Latissimus dorsi tendon transfer for massive irreparable cuff tears: an anatomic study

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.

Muscle Injury Around the Shoulder

Acute shoulder tendon and intra-articular injuries are common and their imaging well described. However, a subset of patients present with more unusual acute shoulder muscle injury. Of these, pectoralis major muscle injuries are encountered the most often and are increasingly prevalent due to a focus on personal fitness, particularly bench-press exercises. Other muscle injuries around the shoulder are rare. This article reviews the anatomy, mechanism of injury, and the imaging findings in relation to injuries of these muscles around the shoulder. We focus on pectoralis major injury but also review proximal triceps, latissimus dorsi, teres major, and deltoid muscle injuries, providing imaging examples.

Reverse Total Shoulder Arthroplasty with Concurrent Latissimus Dorsi Tendon Transfer

PURPOSE OF REVIEW

Reverse total shoulder arthroplasty (rTSA) has emerged as an effective treatment option for patients with rotator cuff arthropathy resulting from irreparable rotator cuff tears. However, patients with combined loss of abduction and external rotation may still experience functional deficits after rTSA. One option to address this has been the latissimus dorsi tendon transfer (LDTT), or modified L'Episcopo procedure. The purpose of this review is to describe the role of LDTT with rTSA and to critically evaluate the evidence on whether a supplemental LDTT ultimately improves patient function.

RECENT FINDINGS

Patients with an intact rotator cuff demonstrated a significant increase in active external rotation following rTSA compared to those with a deficient rotator cuff following rTSA. Compared to their pre-operative baseline assessments, patients who undergo rTSA with LDTT report significant improvements in active external rotation. However, a randomized trial comparing rTSA patients with and without LDTT failed to demonstrate a significant difference in active external rotation or patient-reported outcomes between groups. Observational studies have shown that patients experience significant improvements in active range of motion and various patient-reported outcome measures following rTSA with latissimus dorsi tendon transfer. When directly comparing rTSA with LDTT to rTSA alone, the current literature fails to demonstrate a statistically significant difference in active external rotation or patient-reported outcomes at short-term follow-up. Further randomized controlled trials are required to fully understand the potential benefits of added tendon transfer in the rTSA patient population.

Anatomical study of the teres major muscle: description of an additional distal muscle slip

Background

Understanding muscle and tendon anatomy is of tremendous importance to achieve optimal surgical execution and results in tendon transfers around the shoulder. The aim of this study was to introduce and describe an additional distal muscle slip of the teres major (TM).

Methods

Sixteen fresh-frozen cadaver shoulders were dissected with the deltopectoral approach. The ventral latissimus dorsi (LD) tendon was harvested, and the shoulders were analyzed for the presence/absence of a distal teres major slip (dTMs) and its dimensions and relationship with the TM and LD tendons.

Results

The dTMs was identified in 12 shoulders (75%). It was always distal to the TM tendon and visible during the deltopectoral approach. There was a clear separation between the TM proximally and dTMs tendon distally. At the humeral insertion, both tendons had a common epimyseal sheet around the teres major and inserted continuously at the humerus. The mean width of the dTMs tendon at the insertion was 13 ± 4 mm (range, 7–22 mm). The total lengths of the dTMs tendon and LD tendon were 40 ± 7 mm (range, 25–57 mm) and 69 ± 7 mm (range, 57–79 mm), respectively (p < 0.001). The dTMs muscle showed direct adhesions in ten shoulders (83%) with the LD muscle.

Conclusions

This is the first macroscopic description of an additional distal slip of the teres major muscle. The dTMs has a separate (distal) but continuous (mediolateral) insertion at the humerus within a common epimyseal sheet around the TM. The dTMs tendon is visible during the deltopectoral approach and can therefore provide a lead structure, particularly in ventral LD transfers with the deltopectoral approach.

Long-term outcomes of latissimus dorsi transfer for irreparable rotator cuff tears

PURPOSE

The primary objective of this retrospective study was to validate electrophysiological results of latissimus dorsi tendon transfer (LDTT) to determine if this transfer is active for different daily living tasks, and the secondary objective was to correlate these clinical results.

METHODS

With a mean follow-up of 4.7 years, 14 latissimus dorsi tendon transfers were retrospectively reviewed. Patients were clinically evaluated with the constant score and the SSV. Healing of the tendon on the greater tuberosity and atrophy of the LDTT muscle was determined by ultrasound and compared with the contralateral side. Electrical activity was analyzed by electromyography in active elevation, abduction, and external rotation.

RESULTS

Twelve patients are satisfied (SSV). At the last follow-up, the EMG found a significant electrical activity in the abduction and external rotation and a lower activity in adduction and internal rotation. The mean constant score increased from 29 to 51, the mean forward elevation increased from 89° to 135°, the mean abduction from 92° to 105°, and the external rotation from 12° to 24°. The ultrasound found 12 healed tendons and two ruptures at the myotendinous junction.

CONCLUSION

Electrical activity in abduction and external rotation testifies that the LDT transfer acts as an active muscle transfer and acts not only a muscle tenodesis that covers the humeral head.

Comparing Clinical Outcomes After Subacromial Spacer Insertion Versus Other Reconstruction Methods in the Treatment of Irreparable Massive Rotator Cuff Tears

Background:

Previous studies on subacromial spacer (SAS) insertion have been limited to case series that did not compare the effectiveness of this technique with other techniques.

Hypothesis:

Outcomes after SAS insertion for the treatment of irreparable massive rotator cuff tears (IMRCTs) will be similar to those of other techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study was based on data collected from patients who underwent correction of IMRCTs between January 2010 and October 2017. Group 1 patients (n = 17) received SAS insertion with or without partial repair; group 2 patients (n = 36) were treated with other techniques (isolated partial repairs or bridging grafts). Preoperative tear size and global fatty degeneration index values were evaluated. Range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand score, and acromiohumeral distance (AHD) were assessed preoperatively and at final follow-up at least 2 years after the surgery (range, 24-60 months). In both groups, ultrasonographic examination was performed at 3 and 6 months postoperatively, and magnetic resonance imaging (MRI) was performed at 1 year.

Results:

Tear size and preoperative global fatty degeneration index were not significantly different between the groups (all P > .05). There were no differences in functional scores between the groups at final follow-up (all P > .05). AHD was maintained at final follow-up in group 1 (mean ± SD: 6.2 ± 2.1 mm [postoperatively] vs 6.7 ± 2.3 mm [final follow-up]; P = .678), and there was no difference compared with group 2 (7.2 ± 3.2 mm; P = .244). Patients with retears in group 2 (23 of 36, 63.9%) had lower ASES (P = .041) and SST (P = .027) scores at final follow-up when compared with patients in group 1. Six patients (35.3%) in group 1 had partial repairs; these patients had better external rotation at 90° (P = .047), better SST scores (P = .036), and higher AHDs at final follow-up (P = .046) than those in group 1 who had no repair. Three patients (50%) showed retears of partially repaired tendons on MRI. Of 13 patients (76.5%) in group 1 with postoperative MRI, 12 (92.3%) showed fibrotic tissue in the subacromial space not seen preoperatively.

Conclusion:

There was no difference in outcomes between SAS and the other reconstruction methods for treating IMRCTs. However, given the high retear rate associated with other techniques and poor functional outcomes after retear, SAS insertion could be a viable option for treating IMRCTs.

Variants of latissimus dorsi with a perspective on tendon transfer surgery: an anatomic study

BACKGROUND

The latissimus dorsi (LD) is often used for tendon transfers to treat massive irreparable posterosuperior rotator cuff tears. The operation requires the LD tendon to be mobilized to reduce tension on the tendon. In that respect, any connection between the LD tendon and contiguous muscles may hamper tendon mobility and affect the surgical outcome. The goal of this study was to document the occurrence of connections between the LD and adjacent muscles and nerves.

METHODS

We studied the scapular region on 48 embalmed cadavers. The skin and superficial fascia were removed according to Cunningham's manual of dissection, and the muscle was exposed.

RESULTS

It was found that the LD and teres major (TM) muscles are connected by muscle fibers in 10% of the cadavers studied. Another vital discovery was that in some cadavers, the LD tendon was penetrated by a nerve.

CONCLUSION

Fascial connections between the LD and TM are well known, but these muscle links are comparatively unusual. From the results of this study, one should pay particular attention to muscle links between the LD and TM during dissection of the LD for transfer. It can also be suggested that during transfer surgery, the LD tendon should be cautiously examined for the possibility of a nerve penetrating it.

Performance and return to sport in elite baseball players and recreational athletes following repair of the latissimus dorsi and teres major

BACKGROUND

Tears of the latissimus dorsi (LD) and teres major (TM) are rare but disabling injuries in the overhead athlete.

METHODS

All patients who underwent an LD and/or TM repair between January 1, 2010, and June 6, 2016, with more than 12 months' follow-up were included. Demographic information and postoperative range of motion were recorded. Patients were contacted via phone and answered questions to provide the following: Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow outcome score, American Shoulder and Elbow Surgeons (ASES) shoulder score, and visual analog scale (VAS) score. Performance data for professional athletes were recorded preoperatively and postoperatively and compared by paired t tests.

RESULTS

Eleven male patients aged 29.9 ± 12.4 years were included; 86% were right hand dominant, 86% underwent surgery on the dominant side, and 73% were pitchers (7 professional and 1 collegiate). The mean time from injury to repair was 389 ± 789 days; 36% of repairs were performed within 6 weeks of injury. At final follow-up, the VAS score was 0.7 ± 1.9, the ASES score was 100 ± 0, and the KJOC score was 93 ± 5. Professional (major and minor league) pitchers had a mean total time participating in professional baseball of 6.6 ± 3.9 years, with 3.9 ± 2.3 years before surgery and 2.7 ± 1.8 years after surgery. Among professional pitchers, the VAS pain score was 0.0 ± 0.0, the ASES score was 100 ± 0, and the KJOC score was 89 ± 2. All professional pitchers returned to the same level of play. No significant differences existed between any preoperative and postoperative performance metrics for pitchers (P > .05).

CONCLUSION

Repair of LD and TM tears in both professional and recreational athletes produces reliable functional recovery with minimal pain and the ability to return to preoperative athletic activity, even among elite throwing athletes.

Sports Injuries to the Latissimus Dorsi and Teres Major

Injuries to the latissimus dorsi and teres major muscles, while rare, are debilitating. They are seen in a variety of sports, although disproportionately in the throwing shoulder of baseball pitchers. There have been 25 case reports and 2 case series published on the nonoperative and operative management of these injuries. Latissimus dorsi and teres major muscle anatomy, function, and common injury patterns are well described in these case reports. Also well detailed are the typical patient presentation, physical examination, and imaging findings. Latissimus dorsi tendon injuries are sometimes treated operatively, whereas latissimus dorsi muscle belly or isolated teres major injuries are treated nonoperatively. Nonoperative treatment includes oral anti-inflammatories and shoulder physical therapy. A number of surgical patient positions, approaches, and fixation constructs have been described, although 2 techniques of positioning and surgical approach are used most commonly. Fixation is most often performed with suture anchors. Return-to-play timing, shoulder strength, and healing on magnetic resonance imaging are variable. No standard of care currently exists for the treatment of latissimus dorsi or teres major injuries. If treating a patient with an injury to either muscle, the clinician should be familiar with accumulated experience as reported in the published literature.

Teres major muscle - insertion footprint

Teres major muscle (TM) and latissimus dorsi muscle (LD) are frequently used in muscle transfers around the shoulder girdle. Some authors have suggested harvesting techniques in which the muscle is detached in continuity with a bone segment. Information on the bony attachment footprint of these muscles is lacking. The purpose of this study was to investigate the region of attachment of the TM to facilitate safe and complete harvesting with a bone segment where it is indicated, and to determine the relationship of the TM footprint with that of the LD. Twenty-eight upper extremities of 14 human cadavers (six female, eight male) were investigated during the students' dissection course in the winter term 2012. The attachment footprints were photographed and the images were processed with ImageJ Version 1.46r. The TM attachment footprint at the crest of the lesser tubercle had an average dimension of 187 ± 89 mm2 . It was 49.6 ± 7.9 mm long and 7.4 ± 2.5 mm wide. The bony attachment of the LD within the bicipital groove, just below the tendon of the long head of the biceps muscle, had an area of 94 ± 37 mm2 . It was 36.5 ± 8 mm long and 3.7 ± 1.2 mm wide. Both muscles were separated by 4.4 ± 1.7 mm and their attachments overlapped in the craniocaudal direction by 24.4 ± 12.4 mm. Earlier studies have investigated the dimensions of the muscles' tendons close to the attachment not the bony attachment itself. The dimension of the attachment of the TM was larger than that of the LD. The ratio between the footprint areas was approximately 2:1. This information should be considered by surgeons undertaking transfers, which include a bony segment of the muscle insertion.

Recovery of active external rotation and elevation in young active men with irreparable posterosuperior rotator cuff tear using arthroscopically assisted latissimus dorsi transfer

BACKGROUND

Massive irreparable posterosuperior rotator cuff tears represent a serious functional disablement for young and active patients in their daily activities. Latissimus dorsi (LD) muscle-tendon transfer can restore elevation and external rotation where supraspinatus and infraspinatus function is lost.

MATERIALS AND METHODS

Between 2009 and 2013, 45 consecutive patients underwent arthroscopically assisted LD transfer for an irreparable posterosuperior rotator cuff tear. Thirty-three patients agreed to participate in this retrospective study. For 8 patients, we used a standard passage of the LD through the plane between the infraspinatus-teres minor and the deltoid muscles. For the remaining 25 patients, we transferred the LD tendon in front of the triceps muscle according to a personal described technique. The follow-up period was 35.7 months. Final follow-up included assessment by standard radiographs, bipolar surface electromyography, pain score by visual analog scale, Constant-Murley shoulder score, and Disabilities of the Arm, Shoulder, and Hand score. For quantitative strength evaluation measurements, a Biodex dynamometer was used.

RESULTS

Overall clinical outcomes improved at the final follow-up and were significantly age related. We found similar results for revision and primary patients with mean increase in Constant-Murley scores of 29.5 and 30.5 points, respectively. In our series, we recorded osteoarthritis progression in 33.3% of patients.

CONCLUSION

Arthroscopic LD tendon transfer for irreparable posterosuperior rotator cuff tears can achieve good clinical outcomes at a midterm follow-up, especially in active men 60 years of age or younger and in patients with low preoperative elevation (<80°) but an intact or reparable subscapularis tendon.

Imaging Injuries in Throwing Sports Beyond the Typical Shoulder and Elbow Pathologies

This review article describes injuries that occur in the upper extremities of athletes less commonly than those typically discussed with shoulders and elbows. A survey of osseous, musculotendinous, ligamentous, and neurovascular injuries is presented along with associated imaging findings and standard treatment options. This article does not focus on the classic throwing injuries of the shoulder or elbow; the goal is to survey injuries in throwing sports that involve structures away from the glenohumeral, acromioclavicular, or elbow joints. The goal of this article is to introduce readers to these less common injuries, describe their clinical presentations, and characterize their typical imaging appearances.

Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Preoperative Factors Associated With Outcome Deterioration Over 2 Years

BACKGROUND

Arthroscopic partial repair is a treatment option in irreparable large-to-massive rotator cuff tears without arthritic changes. However, there are indications that arthroscopic partial repair does not yield satisfactory outcomes.

PURPOSE

To report the clinical and radiographic results of arthroscopic partial repairs in patients with irreparable large-to-massive cuff tears. In addition, an analysis was performed regarding preoperative factors that may influence patient outcomes and patient-rated satisfaction over time.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 2005 to 2011, a total of 31 patients who underwent arthroscopic partial repair for irreparable large-to-massive cuff tears were retrospectively evaluated. Partial repair was defined as posterior cuff tissue repair with or without subscapularis tendon repair to restore the transverse force couple of the cuff. Pain visual analog scale (PVAS), questionnaire results (American Shoulder and Elbow Surgeons [ASES] and Simple Shoulder Test [SST]), and radiographic changes (acromiohumeral distance and degenerative change) were assessed preoperatively, at first follow-up (roughly 1 year postoperatively), and at final follow-up (>2 years postoperatively). Patients rated their satisfaction level at each postoperative follow-up as well. Preoperative factors that might influence outcomes, such as patient demographics, tear size, and fatty infiltration, were investigated.

RESULTS

The preoperative, first follow-up, and final follow-up results for mean PVAS (5.13, 2.13, and 3.16, respectively) and questionnaires (ASES: 41.97, 76.37, and 73.78; SST: 3.61, 6.33, and 6.07, respectively) improved significantly (all P < .05). Radiographic evaluation showed no difference compared with preoperative status. Nevertheless, patient-rated satisfaction at final evaluation was inferior: 16 good responses ("very satisfied" and "satisfied") and 15 poor responses ("rather the same" and "dissatisfied"). Despite initial improvements in both groups (P < .05), patients with poor satisfaction demonstrated statistically significant deterioration in mean PVAS (from 2.07 to 4.67), questionnaire scores (ASES: from 74.56 to 59.80; SST: from 5.11 to 3.81), and acromiohumeral distance (from 7.19 to 5.06 mm) between the first and final follow-up (all P < .05). Patients with good satisfaction showed no significant difference or they improved (P > .05) from the first to the final follow-up. Among preoperative factors, fatty infiltration of the teres minor was identified as the only statistically significant factor affecting patient-rated satisfaction (P = .007).

CONCLUSION

This study showed that arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up. However, about half of the patients in the study were not satisfied with their outcomes, which had deteriorated over time. Preoperative fatty infiltration of the teres minor was the only factor that correlated with worse final outcomes and poor satisfaction after arthroscopic partial repair.

Latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: surgical technique

Massive rotator cuff tears remain a complex and challenging problem for both the patient and the surgeon. Although significant advancements in surgical techniques as well as technology for arthroscopic and mini-open rotator cuff repairs have been made, many massive tears result in failed repair with continued progressive tendon retraction and degeneration. In cases when primary tendon to bone healing is impractical, latissimus dorsi tendon transfer provides promising and reproducible clinical results. Herein, we present a latissimus tendon transfer surgical technique, a procedure we have used as a salvage operation for failed arthroscopic/mini-open primary rotator cuff repair.

Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: an anatomic study

BACKGROUND

Several tendon transfers have been described to reconstruct irreparable subscapularis (SS) tears, but their outcomes are variable and unsatisfactory in the presence of anterior glenohumeral subluxation. We evaluated the anatomic feasibility of the latissimus dorsi (LD) or teres major (TM) muscle tendon transfer to reconstruct an irreparable SS tendon tear.

MATERIALS AND METHODS

The dimensions of the LD and TM tendons and the distance between their insertion and the SS tendon insertion were determined In 20 cadaveric shoulders. Feasibility of the isolated LD and TM tendon transfer to 3 locations on the SS tendon insertion, transfer of the LD to the proximal half, TM to the lower half of the SS tendon, and combined transfer of the LD/TM tendon to the central aspect of the SS tendon was assessed.

RESULTS

The LD and TM were an average length of 5.9 cm and 2.3 cm and an average width of 2.2 cm and 2.4 cm, respectively. The mean distances from the center of the LD and TM tendons insertion to the central aspect of the SS tendon insertion was 4.0 cm and 4.7 cm, respectively. All of the tendon transfers were feasible, and the risk of nerve compression was low, except for the combined tendon LD/TM transfer to the proximal third of the SS tendon.

CONCLUSIONS

This study shows that transfer of the LD/TM to the lesser tuberosity to reconstruct an irreparable SS tear is feasible, with a low risk of nerve compression, with the exception of the combined LD/TM and more proximal TM tendon transfers.

Latissimus dorsi tendon transfer for irreparable tears of the rotator cuff: An anatomical study to assess the neurovascular hazards and ways of improving tendon excursion

Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon.

Sonography and MRI of latissimus dorsi strain injury in four elite athletes

OBJECTIVE

The objective of this study was to describe the MR and sonographic findings in latissimus dorsi (LD) muscle strain in athletes, and to review the most common injuries described in the literature, most of which are humeral avulsions.

MATERIAL AND METHODS

Four injuries and two reinjuries of the myotendinous junction of the LD were followed from the day of injury until the return to play. Sonography (US) and MR imaging were performed in each case to confirm the diagnosis and to monitor the healing process.

RESULTS

All cases had acute and isolated pain in the back of the shoulder while performing an eccentric maneuver of the arm and the shoulder. US and MR images demonstrated that injuries were located in the middle and cranial portion of the latissimus dorsi surrounding the myotendinous junction. After rehabilitation, all players played at high level again.

CONCLUSIONS

Isolated lesions of LD are very rare. They can be demonstrated by US and MR images.

Isolated rupture of the teres major tendon

Acute isolated rupture of the teres major is an uncommon injury. This article presents the first report of midterm subjective and objective functional results following nonoperative management of an isolated teres major rupture. A 30-year-old right hand dominant man presented after a waterskiing traction injury to his left upper extremity. On physical examination, the patient had swelling and retraction of the teres major at the lower scapular border, which was accentuated with resisted adduction of the extremity. His teres major attachment at the humerus was not palpable. Magnetic resonance imaging revealed an isolated teres major tendon rupture. The patient was treated non-operatively with a rehabilitation protocol emphasizing rotator cuff, periscapular, and latissimus muscle strengthening. By 3 months postinjury, the patient had returned to all of his usual sporting activities, despite a persistent muscle retraction deformity over the teres major. At 3-year follow-up, the patient had no subjective complaints in the injured extremity and excellent functional outcome scores. A mean 37 kg loss of internal rotation strength (as measured by dynamometer) in the affected extremity with the arm abducted to 90° existed, although this difference was not subjectively appreciable. Although previously published reports have presented various options for the management of teres major injuries, the present case demonstrates that nonoperative treatment can produce excellent midterm subjective results in spite of objective internal rotation weakness.

Latissimus dorsi and teres major tears in professional baseball pitchers: a case series

BACKGROUND

Latissimus dorsi and teres major tendon tears are uncommon injuries. Only a few case reports exist, mainly in high-level athletes.

PURPOSE

To describe a series of latissimus dorsi and teres major tendon tears in professional baseball pitchers.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Injury data from 3 Major League Baseball clubs were collected over a total of 10 seasons. Any baseball player who sustained an injury to either the latissimus dorsi or teres major identified on magnetic resonance imaging (MRI) was included. All injured players were treated nonoperatively with a goal of returning to full velocity throwing at 3 months from the time of injury.

RESULTS

Ten players sustained injuries to the latissimus dorsi and/or the teres major during pitching. The MRI findings documented 5 isolated latissimus dorsi tears, 4 isolated teres major tears, and 1 combined injury. All athletes returned to pitching, and all but 1 player returned to baseball at the same level of competition in the same season. Nine of 10 players returned at 3 months from the time of their injury. One recurrence was seen 6 months after returning to throwing; however, this healed with further nonoperative treatment, and the player returned to competition at the same level 6 weeks later. One player had continued shoulder symptoms and retired at the end of the season.

CONCLUSION

Although uncommon, tears of the latissimus dorsi and teres major occur in professional baseball players. Acute injuries are demonstrated on standard shoulder MRI, although larger field-of-view images are required to accurately assess the injury. Most heal successfully with nonoperative treatment, and most players are able to return to the same level of competition in 3 months.