an orthopedic surgeon for surgical treatment were coordinated in a combat environment. Completion of a progressive rehabilitation program after pectoralis major tendon repair also contributed to this patient's full recovery and return to duty. Had the physical therapist only followed the initial referral request, given this patient's military duties and sports and recreational activities, this case probably would have resulted in suboptimal outcomes.

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