Approach to Latissimus Dorsi and Teres Minor Injuries in the Baseball Pitcher

Latissimus Dorsi Tendon Rupture Repair: A Surgical Technique Video Case Report and Cadaveric Anatomic Demonstration

Isolated latissimus dorsi tendon rupture is an exceedingly rare injury with a paucity of literature available to help guide management. The anatomy of the posterior aspect of the axilla and chest wall is complex. Nonoperative treatment has been described as an acceptable form of management for these injuries. A small subset of case reports and case series also show success with latissimus dorsi repair. We show a one-incision technique for repair of a humeral-sided avulsion of the latissimus dorsi tendon.

Baseball Pitchers who Suffer Latissimus Dorsi and Teres Major Tendon Injuries Have a High Return to Play Rate After Either Operative or Nonoperative Treatment

Purpose

To provide a concise overview of the prevalence, diagnostic workup, management options, surgical techniques, and reported outcomes in the treatment of latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers.

Methods

A systematic review of studies reporting on professional baseball players who sustained LD or TM injuries was performed. Data were collected including patient presentation, injury management strategies, return-to-play (RTP) rates, time to RTP, patient-reported outcome measures, player performance after RTP, preinjury factors associated with injury, and complications.

Results

Nine studies with 159 professional baseball players with a LD or TM injury were identified. All studies (2 retrospective cohort studies with high risk of bias and 7 case series) reported shoulder pain after pitching, and magnetic resonance imaging was performed in all cases to confirm diagnosis. Twenty-three patients underwent surgical treatment, whereas 136 patients underwent nonsurgical treatment. Overall RTP rates and performance between surgical and nonsurgical groups were similar (75% to 100% vs 75% to 93%), although the largest study reported improved performance with surgery. Two studies described a surgical technique with a posterior axillary approach and endosteal button fixation of the LD tendon. All studies reported a progressive strengthening and throwing program prior to returning to sport.

Conclusion

Professional baseball players who suffer a LD or TM injury have predictable clinical presentations and imaging findings. There is a high RTP rate and performance with both surgical and nonsurgical management. The heterogeneity and low level of evidence of available literature precludes comparative conclusions between treatment approaches.

Level of Evidence

IV systematic review of Level III and IV studies.

Is workload associated with latissimus dorsi and teres major tears in professional baseball pitchers? An analysis of days of rest, innings pitched, and batters faced

BACKGROUND

Latissimus dorsi (LD) and teres major (TM) tears have become increasingly recognized injuries in professional baseball pitchers. The purpose of this study was to determine whether workload, as measured by the number of days of rest between outings, number of innings pitched, number of batters faced, and being a starting pitcher, is associated with an increased risk of sustaining an LD-TM tear in professional baseball pitchers.

METHODS

All professional baseball pitchers who sustained an LD-TM tear between 2011 and 2017 were identified using the Major League Baseball Health and Injury Tracking System. A separate player-usage data set was used to determine workload. We then compared workload variables between pitcher-games 2, 6, 12, and >12 weeks prior to a documented LD-TM tear and pitcher-games from a non-LD-TM tear control group. In a paired analysis, we compared the acute workload (2, 6, and 12 weeks) prior to injury and the injured pitchers' non-acute workload >12 weeks prior to injury.

RESULTS

A total of 224 unique LD-TM tears were documented in the Major League Baseball Health and Injury Tracking System database. In most periods, player-games with more innings pitched and more batters faced were associated with a higher incidence of subsequent LD-TM tears. The number of days of rest was not a significant predictor of an LD-TM tear in the acute workload setting, but pitchers who sustained an LD-TM injury averaged fewer days of rest over the previous ≥12 weeks than controls (P < .001). Pitchers who faced >30 batters per game showed a 1.57-fold increase in the percentage of pitchers with a subsequent LD-TM tear as compared with pitchers who faced ≤5 batters per game. Significantly more starting pitchers were in the case group that sustained LD-TM tears over multiple time points than in the control group.

CONCLUSION

Having a greater pitcher workload and being a starting pitcher were associated with an increased risk of sustaining LD-TM tears in professional baseball players. The average number of days of rest was only a risk factor for LD-TM tears over a 3-month or longer period.

Anchoring Apparatus of Long Head of the Biceps Tendon: Ultrasonographic Anatomy and Pathologic Conditions

The long head of the biceps tendon (LHBT) has been recognized as an important generator of anterior shoulder pain, causing a significant reduction in the shoulder flexion range. Various tendinous and ligamentous structures form the anchoring apparatus of the LHBT along its course to maintain its appropriate location during shoulder movements, including the coracohumeral ligament (CHL), superior glenohumeral ligament (SGHL), subscapularis (SSC) tendon and supraspinatus (SSP) tendon as well as the less recognized tendons of pectoralis major (PM), latissimus dorsi (LD) and teres major (TM). Lesions of this stabilizing apparatus may lead to an instability of the LHBT, resulting in pain at the anterior shoulder. Ultrasonography (US) has been increasingly used in the assessment of shoulder injuries, including the anchoring apparatus of the LHBT. An accurate diagnosis of these injuries is often challenging, given the complex anatomy and wide spectrum of pathologies. In this review article, US anatomy and common pathologic conditions that affect the anchoring apparatus of the LHBT are discussed, including biceps pulley lesions, adhesive capsulitis, chronic pathology of SSC and SSP tendons, tears in the PM tendon and injuries to the LD and TM. Knowledge of a normal anatomy, an appropriate scanning technique and US findings of common pathologic conditions are the keys to accurate diagnoses.