- October 2008 - Volume 31 · Issue 10:
Spontaneous rupture of the latissimus dorsi muscle is a rare injury, and few reported cases were avulsion injuries at their humeral insertion. Seven cases of spontaneous rupture of the latissimus dorsi muscle have been reported, but only 1 occurred at the myotendinous junction.1-7 The mechanism of this injury is reported to be forceful resisted arm adduction or extension, and reported injuries were rock climbing and attempting to pull up on an overhead handhold,5 waterskiing injury during pull-up with ski rope,3 overuse in golf in the leading arm, 6 and abduction-external rotation with horizontally extended arm during a professional steer wrestling performance.2 The latissimus dorsi muscle is not a critical muscle for activities of daily living; however, the significance of the muscle is increased in professional or elite athletes. This article presents a case of rupture of the latissimus dorsi muscle at the myotendinous junction that ocurred during a sports activity.
A 38-year-old, right-hand-dominant semi-professional tennis player presented with right shoulder pain of 2 months duration. He had no previous shoulder injury or pain. The patient noted pain in the posterior axillary fold region after playing competitive match 2 months previously. The pain gradually began after the match and the pain was repeated by every overhead serve or powerful stroke, which prevented him from playing tennis. The patient reported experiencing sharp pain during the early follow-through phase of a serve. Although his sports activity had been decreased, his activities of daily living were not restricted. He was a well-developed man without obvious wasting or gross deformity.
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|Figure 1: Gross view of the patients axillary region (A). Right side shows swollen axillary region (B). |
Physical examination revealed soft tissue swelling in the axillary region with tenderness (Figure 1). Active shoulder motion was normal and manual strength testing showed a decrease in extension (4/5) and adduction (4+/5). There was pain with adduction and extension of the arm against resistance. There was no evidence of any shoulder instability or neuromuscular abnormality. Plain radiographs were normal, but T2-weighted magnetic resonance imaging revealed a full-thickness tear in the musculotendinous junction of the latissimus dorsi (Figure 2). While tracing the latissimus dorsi muscle by ultrasound, a tear muscle was also found (Figure 3).
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|Figure 2: Coronal (A) and axial (B) T2-weighted images show fluid collection of the injured site. The green box shows the injured area. Yellow outlines the latissimus dorsi muscle. Figure 3: Ultrasound of the myotendinous junction of the latissimus dorsi muscle. Pink outlines the latissimus dorsi muscle. The black area inside the muscle indicates the ruptured muscle.|
Considering the patients desire to recover his full performance to play tennis with no handicap and our concern about loss of maximum muscle strength in overhead service, surgical repair was performed. Preoperatively, ultrasound-guided surface marking of the torn site was performed to minimize the incision and damage to the soft tissues. Under general anesthesia, the patient was positioned in a lateral decubitus position. An axillary incision (Figure 3) was made and dissection was done down to the ruptured tendon. Definite rupture and fluid accumulation was identified and the torn margins were not in contact with each other (Figure 4). After debridement of the scar tissue, the latissimus dorsi muscle was repaired with no dead space remaining.
The shoulder was immobilized in adduction and internal rotation for 2 weeks, and passive range of motion exercise was started. The patient was allowed to use the arm freely for activities of daily living after 4 weeks. Ultrasound was used for the evaluation of the muscle 3 months postoperatively. Ultrasound showed intact muscle continuity without any abnormal findings (Figure 5). Noncompetitive tennis play was allowed 4 months postoperatively, and full forehand ground stroke and backhand ground stroke activity was allowed 5 months postoperatively. Muscle strength was evaluated 4.5 months postoperatively, using a Myometer (Mercmesin Co, Nottingham, United Kingdom) and the strength was 95% to 120% of the contralateral shoulder in adduction, internal rotation, extension, and flexion. Playing tennis with full activity, including overhead motions, was allowed 6 months postoperatively, and the patient was fully satisfied with the result.
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|Figure 4: Top incision line (A). Ruptured muscle (B). Arrow indicates torn edge of the latissimus dorsi muscle. After repair (C). Arrow indicates the ruptured area now repaired. |
Functionally, the latissimus dorsi muscle adducts, internally rotates, and extends the shoulder. In addition, the latissimus dorsi muscle, acting with the pectoralis major and teres major muscles, also helps to depress the raised arm against resistance and to pull the trunk upward and forward when the arms are fixed above the head, as in climbing.8 There are a few electromyographic analyses of shoulder function in tennis players, and the latissimus dorsi muscle is reported to show moderate activity in stage II (cocking), III (acceleration), and IV (follow-through) of a serve.9,10 The latissimus dorsi muscle is known to be highly active in the early portion of stage IV, and this correlates to our case in that the patient felt sharp pain during the early phase of acceleration of the serve. According to these studies, the latissimus dorsi muscle shows minimal to low activity in the forehand stroke, but shows moderate activity in the acceleration phase of backhand ground stroke.9 From these studies we deduced that the latissimus dorsi muscle plays a role in active tennis players and should not be overlooked.
There are also reports in the literature that describe functional evaluation of the shoulder after latissimus muscle transfer.8,11-13Although the conclusions are contradictory among studies, a well designed study by Fraulin et al11 measured static and dynamic muscle power as well as muscle endurance. Dynamic muscle testing demonstrated a deficit of muscle power and endurance of shoulder extension and adduction following latissimus dorsi muscle transfer.11 From these studies, the authors believed that the latissimus dorsi muscle could not be ignored in elite athletes and should be completely recovered. Considering this knowledge of functional importance and the patients desperate hope for an early return to competitive matches, surgical repair was chosen as a treatment plan.
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Figure 5: Ultrasound of the myotendinous junction of the latissimus dorsi muscle 3 months from surgical repair. Pink outlines the latissimus dorsi muscle. The black area that existed postoperatively has disappeared.
Six articles in the literature describe spontaneous rupture of the latissimus dorsi muscle; however, 5 are avulsion injuries at the humerus insertion. Only 1 case of a ruptured myotendinous junction of the latissimus dorsi muscle has been reported, which was treated conservatively.2 The case described a ruptured latissimus dorsi in a professional steer wrestler, and the strength was described to be 85% to 90% of normal in adduction and internal rotation at follow-up assessment performed 4.5 months after the initial injury. This 10% decrease may be slight, but even a mild impairment of function may be disabling for professional or semi-professional athletes.
We recommend surface marking before surgery using ultrasound. This procedure makes the operation easier, and it is worth comparing the image of ultrasounds after surgery.
The surgical repair of the myotendinous junction of the latissimus dorsi muscle is compatible with a full return to high-level sporting activities that require strong and defatigable shoulder adduction and extension, especially in a tennis player.
Rupture of the latissimus dorsi muscle should be suspected in an athlete who has a painful axilla during resistive adduction and extension. Although conservative treatment for rupture of the latissimus dorsi muscle at the myotendinous junction seems to be satisfactory in non-athletic patients, surgical repair seems to be more effective for elite athletes. Operative findings revealed that spontaneous repair might be impossible due to a large gap and fluid collection at the torn area. Repair of the torn muscle seems to enhance rehabilitation, and the patient was able to return to a preinjury level of activity within 6 months.
- Budoff JE, Gordon L. Surgical repair of a traumatic latissimus dorsi avulsion: a case report. Am J Orthop. 2000; 29(8):638-639.
- Butterwick DJ, Mohtadi NG, Meeuwisse WH, Frizzell JB. Rupture of latissimus dorsi in an athlete. Clin J Sport Med. 2003; 13(3):189-191.
- 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.
- 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.
- Livesey JP, Brownson P, Wallace WA. Traumatic latissimus dorsi tendon rupture. J Shoulder Elbow Surg. 2002; 11(6):642-644.
- 6. Spinner RJ, Speer KP, Mallon WJ. Avulsion injury to the conjoined tendons of the latissimus dorsi and teres major muscles. Am J Sports Med. 1998; 26(6):847-849.
- 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.
- Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E, Smith CJ. Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg. 1986; 78(3):336-344.
- Ryu RK, McCormick J, Jobe FW, Moynes DR, Antonelli DJ. An electromyographic analysis of shoulder function in tennis players. Am J Sports Med. 1988; 16(5):481-485.
- Moynes DR, Perry J, Antonelli DJ, Jobe FW. Electromyography and motion analysis of the upper extremity in sports. Phys Ther. 1986; 66(12):1905-1911.
- Fraulin FO, Louie G, Zorrilla L, Tilley W. Functional evaluation of the shoulder following latissimus dorsi muscle transfer. Ann Plast Surg. 1995; 35(4):349-355.
- Laitung JK, Peck F. Shoulder function following the loss of the latissimus dorsi muscle. Br J Plast Surg. 1985; 38(3):375-379.
- 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.
Drs Park, Lhee, and Keum are from Konkuk University Hospital, Seoul, Korea.
Drs Park, Lhee, and Keum have no relevant financial relationships to disclose.
Correspondence should be addressed to: Sang-Hoon Lhee, Department of Orthopedic Surgery, Konkuk University Hospital, 4-12, Hwayang-dong, Kwangjin-gu, Korea (143-719).