**3. Indication for surgey**

Unfortunately very few studies are available in literature that scientifically demonstrate the benefits of one treatment rather than another.

> conservative treatment in some areas and in some types of injury cannot guarantee. In literature, little has been written on myorrhaphy of the skeletal muscle and almost all of the reports focus on injuries of the biceps brachii and petctoralis majors. If these two muscles are severely damaged, a major deficit in strength and the cosmetic damage is not to be underes‐ timated in the case of professional body-builders. The suture of muscle damage is in fact taken into consideration if the action of the muscle is not compensated for by other synergistic muscles or if the hematoma is so large that it compresses the main vessels and determines

> **Figure 2.** Ryan's Classification for muscle damage. The thin lines represent the muscle fibers, the thick lines represent

Surgical Treatment

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http://dx.doi.org/10.5772/56736

The timing of the intervention is not clearly defined in the literature, Kragh et al. [16] recom‐ mend to do it the day after the traumatic event because delay it causes the suffering of muscle

A complete lesion of the pectoralis major still allows a normal active mobilization of the shoulder, but will cause an important decrease in strength in adduction and internal rotation of the arm [17] so an early surgical reconstruction is indicated in athletes. In fact, with conservative treatment a significant loss of torque, measured using the isokinetic strength test, has been observed [18, 19] while following surgical treatment a significant increase in isokinetic torque of the muscle has been reported [20, 21]. In addition, the aesthetic damage caused by the gap following injury can cause the end of the career for body-builders and similar profes‐ sionals for whom the aesthetics of the muscle is essential. Conservative treatment is recom‐

ischemia of the tissue or overlying skin [15].

tissue and of the epimysium.

**4. Pectoralis major**

the fascia.

Traditionally muscle injuries are treated conservatively and surgery is frowned upon by many surgeons for this type of lesions of the musculoskeletal system. It is common belief that surgical treatment gives results similar to, or even worse than conservative treatment [9]. Therefore it is not recommended for the fear of causing damage which would lead to further complications. The presence of hematoma and a palpable gap in the muscle belly make surgical suture difficult to perform because it is often impossible to get the fascial ends to close and the muscle fibers are hard to draw back together [5].

However, animal studies have shown that surgically sutured muscle heals more quickly and more functionally. The suture in fact decreases the distance between the muscule stumps allowing a more rapid recovery [10], decreasing major defects in scarring [11], improved healing and a decrease in deep superabundant scar tissue [3].

Obviously, surgery can lead to numerous, although fortunately infrequent, complications; therefore it is a viable option only when it guarantees clear and obvious improvements for the patient or when the lesion cannot heal if treated with the conservative approach.

Generally, surgical treatment is indicated for severe muscle tears [1, 12], in grade 4 lesions on the Ryan classification [13, 14] or when over 50% of the muscle fibers are involved. Grade 1 refers to injuries of a few muscle fibers; grade 2 - injury of a moderate number of muscle fibers; grade 3 - rupture of a moderate number of fibers associated with partial lesion of the fascia; grade 4 -those that involve injury through the full thickness muscle and the fascia (Figure 2).

From the clinical point of view, a massive rupture of the muscle leads to a loss of its strength which may be acceptable in patients with a low functional demand. However, athletes or people with high functional demands need the full recovery of muscle strength which

**Figure 2.** Ryan's Classification for muscle damage. The thin lines represent the muscle fibers, the thick lines represent the fascia.

conservative treatment in some areas and in some types of injury cannot guarantee. In literature, little has been written on myorrhaphy of the skeletal muscle and almost all of the reports focus on injuries of the biceps brachii and petctoralis majors. If these two muscles are severely damaged, a major deficit in strength and the cosmetic damage is not to be underes‐ timated in the case of professional body-builders. The suture of muscle damage is in fact taken into consideration if the action of the muscle is not compensated for by other synergistic muscles or if the hematoma is so large that it compresses the main vessels and determines ischemia of the tissue or overlying skin [15].

The timing of the intervention is not clearly defined in the literature, Kragh et al. [16] recom‐ mend to do it the day after the traumatic event because delay it causes the suffering of muscle tissue and of the epimysium.
