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MRI showing complete rupture of the latissimus dorsi from the insertion on the humerus. The patient has both arms above his head. The arrow shows the retracted tendon of the latissimus dorsi.
Injury to the latissimus dorsi is a rare injury, and has only been described a few times in the literature.1-5 Treatment of this injury has been both conservative and surgical, but a standard of care has not yet been established. This article presents a 42-year-old healthy man who sustained a complete avulsion of the latissimus dorsi while water skiing. Because the patient was an active recreational athlete, we treated him operatively with interference screw fixation supplemented with fiberwire suture around the humerus.
A 42-year-old man presented 1 day after injuring his left shoulder while water skiing. He described immediate pain and a tearing sensation in the posterior aspect of the left shoulder. The patient, an avid weightlifter with some knowledge of muscle anatomy, felt as thought he had ruptured his lat muscle.
The patients medical history was significant for successful surgery on the right shoulder for traumatic instability several years earlier. He reported no injury to the left shoulder before this incident. He reported no use of steroids or any other medications.
Physical examination demonstrated ecchymosis, swelling, and a palpable tender mass in the posterior aspect of the axilla. The patient had a full passive range of motion and an active assisted range of motion. Motions above shoulder height were painful. Resisted adduction was painful and resulted in a ball-shaped mass in the upper back. A latissimus dorsi tendon rupture was suspected. Plain radiographs were negative for fracture or malalignment. Magnetic resonance imaging (MRI) confirmed a complete rupture at the insertion site of the latissimus dorsi (Figure 1).
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|Figure 2: Location of the posterior incision. Figure 3: Anatomic drawing of the anterior and posterior incisions. Figure 4: Location of the anterior incision.|
Under general anesthesia, no glenohumeral joint instability was noted. The patient was placed in a semilateral position, allowing access to the anterior and posterior aspects of the shoulder. A posterior axillary incision was made starting at the posterior edge of the deltoid insertion and traveling anterior approximately 4 cm toward the axilla (Figures 2, 3). The avulsed latissimus dorsi tendon was recognized at the depths of this incision. It had avulsed directly from the insertion on the humerus without a piece of bone. The tendon edges were cleaned and sutured using a No. 2 fiberwire suture (Arthrex, Naples, Florida) in a whipstitch fashion. The diameter of the tendon measured 8 mm. A second incision was created anteriorly, allowing access to the insertion site on the humerus (Figures 3, 4). An 8-mm reamer was used to drill a hole at the anatomic insertion site of the latissimus dorsi just medial (posterior) to the biceps tendon (Figure 5). Using a beath pin, the sutures were passed from medial to lateral through the entry hole. The tendon stump was pulled into the hole, and an 8-×23-mm bioabsorbable soft tissue interference screw (Arthrex) was used for fixation to the humerus (Figure 6). After fixation, the No. 2 fiberwire suture was passed around the humerus in a cerclage fashion staying directly on bone and deep to the radial nerve, biceps tendon, and deltoid. It was tied, giving us an excellent repair of the latissimus to the anatomic insertion site (Figure 7).
Postoperatively, the patients left arm was placed in a shoulder immobilizer for 2 weeks. He was then switched to a sling and began passive motion exercises with a physical therapist 2 times per week. Five weeks postoperatively, he was allowed to begin stretching and active range of motion exercises with a gentle strengthening program. Eight weeks postoperatively, he resumed recreational weightlifting. Eleven weeks postoperatively, motion, strength, and function were normal and equal to the opposite extremity. The patient had resumed all activities, including heavy weightlifting, tennis, water skiing, and nonprofessional triathlon participation.
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|Figure 5: Anatomic drawing of the latissimus dorsi tendon being passed from posterior to anterior with the anatomic insertion site just medial to the bicipital groove. Figure 6: Intraoperative image (A) and anatomic drawing (B) of the latissimus dorsi tendon after it has been pulled into the prepared hole and just before insertion of the biotenodesis screw. Figure 7: Anatomic drawing of the final fixation. Note the suture on bone, deep to the biceps tendon and radial nerve. |
We have found only 5 documented cases of traumatic latissimus dorsi rupture in the English medical literature.1-5 The variable patient demographics of these case reports, differences in treatment, and lack of clinical evidence as to postoperative function make decision making for this type of injury difficult. However, nonoperative treatment of this injury would be debilitating for athletes who rely on the latissimus dorsi function, such as water skiers and rock climbers. This patient, an avid water skier and high-level recreational athlete, elected to have his avulsed latissimus dorsi tendon surgically reattached. The biomechanically sound technique developed by Mazocca et al6 seemed to provide a satisfactory fit. The procedure allowed for this patients accelerated rehabilitation program and return to preinjury levels of activity at 11 weeks postoperatively.
- Butterwick DJ, Mohtadi NG, Meeuwisse WH, Frizzell JB. Rupture of latissimus dorsi in an athlete. Clin J Sports Med. 2003; 13(3):189-191.
- Henry JC, Scerpella TA. Acute traumatic tear of the latissimus dorsi tendon from its insertion. 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.
- Spinner RJ, Speer KP, Mallon WJ. Avulsion injury to the conjoined tendons of the latissimus dorsi and the teres major muscles. Am J Sports Med. 1998; 26(6):847-849.
- Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005; 21(11):1296-1306.
Dr Levine is from Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi; and Dr Savoie is from the Department of Orthopedics, Tulane University School of Medicine, New Orleans, Louisiana.
Drs Levine and Savoie have no relevant financial relationships to disclose.
Correspondence should be addressed to: Felix H. Savoie III, MD, Tulane University School of Medicine, Department of Orthopedics, 1430 Tulane Ave SL-32, New Orleans, LA 70118-2699.