Working Diagnosis:
High-grade latissimus dorsi tear with intramuscular hematoma

Treatment:
Rest, ice, antiinflammatories and physical therapy focused on strengthening of the latissimus dorsi, back, and core. Was advised to pursue surgical repair by two orthopedic surgeons.

Outcome:
The patient declined surgical repair and wanted to keep his treatment strictly non-operative. Per his athletic trainer, as of 6 months post-injury with regularly scheduled physical therapy and home exercises, he is throwing at up to 60 percent of original baseline speed and distance, is able to pitch without pain and has not yet returned to competitive play with his baseball team

Author's Comments:
This case involved a fairly rare injury and highlights some key points when encountering injuries of the latissimus dorsi in the athletic population. Shoulder examination can appear to be totally normal in terms of strength, active range of motion and a lack of tenderness to palpation yet patients can still have a noticeable decline in their pitching capability with this type of injury. MRI chest with extended views is the diagnostic gold standard for latissimus dorsi injuries. One additional consideration is that intramuscular hematomas can arise and increase intrafascial pressures which can lead to heightened risk of thoracodorsal nerve irritation or compartment syndrome. Ultrasound guided aspiration can be considered in cases with symptomatic hematomas, otherwise the hematoma can be left alone to eventually resorb.

Initial treatment involves rest, ice, NSAIDs and eventually physical therapy. From a brief literature review, latissimus dorsi tendon injuries tended to be treated operatively, while latissimus dorsi muscle belly injuries tended to be treated nonoperatively. One cohort study revealed that professional players treated non-operatively saw a decline in performance metrics, while those who were treated operatively had no significant difference in performance after surgery. Another study demonstrated that professional pitchers were able to return to the same or higher level of play with non-operative treatment though this study had a much smaller sample size compared to the cohort study.

Editor's Comments:
This case illustrates a rare but potentially devastating injury. While true incidence is unknown, a recent study of pitchers (a group at elevated risk) over a 7-year period across all professional baseball levels, identified only 224 tears. Thus evidence guiding optimal management remains limited.
The Latissimus Dorsi (LD) functions in shoulder adduction, extension, and internal rotation, making it critical during the late-cocking and acceleration phases of pitching. Eccentric or supraphysiologic concentric contraction forces generated during these phases have been postulated to predispose the LD to injury.
Clinical diagnosis of LD tears is challenging, as standard shoulder examinations often appear normal despite significant functional impairment. MRI with extended field-of-view imaging is the diagnostic gold standard, though ultrasound has also shown efficacy in identifying injury location, extent, and complications, making it similarly useful in guiding treatment decisions. If diagnosed acutely, evaluation for an intramuscular hematoma(s) is essential, as this finding may warrant serial examinations for 24–48 hours to monitor for compartment syndrome and thoracodorsal nerve injury.
Definitive treatment varies by injury location and severity. LD tendon avulsions are treated operatively in physically active individuals, with a study showing an average recovery time of 406 days and no significant decline in performance. No published cases describe surgical repair of isolated LD muscle belly or myotendinous junction (MTJ) tears, however based on outcome data, the preference toward conservative management warrants reconsideration. While studies have shown that conservative treatment leads to faster return to play (average 170 days), players have also shown persistent performance deficits in WHIP and games played, as well as a recurrence rate of 13%. This patient’s six-month outcomes—throwing at 60% of baseline speed and distance is consistent with these described deficits. Unfortunately, due to the rarity of this condition, alternative treatments for LD muscle belly or MTJ injuries remain largely unexplored. However, studies that evaluated similar injuries involving the pectoralis major and the proximal and distal biceps femoris have demonstrated significantly improved outcomes following surgical repair of MTJ tears when compared with conservative management. Two additional modalities with potential benefit include shockwave and PRP. Laboratory studies have shown shockwave therapy stimulates regeneration of skeletal muscle tissue and accelerates repair processes. The literature also suggests that ultrasound-guided leukocyte-rich PRP may accelerate healing at the MTJ and promote faster return to play. However, to date, no studies have evaluated platelet-rich plasma (PRP) or shockwave therapy for LD muscle belly or MTJ injuries. Thus, more data is needed to determine their efficacy in treatment of LD MTJ (as in this patient) and muscle belly injuries.

References:
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