Q: Our son is in the military and just ruptured his major chest muscle bench pressing. They made this diagnosis without even an X-ray. Should we accept the physician's assistant's opinion or insist on him seeing a real doctor and having some X-rays taken?

A: Physicians in the military are often spread thin so they do rely on an assistant to carry out the triage, a method of screening and preliminary examination. Those recruits or soldiers who have an obvious problem that doesn't require the expertise of a medical doctor are sent for treatment right away.

In the case of a ruptured pectoralis major (chest) muscle, the clinical signs are very obvious. There is usually some visible swelling and bruising when it is a recent (acute) injury.

With a chronic injury, there may be atrophy (wasting) of the muscle. In either case, with a complete rupture, the tendon and the attached muscle pull back (retracts) and bunch up. All of these clinical signs are very apparent, especially when looking at one arm compared to the other.

In some cases, an X-ray or other imaging study may be needed. The physician's assistant (PA) can order those as well. The PA is highly trained to know when a patient should see the orthopedic surgeon. You can trust his or her judgment. X-rays are often negative unless there has been a bone fracture at the same time or a piece of bone (avulsion) has pulled away with the tendon rupture.

Ultrasound imaging can show damage to the muscle and the presence of any hematomas (pockets of pooled blood). MRIs help the surgeon see exactly where the damage has occurred and if the tendon is partially or fully ruptured. The MRI also shows the current location of the tendon and how far back it has retracted from the bone.

Since the insertion of the pectoralis major tendon is so close to the biceps tendon, the MRI clears up any confusion about what is included in the damage. All of this information can help when deciding what type of treatment is best.

Reference: CDR Matthew T. Provencher, MD, MC, USN, et al. Injuries to the Pectoralis Major Muscle. In The American Journal of Sports Medicine. August 2010. Vol. 38. No. 8. Pp. 1693-1705.