Latissimus Dorsi Tear in an Olympics-Level Tennis Player: Case Report and Review of Literature

Abstract

Latissimus dorsi tears are extremely rare and are encountered primarily in high-level athletes. Noted initially in baseball pitchers, cases have been described in other sports too, with one report of a latissimus dorsi tear at the muscle–tendon junction in a tennis player. Anecdotal outcomes have been comparative after both non-operative and operative treatments. Although no clear indications for operative intervention exist, there is a general consensus that partial non-retracted tears can be managed with non-operative treatment, whereas complete tears warrant surgical repair. This case report describes a complete rupture with retraction of the latissimus dorsi tendon that occurred during a competitive match in an international level tennis player. Due to compelling sports participation reasons, this tear was managed with non-operative treatment. The player returned to competitive tennis within 6 weeks and won the Asian Games men’s doubles tennis gold medal 53 days following his injury. He has had no subsequent shoulder-related symptoms despite his continuous participation in international level tennis for the past 18 months. We analyse the role of the latissimus dorsi in tennis and also review the available literature on this uncommon sports injury.

Introduction

Sports injuries to the latissimus dorsi and/or teres major are extremely rare, and are almost exclusively encountered in competitive and high-level athletes. Although noted primarily in baseball pitchers [1], isolated case reports of these uncommon injuries have been reported in other sports such as cricket [2], wrestling [3], body building [4], athletics [5], hockey [6], golf [7], volleyball [8], basketball [8], handball [9], water skiing [10], rock climbing [11], and rodeo steer-riding [12]. There is one isolated case report of a latissimus dorsi tear in a tennis player [13].

These injuries are potentially debilitating to an overhead athlete and are reported to require lengthy rehabilitation periods and time away from sports. Although no clear indications for surgical intervention exist, and anecdotal outcomes have been comparative after both non-operative and operative treatment, there is a general consensus that partial non-retracted tears can be managed with non-operative treatment, whereas complete tears warrant surgical repair.

This article describes a case of complete rupture with retraction of the latissimus dorsi tendon that occurred during a competitive match in an international level tennis player and its treatment. We also analyse the role of the latissimus dorsi in tennis and review the available literature on this uncommon sports injury.

Case Report

A 38-year-old male professional right-hand dominant tennis player, previously ranked number 3 in men’s doubles tennis world rankings, sustained a right shoulder injury during a match at Wimbledon. Whilst attempting an awkward volley at the net, he felt a sharp pain in the posterior aspect of his shoulder, associated with a dead-arm sensation. Despite immediate primary treatment, he was unable to lift his arm and hence conceded the match.

On presentation 4 days following the injury, physical examination revealed asymmetry of the posterior axillary fold contours, a palpable soft-tissue prominence with focal tenderness in the posterior axillary fold, and presence of axillary swelling with ecchymosis. The latissimus dorsi revealed significant weakness and an attempted latissimus “pull-down” manoeuvre caused severe pain. Resisted adduction of the shoulder accentuated the muscle deformity in the posterior axillary fold suggesting a complete tendon avulsion.

The MRI revealed a complete isolated tear of the latissimus dorsi tendon at the humeral attachment with 2 cm of retraction (Fig. 1). The muscle–tendon junction was normal. The teres major was normal. These findings were confirmed on a diagnostic dynamic ultrasound evaluation in which the latissimus dorsi tendon was avulsed and was noted to be ‘floating’ in the adjacent hematoma.

Fig. 1.

MRI demonstrating a complete isolated tear of the latissimus dorsi tendon at the humeral attachment with 2 cm of retraction, and surrounding haematoma

Although the senior author has an experience of operating on 2 acute and 2 chronic combined latissimus dorsi–teres major tears successfully, a decision was taken to treat this injury non-operatively. The reasons for this were two-fold. The Asian Games were 6 weeks away and his participation in this tournament was critical for not only him, but also the nation as a whole. Any surgical repair would have certainly prevented his participation in such a short time frame. Moreover, there is no convincing evidence in the literature that isolated complete latissimus dorsi tendon avulsions with minimal retraction, and normal teres major, result in functional deficiency even in athletes (Table 1).

Table 1.

Latissimus dorsi tears in athletes: an overview of sports associated with the injury, site of injury (LD = latissimus dorsi, TM = Teres Major), surgical versus non-operative treatment, and return to play after injury

Authors	Sport	Site of injury					Treatment		Return to play	RTP time (months)
		LD tendon	TM tendon	LD + TM tendon	MT junction	Muscle belly	Surgery	Non-Op
Onur Hapa et al. [3]	Wrestling	1					1		Y	5
Malte Holschen et al. [29]	CrossFit	1					1		Y	6
Hiemstra et al. [30]	Steer wrestling	1					1		Y	NA
Henry et al. [31]	Water skiing	1					1		Y	6
Spinner et al. [7]	Golf			1				1	Y	1
Friedman et al. [4]	CrossFit				1			1	Y	6
Fysentzou [32]	Soccer	1						1	Y	3
Balius et al. [9]	Handball					1		1	Y	2
Takase et al. [33]	Tennis					1		1	Y	4
Park et al. [13]	Tennis				1		1		NA	NA
Gregory et al. [34]	Weightlifting	1					1		Y	6
Schickendantz et al. [20]	Baseball	5	4	1				10	Y	4.1
Nagada et al. [21]	Baseball	2	3	1		10		16	Y	3
Naidu et al. [2]	Cricket	3					2	1	Y	3/4.25
Erickson et al. [35]	Baseball	NA					11		Y	6
Erickson et al. [15]	Baseball	NA					13	107	Y	13.5/5.6

Non-operative treatment consisted of a short period of rest, with use of cryotherapy, and nonsteroidal anti-inflammatory medication. To decrease the pain and subsequent fibrosis, an ultrasound-guided aspiration of hematoma with bupivacaine injection was performed. Once pain relief had been achieved 2 weeks following the injury, rehabilitation was initiated to achieve restoration of shoulder range of motion. Full and pain-free shoulder range of motion was achieved at 4 weeks. Isometric latissimus dorsi and teres major strengthening was started after completion of 3 weeks, followed by resistance training. By the fifth week following injury, he was able to return to tennis groundstrokes, and was progressively increased to high-ball strokes and serves. He was serving with speed and confidence by the end of the sixth week and considered himself normal 4 days prior to his departure for the tournament.

The player was able to participate for the entire duration of the tournament without significant symptoms and needed nonsteroidal anti-inflammatory medication once daily on match days as a precautionary measure. He won the Asian Games men’s doubles tennis gold medal 53 days following his shoulder injury and immediately thereafter reached the quarter finals of the US Open tennis championships a week later. He has continued playing thereafter, has won numerous international matches and two ATP tournaments, and has now completed over 18 months since his initial injury without any recurrence of shoulder symptoms. At latest evaluation, his shoulder was clinically normal with complete range of movements and no evidence of any strength deficit. He was performing his upper body strength and conditioning workouts with the same intensity as pre-injury. Since he had no symptoms, was clinically normal, and functionally back to pre-injury levels for over a year, no isokinetic strength evaluation or imaging to document healing status was performed.

Discussion

The latissimus dorsi originates at the iliac crest, thoracolumbar fascia, and inferior thoracic and lumbar spinous processes. This broad large muscle is fan shaped and overlies the teres major. The tendon inserts at the intertubercular groove at the medial lip and floor. The insertion lies medial to the pectoralis major insertion on the humerus and lateral and proximal to the teres major insertion [1, 14]. The muscle tendon unit starts at the midline medially, travels superolaterally, externally rotates 90°, and continues laterally to insert on the humerus (Fig. 2). The superior aspect of the tendon is in continuity with the distal aspect of the muscle, and conversely, the lower aspect of the tendon is continuous with the proximal aspect of the muscle. The average length of the tendinous portion of the latissimus is approximately 8.4 cm (range 6.3–10.1 cm), and the average width of the tendon at its insertion of the humerus is approximately 3.1 cm (range 2.4–4.8 cm) [14]. The radial nerve lies over the anterior surface of the latissimus dorsi tendon and travels in a proximal medial to distal lateral direction towards the spiral groove of the humerus. The radial nerve passes directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions [14].

Fig. 2.

The latissimus dorsi muscle–tendon unit starts at the midline medially, travels superolaterally, externally rotates 90°, and continues laterally to insert on the humerus. This broad large muscle is fan-shaped and overlies the teres major. The tendon inserts at the intertubercular groove lateral and proximal to the teres major insertion

The function of the latissimus dorsi muscle tendon unit is to aid in depressing the arm in conjunction with the teres major and pectoralis major. It adducts, extends, and internally rotates the shoulder. In addition, it assists in pulling the trunk upward and forward when the arms are in the fixed overhead position, which puts it at risk of injury during climbing [15].

The latissimus dorsi is a prominent shoulder adductor with mean maximum adductor moment arm magnitude occurring beyond 69° of abduction [16]. Moment arms during scapular plane elevation show the pectoralis major, latissimus dorsi, and the teres major as the major adductors. The extensor moment arm of the latissimus dorsi peaks at 45° of forward flexion, whilst the teres major has the largest extensor moment arm. The most prominent shoulder depressors are the pectoralis major, latissimus dorsi and teres major. In particular, the latissimus dorsi and teres major show large shoulder adductor and extensor moment arms, whilst the pectoralis major is a prominent adductor. The inferiorly directed lines of action of these muscles, together with their insertions far from the glenohumeral joint centre of rotation (on the proximal humeral shaft), give these muscles exceptional depressor function and significant mechanical advantage during tasks requiring both humeral depression and internal rotation, such as climbing and swimming [17]. Data suggest that both the latissimus dorsi and teres major have the greatest mechanical advantage during early to mid-range abduction in the coronal plane, scapular plane and sagittal plane (between 30 and 50 of abduction), and may therefore be able to provide greater torque capacity with the upper limb in these shoulder joint configurations.

Jobe et al. [18] performed electromyography analysis of the latissimus dorsi whilst performing a throwing action and found it to be one of the highest power generators during the acceleration phase. In addition, the latissimus sustains an eccentric contraction during other phases of the pitching cycle. This eccentric contraction coupled with forceful concentric contraction during acceleration, followed by a rapid return to eccentric contraction, puts this muscle tendon unit at significant risk of injury.

The mechanism of injury involves resisted contraction with the arm in the hyper-abducted, externally rotated, and/or hyperextended position. Injuries can occur at several locations anywhere along the course of the latissimus dorsi muscle tendon unit. Direct tendon avulsion, tendon mid-substance, musculotendinous junction, muscle belly, and costal muscle origin have all been reported as sites of injury. Muscle belly strains are the most commonly encountered injury pattern followed by tendon avulsions.

There is a lack of consensus amongst clinicians and some favour non-operative care, even with retracted tendons in high-level athletes. Others argue for operative treatment to ensure early return to play, and avoid a strength deficit, cosmetic deformity, or re-tear.

Erickson [19] proposed the following MRI-based grading system following a retrospective study of latissimus dorsi and teres major (LD/TM) tears. This classification of severity provides a basis for inter clinician standardisation.

• Grade I: fluid tracking along LD/TM

• Grade II: partial-thickness tear

• Grade III: full-thickness tear, < 2 cm of retraction

  • A: muscle is torn off of the humerus.
  • B: tear is at the musculotendinous junction.
• Grade IV: full-thickness tear, > 2 cm of retraction

  • A: muscle is torn off of the humerus.
  • B: tear is at the musculotendinous junction

Based on the results of their study, they proposed non-operative management in players who sustain grade I or II tears, and early surgical intervention to repair the LD/TM avulsion in players who sustain grade III or IV injuries. This approach appeared to provide athletes with the most predictable and successful return to sport outcomes. Players often took 6 weeks or longer for successful return to sport following non-operative treatment for grade I and II injuries. Hence, LD/TM tears can be successfully treated non-operatively or operatively based on the severity of the injury.

Schickendantz [20] reported the results of conservative management of latissimus dorsi injuries in 10 professional baseball pitchers. Over the course of 10 seasons, the authors found that all athletes returned to pitching within 3 months of the injury during the same season. Only one recurrence was found 6 months after returning to throwing. This patient returned to competition with continued nonsurgical treatment at the same level in 6 weeks. Only one athlete had continued shoulder symptoms and retired but after completion of a full competitive season. Based on these results, the authors recommended conservative management of these injuries in overhead throwing athletes.

Naidu et al. [2] in a case series noted three latissimus dorsi tendon ruptures in cricket bowlers. They theorised that increase in bowling loads with the advent of T20 games and change in bowling techniques resulted is an increased risk of LD injuries. A fast bowlers’ “slower delivery” with the ball coming out of the back of the hand and the arm in forced internal rotation at the point of maximum extension caused maximum eccentric loading of the LD. They also theorised that leg-spin bowlers put an internal rotation force on the extended arm with every leg-spin delivery performed, creating chronic stress on the LD attachment. In their series of three patients; two operative and one non-operative; all patients returned to play.

Erickson et al. [15], in a study period from 2006 to 2011, noted 120 pitchers with latissimus dorsi/teres major tear. The return to sport rate amongst players treated non-operatively and operatively was identical at 75%. They noted that time to return to the same level of competition was 170 for pitchers treated non-operatively and 406 days for those treated operatively.

Nagada et al. [21] in their retrospective review of professional baseball players with an injury to the latissimus dorsi and/or the teres major noted 16 pitchers diagnosed and treated. All pitchers were managed conservatively with a period of rest, rehabilitation and return to pitching after a throwing program. They noted that 94% returned to the same or higher level of play. The mean time to pitching was 61.9 days.

Although a few papers have reported successful return to sport following non-operative treatment for latissimus dorsi tears, it is unclear whether all of these were complete and retracted tears. Considering that this high-level player had a successful outcome within a relatively short period of time with non-operative treatment despite having a complete tear with 2 cm retraction, we analyse the biomechanical role of this muscle in tennis.

The tennis serve is the most complex stroke in competitive tennis [22] and has eight stages within three distinct phases: preparation, acceleration and follow-through. Each stage is a direct result of muscle activation and technical adjustments of the previous stage. The combination and coordination of limb and joint movements, required to build and transfer forces from the ground up through the lower body-core kinetic chain up into the upper body and out through the racket into the ball, contribute to the complexity of the stroke. Similar force production and transfer are also used for forehand and backhand groundstrokes. Any breakdown in the kinetic chain would affect the ability to serve and hit strokes optimally. Analysis of the kinetic chain in mathematical models reveals that a 20% reduction in kinetic energy from the trunk requires a compensatory 34% increase in velocity of movement, or a 70% increase in mass to achieve the same kinetic energy to the hand.

During the acceleration phase of the tennis serve, servers move from maximum glenohumeral joint external rotation to ball contact in less than 1/100th of a second [23]. High muscle activity is noted in the pectoralis major (115%), subscapularis (113%), latissimus dorsi (57%) and serratus anterior (74%) during internal rotation of the humerus. During the deceleration phase, the deceleration force activity between the trunk and the arm can be as high as 300 Nm [24]. There is moderately high activity in the posterior rotator cuff, serratus anterior, biceps brachii, deltoid and latissimus dorsi musculature during this phase [25]. Spinner hypothesised that latissimus dorsi function is not important in humans because it is less well-developed than other shoulder muscles as compared with lower primates that use their arms for arboreal locomotion [7]. We postulate that in athletic individuals, the well-developed teres major (adduction and extension) and pectoralis major (adduction and internal rotation) compensate for the moderately deficient latissimus dorsi.

A similar compensation is noted in reconstructive surgery where the latissimus dorsi muscle is a source of tissue for free flap transfer. Brumback [26] reported that none of the patients in his series of latissimus dorsi transfer for lower leg trauma noted any change in ability to perform activities of daily living, or had to modify sports-related activities because of shoulder function. Similarly, in the study by Laitung and Peck [27], most patients were followed after latissimus dorsi removal because leg trauma encountered no difficulty in their occupational and sports activities, nor significant functional loss at the shoulder in casual as well as in forceful activities. On the other hand, Forthomme [28] noted highly significant deficit on the operated shoulder reaching 31 ± 12% for adduction and 13 ± 13% for internal rotation 6 months after latissimus dorsi harvest in reconstructive breast surgery. The authors observed that women who underwent a unilateral pedicled latissimus transfer also suffered from a deficit in work-simulated activities like ladder climbing, overhead painting and pushing up from a chair.

We conclude that latissimus dorsi tears are uncommon sports injuries and that not all complete isolated tears of the latissimus dorsi tendon with minimal retraction warrant surgical intervention. This may be especially valid for racquet sports and throwing sports where the teres major and pectoralis major possibly compensate for any strength deficit of the latissimus dorsi. Repair, however, may be preferable for sports such as rock climbing where the latissimus dorsi is critical in pulling the trunk upward and forward when the arms are in the fixed overhead position, since compensatory mechanisms in this shoulder configuration may be inadequate.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

Informed consent was obtained from the patient/athlete prior to reporting his case.