Open repair of an acute latissimus tendon avulsion in a Major League Baseball pitcher

Early surgical repair of combined latissimus dorsi and teres major avulsion

A combined avulsion of both the latissimus dorsi muscle and teres major muscle is a rare occurrence and data focused on the treatment of this type of injury is limited to case studies and series. This case report presents the outcomes of early surgical repair for avulsions of the latissimus dorsi and teres major tendons in a high-demanding athlete. The patient underwent surgical repair using a single incision technique and endosteal button fixation of the avulsed tendons. This procedure was performed within 4 weeks of the initial injury, followed by a progressive mobilisation regimen in the postoperative phase. After a period of 3 months, the patient successfully participated in his first international competition. This report describes the effectiveness of early surgical repair after latissimus dorsi and teres major tendon avulsion. The single incision technique and the use of endosteal buttons for tendon fixation yielded excellent results for a professional judoka.

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.

Teres Major and Latissimus Dorsi Repair With Biceps Tenodesis Utilizing Cortical Suspensory Fixation Buttons

Teres major (TM) and latissimus dorsi (LD) ruptures are relatively rare in the general population and have primarily been observed in overhead throwing athletes. Although the gold standard of care has traditionally been nonoperative, surgical repair of TM and LD tendon ruptures has become increasingly prevalent in high-level athletes who fail to return to play. Literature is scarce regarding operative repair of these tendon ruptures. Therefore, our goal is to present a potential technique for open repair to surgeons who may be faced with this unique orthopedic injury. Our technique details an open TM and LD repair, in addition to biceps tenodesis, using cortical suspensory fixation buttons with a combined anterior and posterior approach.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis

Background

The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players.

Purpose

To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary.

Results

Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar.

Conclusion

RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

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.

Simultaneous Bilateral Latissimus Dorsi Tendon Ruptures: A Case Report

CASE

We report a case of a 55-year-old man who sustained bilateral, complete latissimus dorsi tendon ruptures during a water-skiing accident. Physical examination and magnetic resonance imaging confirmed the patient's diagnosis but also revealed a tear of the teres major on the left side. Staged primary repair was performed on each side, with a 6-week interval between procedures. At 1-year follow-up, the patient had an excellent clinical outcome.

CONCLUSION

Staged surgical repair of bilateral latissimus dorsi tendon ruptures can be performed, leading to excellent clinical and functional outcomes for patients.

Differences in shear elastic modulus of the latissimus dorsi muscle during stretching among varied trunk positions

The latissimus dorsi (LD) can be divided into the upper, middle, and lower parts, but the effective stretching positions for each part are unknown. In this study, we aimed to investigate effective trunk positions for stretching of the LD. A total of 14 healthy males participated in this study. The following seven trunk positions were chosen as the LD stretching positions; upright of the trunk (Baseline), flexion of the trunk (Flex), contralateral bending of the trunk (LB), contralateral rotation of the trunk (Rot), flexion and contralateral bending of the trunk (Flex + LB), flexion and contralateral rotation of the trunk (Flex + Rot), and contralateral bending and contralateral rotation of the trunk (LB + Rot). Maximal elevation of the upper limb was passively added to all positions. The shear elastic modulus, used as the index of muscle elongation, was measured at the four parts (upper, middle, lower, distal parts) of the LD. The shear elastic moduli showed obviously high values in Rot and LB + Rot at the upper, middle, and distal parts, and also in LB, Rot, and LB + Rot at the lower part. These findings suggest that contralateral trunk rotation, or a combination of contralateral trunk bending and rotation are effective trunk positions for stretching all parts of the LD. Contralateral trunk bending was also effective for stretching the lower part of the LD.

[Rupture of the pectoralis major tendon and other extra-articular tendons of the shoulder : Recognition and treatment]

Ruptures of the pectoralis major (PM) tendon are rare but have increased in recent years, especially during fitness exercising, such as bench pressing. The pathomechanism is an eccentric load under pretension of the PM (falling onto the outstretched arm, injuries during ground combat, boxing and during downward movement when bench pressing). The rupture sequence starts from superior to inferior at the insertion site with initial rupture of the most inferior muscle parts, followed by the sternal part and the clavicular part. Most classifications are based on rupture location, extent and time of injury. In addition to clinical presentation and sonography, magnetic resonance imaging is now established as the gold standard in diagnosing PM pathologies. Surgical management is indicated for all lateral PM ruptures with relevant strength deficits. Treatment in the acute interval (<3 weeks) is the primary goal; however, even in chronic cases or after failed conservative management a secondary operative approach enables notable clinical improvement. Conservative therapy mostly affects patients who have muscular injuries close to the anatomic origin and smaller partial tears. Surgical management aims for anatomic reconstruction of the PM unit with restoration of the original tension to enable optimal strength transmission. Surgical refixation or reconstruction (with autograft/allograft) of acute and chronic PM ruptures shows excellent clinical results with high patient satisfaction. Latissimus dorsi (LD) and teres major (TM) tendon ruptures are rare injuries but can lead to significant impairments in high-performance athletes. In contrast to PM ruptures, LD and TM injuries are primarily treated conservatively with very satisfactory results.

Latissimus Dorsi Myotendinous Repair with Allograft Hamstring Tendon Graft Augmentation: A Case Report

CASE

A 30-year-old male weightlifter presented after suffering a myotendinous rupture of his latissimus dorsi from heavy weightlifting. Latissimus dorsi injuries are rare, with little to no documented technique in the literature on management, particularly of ruptures through the myotendinous junction of the anatomical muscle. This case report describes the surgical technique, approach, and postoperative management of an acutely avulsed latissimus dorsi using an allograft hamstring tendon to repair the myotendinous junction.

CONCLUSION

Allograft hamstring tendon graft augmentation is a viable repair option for patients with latissimus dorsi myotendinous rupture.

Latissimus Dorsi Tendon Repair

Latissimus dorsi tendon ruptures are less-common injuries that can occur in elite throwing athletes. Physical examination of the thrower with a latissimus injury may show ecchymosis of the upper arm and asymmetry of the posterior axillary fold along with possible weakness in shoulder adduction, extension, and internal rotation. Magnetic resonance imaging is used to confirm the diagnosis. Latissimus tendon ruptures are largely treated nonoperatively; surgical repair is only advocated for in professional throwing athletes with complete avulsion injuries or midsubstance latissimus tendon tears. Surgical repair options include the use of suture anchors, cortical suture buttons, or transosseous sutures via a single posterior axillary incision or a 2-incision technique. Given the limited literature on this topic, there have been no studies evaluating the different fixation options or surgical approaches for tendon repair. This article and accompanying video show the technique and discusses the technical pearls of a latissimus tendon repair using suture button fixation via a single-incision approach.

Performance and Return to Sport After Latissimus Dorsi and Teres Major Tears Among Professional Baseball Pitchers

BACKGROUND

Latissimus dorsi and teres major (LD/TM) tears are becoming an increasingly common cause of injury and disability among professional baseball pitchers.

PURPOSE/HYPOTHESIS

To determine performance and return to sport (RTS) among professional baseball pitchers after LD/TM tears treated operatively and nonoperatively and to compare the RTS rate and performance between pitchers who sustained an LD/TM tear and matched controls. The authors hypothesized a high RTS rate among professional baseball pitchers after LD/TM tears, with no significant difference in RTS rate or performance between cases and controls for operative and nonoperative treatment-specifically, in the primary performance outcome variables of WHIP ([walks + hits] / innings pitched), fielding independent pitching, and wins above replacement.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball pitchers who sustained an LD/TM tear between 2011 and 2016 were identified with the Health and Injury Tracking System database of Major League Baseball. Demographic and performance data (before and after injury) were recorded for each player. Performance metrics were then compared between cases and matched controls by operative and nonoperative treatment.

RESULTS

Overall, 120 pitchers had a documented LD/TM tear; 42 (35%) were major league players. Most players (n = 107, 89.2%) were treated nonoperatively. Time to return to the same level of competition was 170 ± 169 days (mean ± SD) for pitchers treated nonoperatively and 406 ± 146 days for those treated operatively. The RTS rate among players treated nonoperatively and operatively was identical at 75%. Players treated nonoperatively had no change in fielding independent pitching or wins above replacement after injury but had a higher (ie, worse) WHIP after injury ( P = .039); they also performed significantly worse in several secondary performance metrics, including number of games played per year ( P < .001). Players treated operatively had no change in any measured performance metrics after surgery. No difference existed between cases and controls in the primary performance variables.

CONCLUSION

The majority of LD/TM tears are treated nonoperatively. The RTS rate is 75% for professional baseball pitchers after LD/TM tears treated operatively or nonoperatively. Players treated nonoperatively saw a decline in several performance metrics, while players treated operatively had no significant difference in performance after surgery.

Magnetic Resonance Imaging Grading System for Tears of the Latissimus Dorsi and Teres Major

Background:

Recent awareness of latissimus dorsi/teres major (LD/TM) injuries has led to an increase in diagnoses. No magnetic resonance imaging (MRI) classification system specific to the LD/TM exists, nor has tear severity been correlated with ability to return to sport (RTS).

Purpose/Hypothesis:

The purpose of this study was to report a novel MRI classification system for LD/TM tears as well as to correlate tear grade with performance and RTS. We hypothesized that the new MRI classification system would have high intra- and interobserver reliabilities and that players with higher grade tears would require operative management.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

All patients with LD/TM tears diagnosed by MRI who were under the care of 2 orthopaedic surgeons were included. On 2 occasions 60 days apart, MRIs were reviewed and graded by 2 authors using a new classification system. Intra- and interobserver reliabilities were calculated. Timing from injury to RTS was recorded, and performance upon RTS was analyzed.

Results:

The proposed grading system had excellent intra- and interrater reliabilities (Cohen kappa >0.850). A total of 20 male patients (mean ± SD age, 26 ± 9.3 years) with LD/TM tears were included (80% were baseball pitchers). Of the 16 players treated operatively, 5 were initially treated nonoperatively by an outside physician but could not RTS (all professional baseball pitchers); 2 of these players had grade IIIA tears and 3 of the players had grade IVA tears. Regardless of initial treatment, ultimately 100% of the professional baseball players were able to RTS at a mean of 8.7 ± 3.3 months, although the initial nonoperative management failed for some of these players and they needed surgical intervention. No statistically significant differences were found between pre- versus postoperative performance in those professional players who were treated surgically.

Conclusion:

The proposed MRI-based grading system for LD/TM tears had excellent reliability. This system may allow physicians to better advise patients and all involved health care providers. Consideration should be given to acutely treat grade III and IV tears with operative repair.

Latissimus Dorsi Tendon Rupture

Isolated injury to the latissimus dorsi is rare. Partial tendon tears may be successfully treated nonsurgically. Complete tendon ruptures require surgical repair. Tendon repair can be approached either through an anterior deltopectoral incision with a secondary small posterior axillary incision or through a long posterior axillary incision. Suture anchors can be used to repair the latissimus dorsi to the humeral attachment. Although the literature is limited to single-patient case series, most patients have returned to full athletic activity after surgical repair.

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

PURPOSE OF REVIEW

Tears of the latissimus dorsi and teres major are uncommon but significant injuries, most frequently seen in high-level, overhead throwing athletes. Diagnosis can be challenging, as there are no pathognomonic signs, symptoms, or physical exam findings associated with latissimus dorsi/teres major tears, and the clinician must have a high suspicion for this injury. While many of these tears can be treated non-operatively, a subset of these benefits from surgical intervention. Rehabilitation following operative and non-operative treatments of these injuries is extensive, and timing of return to sport can be variable from 3 to 12 months.

RECENT FINDINGS

The literature surrounding latissimus dorsi/teres major injuries is sparse. Several small studies have shown good results in patients with mild to moderate tears that were treated non-operatively. Recent evidence has shown good results following operative repair of larger tears, with excellent return to sport rates. Furthermore, focused rehabilitation is imperative when treating patients with latissimus dorsi/teres major injuries to allow these athletes to return to sport. Latissimus dorsi/teres major tears are uncommon but significant injuries in the throwing athlete. Prompt diagnosis, proper treatment, and focused rehabilitation will allow these patients to return to sport in a safe and efficient manner.

Qualitative and Quantitative Anatomy of the Proximal Humerus Muscle Attachments and the Axillary Nerve: A Cadaveric Study

PURPOSE

To provide a quantitative and qualitative anatomic analysis of the pectoralis major, teres major, and latissimus dorsi on the humerus, as well as the deltoid tendinous attachments on the proximal humerus and acromion, and to quantitatively characterize the humeral course of the axillary nerve.

METHODS

Ten nonpaired, fresh-frozen human cadaveric shoulders were analyzed. A portable coordinate-measuring device quantified the location of bony landmarks and tendon attachment areas. The tendon footprints were recorded by tracing their outlines and center points. The footprint areas of the tendons, the distances between the footprint areas and pertinent osseous and soft-tissue landmarks, and the distance between where the axillary nerve courses across the humerus relative to the acromion and greater tuberosity were measured.

RESULTS

Of the 10 specimens, 9 (90%) had 5 distinct tendinous bands attaching the deltoid to the acromion; 1 specimen had 4 bands. The distances between the center of the deltoid footprint on the humerus and the centers of the pectoralis major, latissimus dorsi, and teres major tendon footprints on the humerus were 43.5 mm, 58.5 mm, and 49.4 mm, respectively. The shortest distances from the perimeter of the pectoralis major to the latissimus dorsi and teres major tendon footprints were 3.9 mm and 9.5 mm, respectively. The distance from the superior aspect of the greater tuberosity to the axillary nerve on the humeral shaft was 50.3 mm (95% confidence interval, 47.0-53.5 mm). The distance from the lateral acromion to the axillary nerve was 69.3 mm (95% confidence interval, 64.1-74.5 mm).

CONCLUSIONS

The deltoid muscle had 4 to 5 tendinous insertions on the acromion, and the axillary nerve was 50.3 mm from the tip of the greater tuberosity. The distance between the lower border of the pectoralis major and the axillary nerve was 9.4 mm.

CLINICAL RELEVANCE

Knowledge of the quantitative anatomy of the tendons of the proximal humerus and axillary nerve can aid in identifying structures of interest during open shoulder surgery and in avoiding iatrogenic axillary nerve injury. Furthermore, this study provides direction to avoid injury to the deltoid tendons during open surgery.

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.