Clinical Review

Latissimus Dorsi and Teres Major Injuries in Major League Baseball Pitchers: A Systematic Review

Am J Orthop. 2016 March;45(3):163-167

Injuries to the upper extremity in baseball pitchers are not uncommon, with extensive literature on shoulder and elbow pathology. However, there is minimal literature on isolated teres major (TM) and latissimus dorsi (LD) injuries. As a result, there is no consensus on an optimal treatment method. An extensive Medline search on studies focusing on the treatment of isolated LD and TM injuries in professional baseball pitchers was performed to explore this topic. Of the 20 retrieved articles, 5 met our inclusion criteria. There were a total of 29 patients who underwent conservative treatment and 1 who underwent surgical treatment. The average time required to return to pitching was 99.8 days in the conservative group and 140 days in the surgically treated group. Five patients in the conservative group suffered from complications and/or setbacks during their treatment and rehabilitation. The lone surgical patient suffered no complications, returned to preinjury form, and was elected an all-star the following year. The goal of this review is to provide a concise summary of the current literature in order to assist physicians when discussing treatment options with their patients.

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References

1. Conway JE, Arthroscopic repair of partial-thickness rotator cuff tears and SLAP lesions in professional baseball players. Orthop Clin North Am. 2001;32(3):443-456.

2. Mazoue CG, Andrews JR. Repair of full-thickness rotator cuff tears in professional baseball players. Am J Sports Med. 2006;34(2):182-189.

3. Cerynik DL, Ewald TJ, Sastry A, Amin NH, Liao JG, Tom JA. Outcomes of isolated glenoid labral injuries in professional baseball pitchers. Clin J Sport Med. 2008;18(3):255-258

4. Schickendantz MS, Kaar SG, Meister K, Lund P, Beverley L. Latissimus dorsi and teres major tears in professional baseball pitchers: a case series. Am J Sports Med. 2009;37(10):2016-2020.

5. Jobe FW, Moynes DR, Tibone JE, Perry J. An EMG analysis of the shoulder in pitching. A second report. Am J Sports Med. 1984;12(3):218-220.

6. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli D, Perry J. Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am. 1988;70(2):220-226.

7. Malcolm PN, Reinus WR, London SL. Magnetic resonance imaging appearance of teres major tendon injury in a baseball pitcher. Am J Sports Med. 1999;27(1):98-100.

8. Leland JM, Ciccotti MG, Cohen SB, Zoga AC, Frederick RJ. Teres major injuries in two professional baseball pitchers. J Shoulder Elbow Surg. 2009;18(6):e1-e5.

9. Nagda SH, Cohen SB, Noonan TJ, Raasch WG, Ciccotti MG, Yocum LA. Management and outcomes of latissimus dorsi and teres major injuries in professional baseball pitchers. Am J Sports Med. 2011;39(10):2181-2186.

10. Ellman MB, Yanke A, Juhan T, et al. Open repair of an acute latissimus tendon avulsion in a Major League Baseball pitcher. J Shoulder Elbow Surg. 2013;22(7):e19-e23.

11. Ellman MB, Yanke A, Juhan T, et al. Open repair of retracted latissimus dorsi tendon avulsion. Am J Orthop. 2013;42(6):280-285.

12. Altchek DW, Dines DM. Shoulder injuries in the throwing athlete. J Am Acad Orthop Surg. 1995;3(3):159-165.

13. Limpisvasti O, ElAttrache NS, Jobe FW. Understanding shoulder and elbow injuries in baseball. J Am Acad Orthop Surg. 2007;15(3):139-147.

14. Beck PA, Hoffer MM. Latissimus dorsi and teres major tendons: separate or conjoint tendons? J Pediatr Orthop. 1989;9(3):308-309.

15. Morelli M, Nagamori J, Gilbart M, Miniaci A. Latissimus dorsi tendon transfer for massive irreparable cuff tears: an anatomic study. J Shoulder Elbow Surg. 2008;17(1):139-143.

16. Broome HL, Basmajian JV. The function of the teres major muscle: an electromyographic study. Anat Rec. 1971;170(3):309-310.

17. Brumback RJ, McBride MS, Ortolani NC. Functional evaluation of the shoulder after transfer of the vascularized latissimus dorsi muscle. J Bone Joint Surg Am. 1992;74(3):377-382.

18. Gowan ID, Jobe FW, Tibone JE, Perry J, Moynes DR. A comparative electromyographic analysis of the shoulder during pitching. Professional versus amateur pitchers. Am J Sports Med. 1987;15(6):586-590.

19. Park JY, Lhee SH, Keum JS. Rupture of latissimus dorsi muscle in a tennis player. Orthopedics. 2008;31(10).

20. Gregory JM, Harwood DP, Sherman SL, Romeo AA. Surgical repair of a subacute latissimus dorsi tendon rupture. Tech Shoulder Elbow Surg. 2011;12(4):77-79.

21. Butterwick DJ, Mohtadi NG, Meeuwisse WH, Frizzell JB. Rupture of latissimus dorsi in an athlete. Clin J Sport Med. 2003;13(3):189-191.

22. Henry JC, Scerpella TA. Acute traumatic tear of the latissimus dorsi tendon from its insertion. A case report. Am J Sports Med. 2000;28(4):577-579.

23. Lim JK, Tilford ME, Hamersly SF, Sallay PI. Surgical repair of an acute latissimus dorsi tendon avulsion using suture anchors through a single incision. Am J Sports Med. 2006;34(8):1351-1355.

24. Hiemstra LA, Butterwick D, Cooke M, Walker RE. Surgical management of latissimus dorsi rupture in a steer wrestler. Clin J Sport Med. 2007;17(4):316-318.

25. Hapa O, Wijdicks CA, LaPrade RF, Braman JP. Out of the ring and into a sling: acute latissimus dorsi avulsion in a professional wrestler: a case report and review of the literature. Knee Surg Sports Traumatol Arthrosc. 2008;16(12):1146-1150.

26. Livesey J, Brownson P, Wallace WA. Traumatic latissimus dorsi tendon rupture. J Shoulder Elbow Surg. 2002;11(6):642-644.

Upper extremity injuries are very common in pitchers in amateur and professional baseball. The vast majority involving labral or rotator cuff pathology.^1-3 While uncommon, injuries to the latissimus dorsi (LD) (Figure) and teres major (TM) have been reported in Major League Baseball (MLB) pitchers.⁴ Jobe and colleagues⁵ demonstrated the role of the LD during the various phases of pitching. The LD is most active during the acceleration phase and remains active during the deceleration phase and follow-through.⁶ Anatomically, the TM lies posterior to the LD separated by bursal tissue. The tendon fibers converge and unite along their lower borders, leading to a synergistic mechanism of action.

Due to the rarity of LD and TM injuries, literature on the pathology and appropriate treatments for these injuries is limited. The goal of this review is to present the current literature on professional baseball players who have undergone either nonsurgical treatment or surgery for LD and TM strains and/or avulsion injuries. This review will ultimately assist clinicians when deciding on the optimal treatment method for professional baseball players.

Methods

We performed an extensive Medline database search with the following search algorithm: ([latissimus OR latissimus dorsi OR teres major] AND baseball). The search returned 20 citations. Inclusion criteria consisted of clinical studies that focused on professional baseball pitchers with TM and/or LD injuries that underwent either conservative nonsurgical treatment or surgical repair. There was no exclusion based on the type of injury present, such as avulsion vs strain. Any study with amateur athletes or athletes from other sports such as handball or rugby were excluded. Due to the limited amount of data available, the majority of included studies were case reports and case series.

Based on these parameters, 5 articles met criteria for inclusion. Of the 5 included studies, 3 were case reports and 2 were case series. From the eligible articles, the following information was obtained: publication year, sample size, mean age, mean follow-up duration, type of treatment (conservative vs surgical), ability to return to original level of play, time required to return to original form, and complications (Tables 1, 2).

Results

Nonoperative Management

Four of the 5 included studies implemented only conservative therapy for their patients.^4,7-9 The average duration these patients were followed for during treatment and rehabilitation was 26.3 months. Malcolm and colleagues⁷ followed patients for 8 months, the shortest length among the 4 conservative studies in this review. Leland and colleagues8 followed patients for 17 months, and Nagda and colleagues⁹ had the longest length of observation of 36 months (range 12 to 82 months).Schickendantz and colleagues⁴ followed patients for >12 months, but the exact duration was not specified. In order to calculate the average duration of observation, each patient was assigned a duration of 12 months.

Of the 30 patients included in this review, 29 were treated conservatively. All of the included studies consisted of male patients. The mean age was 26.8 years (range 22 to 28.1 years). Of the 29 injuries treated conservatively, there were 2 LD tendon avulsions, 4 TM tendon avulsions, 1 LD and TM tendon avulsion, 7 LD intramuscular strains, 9 TM intramuscular strains, and 6 LD and TM intramuscular strains.

Treatment Protocol

The various treatment and rehabilitation programs used for the conservative patient population all followed a similar pathway. After initial injury, a rest period focused on stretching was implemented. Patients were started on steroid or anti-inflammatory medications, cryotherapy, or other therapeutic modalities. Once pain-free and full range of motion was achieved, patients began the strength and throwing components of the rehabilitation program. Reoccurrence of symptoms would halt the throwing component of the rehabilitation program until symptoms improved. Patients were progressed through a return-to-throw program and once they could throw off the mound and achieve their preinjury velocity, strength, and range of motion, they were cleared to return to competitive pitching.

In the senior author’s (MSS) practice, all throwers are managed with the same nonoperative protocol.⁴ Initial treatment consists of short periods of rest and symptom control via the application of cryotherapy, among other modalities. Restoration of preinjury range of motion is achieved with active-assisted stretching exercises. As range of motion begins approaching pre-injury levels, strength training is initiated with isometric strengthening of the LD and TM progressing to resistance exercises. Exercising the abdominal core, strengthening the lower body, and cardiovascular conditioning are focal points of the rehabilitation period. Once patients regain preinjury shoulder strength and range of motion without pain, they begin a throwing program that consists of 4 weeks of long toss followed by 2 weeks of throwing from the pitching mound. After completion of the throwing program, the patient is allowed to return to competitive pitching. For patients who did not suffer season-ending injury, the average time required to return to play was 99.8 days (range 72.3 to 182.6 days).