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

References

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Athletes undergoing either conservative or surgical treatment required a significant period of recovery and rehabilitation before they were able to compete at the professional level. In Leland and colleagues⁸, it took about 10 to 12 weeks of rehabilitation for both pitchers to return to pitching against competition. In Schickendantz and colleagues⁴, barring any complications or injury recurrence, it took patients 12 weeks to return to their preinjury level. In Malcolm and colleagues⁷, magnetic resonance imaging after 8 weeks showed marked recovery, and shortly after the pitcher was able to return to the pitching rotation. In Nagda and colleagues⁹, the time lost to injury ranged from 7 weeks to an entire season. Of the 9 pitchers who were lost for the season, 6 had avulsion injuries. The other 3 consisted of an LD strain, TM strain, and LD plus TM strain.⁹ In this study, it seems that avulsion injuries had a more significant impact on patient recovery. On average, it took 35.6 days after injury for players to begin throwing. In contrast, it took an average of 65.5 days after an avulsion injury for players to begin throwing. Ellman and colleagues¹⁰ included the only surgically repaired injury, and it was for an avulsion of the LD tendon. In the surgical case, it took slightly longer for the pitcher to return to preinjury form. It took him 12 to 16 weeks to begin light throwing and his full return to pitching took about 20 to 30 weeks. Since muscle strains and tendon avulsions are significantly different injuries in regards to the type of soft tissue damage and healing potential, they may require different treatment strategies. An avulsion injury may require more aggressive intervention, whereas a strain may only require conservative rehabilitation. Ultimately, there does not seem to be a significant benefit of one treatment option compared to the other. The majority of conservatively managed pitchers were able to return to previous form in a reasonable time frame. While each rehabilitation protocol was slightly different, multiple studies advocated for rehab programs that centered around the following goals: slowly progressing pitchers to light throwing once their pain resolved, followed by long throwing, then throwing off of the mound, and finally returning to competitive pitching. It is important to discuss with patients that rehabilitation generally takes 12 to 16 weeks before they are able to fully return to pitching against competition and that rest should immediately follow any recurrence of pain or stiffness. Once those symptoms resolve, patients may continue the rehabilitation protocol.

As with any form of treatment, there are risks involved. This holds true for both conservative and nonconservative therapy for LD and TM injuries. One risk of nonoperative treatment of an LD avulsion is the development of strength deficits in the muscle.¹⁷ While this deficit may go unnoticed in a recreational athlete, it may be more pronounced in a professional athlete, especially since the LD of a professional baseball pitcher is more active on electromyography during the acceleration phase of the pitching cycle compared to a recreational athlete.¹⁸ Another risk of conservative treatment of an LD avulsion is jeopardizing the potential for future surgery. As a result, some advocate for early surgical intervention of an acute LD avulsion.^19,20 Others, however, recommend conservative management with subsequent surgical intervention if conservative measures fail. One caveat is that surgical intervention to restore the original anatomy may become difficult after a certain period of time due to the buildup of scar tissue. Surgical intervention also has associated risks, such as nerve injury, infection, vascular damage, persistent pain, and the buildup of large amounts of scar tissue. It is important to discuss these risks with patients when deciding on a treatment option.

LD and TM avulsion and tears typically present after an acute event in throwing athletes. There are a number of case reports published that demonstrate successful outcomes with both nonoperative management²¹ and operative repair of LD injuries in non-throwing athletes such as competitive water skiers,^22,23 steer wrestlers,²⁴ professional wrestlers,²⁵ and recreational rock climbers.²⁶ The 5 studies included in this review were the first ones to present LD and TM injuries in MLB pitchers. They discussed the outcomes of mainly conservative and surgical management of LD and TM avulsion and tears. Unfortunately, there remains a limited number of cases on the treatment of these injuries in highly competitive throwing athletes. Further research is required to elucidate the advantages and disadvantages of operative vs nonoperative treatment. The goal of this review is to provide clinicians with a concise summary of the current literature so that they may offer some evidence to their patients when discussing appropriate treatment plans.