Acute isolated rupture of the teres major is an uncommon injury. This article presents the first report of midterm subjective and objective functional results following nonoperative management of an isolated teres major rupture. A 30-year-old right hand dominant man presented after a waterskiing traction injury to his left upper extremity. On physical examination, the patient had swelling and retraction of the teres major at the lower scapular border, which was accentuated with resisted adduction of the extremity. His teres major attachment at the humerus was not palpable. Magnetic resonance imaging revealed an isolated teres major tendon rupture. The patient was treated nonoperatively with a rehabilitation protocol emphasizing rotator cuff, periscapular, and latissimus muscle strengthening. By 3 months postinjury, the patient had returned to all of his usual sporting activities, despite a persistent muscle retraction deformity over the teres major. At 3-year follow-up, the patient had no subjective complaints in the injured extremity and excellent functional outcome scores. A mean 37 kg loss of internal rotation strength (as measured by dynamometer) in the affected extremity with the arm abducted to 90° existed, although this difference was not subjectively appreciable. Although previously published reports have presented various options for the management of teres major injuries, the present case demonstrates that nonoperative treatment can produce excellent midterm subjective results in spite of objective internal rotation weakness.
Acute tendon injuries about the shoulder most commonly involve the long head of the biceps and the pectoralis major,1,2 with few reports of isolated injuries to the teres major3-5 or combined injuries of the teres major and latissimus dorsi.6,7 Rupture of the teres major is a rare injury that has not previously been well understood with regard to mechanism of injury, clinical presentation, and treatment.
A 30-year-old right hand dominant man, active in general aerobic and resistance fitness training presented 4 weeks after sustaining a traction injury to his left upper extremity. The injury occurred when his tow rope suddenly became taut during waterskiing, lifting his body forward and causing a sudden pop and sharp pain in the left shoulder. Following the injury, the patient continued to have a dull pain that intensified with physical activity, and presented to our clinic 4 weeks later.
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|Figure 1: Scapular symmetry with no muscle contraction (A). Medial retraction of the teres major with forceful adduction of the arm (B). |
On physical examination, the patient had obvious swelling and retraction of the teres major at the lower scapular border (Figure 1A), which was more pronounced with resisted adduction of the extremity (Figure 1B). Although the teres major attachment onto the humerus was not palpable, the pectoralis major was visibly and palpably intact. His left shoulder had active range of motion (ROM) as follows: forward elevation to 180°, external rotation to 60°, and internal rotation to T6. In addition to accentuating his deformity, resisted shoulder adduction exacerbated his pain. His neurovascular examination was normal. No weakness to manual muscle testing in internal rotation of the adducted or abducted extremity was found, specifically testing the latissimus dorsi and teres major.
Magnetic resonance imaging (MRI) revealed an isolated teres major tendon avulsion from its humeral attachment (Figure 2), with approximately 2 cm of retraction of the tendon and muscle belly; a posttraumatic fluid collection was visible surrounding the retracted tendon. The tear was best visualized on axial and coronal T2-weighted images. The quality of the teres major muscle was excellent, with no intramuscular injury noted. The rotator cuff and latissimus dorsi tendons were intact, and no other muscle or tendinous injury was identified.
|Figure 2: Axial view MRI with arrow indicating detachment of the teres major from the humerus. |
The patient was treated nonoperatively with a rehabilitation protocol for his shoulder, emphasizing rotator cuff, periscapular, and latissimus muscle strengthening. Six weeks after the injury, his shoulder pain had markedly decreased, allowing him to return to participation in swimming and resistance training. His deformity over the teres major muscle persisted, however. At 16 weeks postinjury he was pain free and had no limitations with regards to his participation in sports such as softball, golf, and basketball. He reported, however, a subjective 30% decrease in his preinjury strength with shoulder adduction and extension maneuvers. Seventy-two weeks after his injury, the patient continued to report subjective improvement in his strength, along with a persistent bulge over the teres major.
At 3-year follow-up, the patient had no complaints in the left shoulder and subjectively felt that the he had returned to 100% of his usual function. Calculated SF-36 physical component score and mental component score were 52.5 and 58.6, respectively. Both were above total population-based normative values of 49.97 physical component score and 49.90 mental component score, and age and sex-matched normative values of 54.10 physical component score and 50.82 mental component score.8 Visual analog scale pain score was 0, simple shoulder test score was 12, and American Shoulder and Elbow Surgeons score was 100. On physical examination, the left shoulder had full and symmetric ROM. With one exception, the strength of the injured shoulder (as measured by dynamometer) was comparable to that of the unaffected shoulder, and within the expected strength variation between dominant and nondominant extremities (Table).9 There was a mean 37 kg loss of internal rotation strength in the affected extremity with the arm abducted to 90°. This difference was not subjectively appreciable.
The teres major is a rectangular-shaped muscle originating at the inferior-lateral border of the scapula and inserting at the medial lip of the intertubercular groove. The muscle is often confluent with the latissimus dorsi tendon near its insertion.10 Similar to the latissimus dorsi, the teres major has been shown in electromyographic studies to internally rotate, extend, and adduct the arm.11 Only 5 reports of teres major injuries currently exist in the literature, each of which varies in the mechanism of injury, diagnostic maneuvers, treatment recommendations, and outcome.3-7
Reported injuries to the teres major have been isolated to active young men (age range, 21-38 years) including baseball pitchers,4,6 water skiers,3 tennis players,5 and golfers.7 Similar to the case described by Maldjian et al,3 in our patient, abrupt acceleration of the tow rope while waterskiing forced the humerus into forward elevation resulting in a huge eccentric contraction of the teres major and subsequent avulsion of its tendinous insertion onto the humerus. In baseball pitchers, teres major injury is thought to occur secondary to the muscle activity generated during the release or follow through phase of throwing, which places extraordinary stress on the tendinous insertions of the latissimus dorsi and teres major.4,6
Patients with acute teres major avulsion often present with sharp pain in the upper arm and posterior axilla, and may demonstrate axillary tenderness or ecchymosis and edema in the axillary fold.3-7 Although most do not demonstrate loss of motion or neurologic deficits,3,4 Takase5 reported limitation in active ROM on immediate postinjury examination of an intramuscular teres major rupture. Several reports have highlighted the presence of a mass in the axillary region and asymmetry of the axillary fold,3,4,6 while others have focused on the presence of pain with extension, adduction, or internal rotation of the arm against resistance.6,7 In our patient, diagnosis was facilitated by the obvious retraction of the teres major near the lower border of the scapula. Similar to previously published reports, our patients pain and deformity were more pronounced with resisted adduction of the injured extremity. Additionally, and unique from previously published reports, direct palpation of the teres major attachment onto the humerus was also performed to aid our diagnosis.
Magnetic resonance imaging typically demonstrates avulsion of the tendon from the medial lip of the intertubercular groove of the humerus, or intratendinous disruption near the teres major insertion site.3,4,6 Intramuscular injuries are less common,6 but have been reported.5 The tendon fibers may be obliterated by fluid signal near the humeral attachment, and marrow or cortical edema may be evident.6,7 Surrounding edema in the axillary region is commonly noted, as well as increased signal within the muscle belly itself.4 Hematoma may track along the tear to the insertion site on the humerus, and along the posteromedial soft tissues including the teres minor.3,7 Musculotendinous retraction is common, along with peritendinous or intramuscular increased T2-weighted signal in the distribution of the tendon and muscle. With an isolated teres major injury, the more superficial muscle belly of the latissimus dorsi and its tendinous insertion in the intertubercular groove appear normal.4
Schickendantz et al6 noted that whether the teres major, latissimus dorsi, or both tendons were involved was based on the location of the tendon obliteration and T2-weighted signal distribution in the adjacent musculature. Several features of the MRI in our case were consistent with those identified in previous studies including the retraction of the tendon and muscle, obliteration of the tendon fibers near their humeral insertion, and posttraumatic fluid collection. Interestingly, and in contrast to previously published reports, in our patient the quality of the teres major muscle itself was excellent, with no edema or hemorrhage tracking through the muscle belly.
Various operative and nonoperative treatments have been proposed for the management of teres major and latissimus dorsi injuries. Most reports of isolated teres major injuries describe successful healing and favorable short-term results with nonoperative management.4,6,7 In fact, Schickendantz et al6 recently reported that 9 of 10 baseball pitchers with nonoperative treatment of teres major and/or latissimus dorsi tendon tears were able to return to competitive pitching at full velocity within the same season of their injury. The authors provided a comprehensive treatment protocol, starting with an initial period of rest and symptom control using modalities and cryotherapy. Early active-assisted ROM stretching exercises were instituted, followed by a shoulder strengthening program including isometric strengthening of the latissimus dorsi and teres major. As ROM returned to normal, progressive resistance exercises were implemented. Abdominal core exercises, lower body strengthening, and cardiovascular conditioning were performed over the course of the rehabilitation period. A structured return to throwing program was initiated after regaining preinjury ROM and strength, along with pain free provocative testing of the injured muscle.6
Several reports have provided less specific descriptions of their nonoperative treatment protocols than Schickendantz et al,6 such as nonsteroidal antiinflammatory medications, physical therapy exercises, and rest.4,7 We managed our patient with a nonoperative rehabilitation plan including rotator cuff, periscapular, and latissimus muscle strengthening, progressing to cardiovascular and resistance training at 6 weeks postinjury. The present report demonstrates that nonoperative treatment of an isolated teres major tendon rupture can produce favorable midterm results.
Prior case reports have documented variable success rates after nonoperative treatment, with significant disparities in the expected time of return to athletic activity. Spinner et al7 reported a full painless ROM and return to play after 1 month in a golfer with a combined injury of the latissimus and teres major. Malcolm et al4 described an isolated teres major rupture in a minor league baseball player, who resumed full off season pitching at 6 months postinjury. The patient experienced no loss of strength or motion, and had no impairment of performance. A repeat MRI at 6 weeks postinjury showed marked resolution of edema within the teres major muscle and tendon, although the tendon did remain retracted. Takase5 reported pain free active ROM and full recovery to overhead tennis at 6 months following intramuscular teres major injury. Follow-up MRI in this patient demonstrated appropriate healing, normal signal intensity, and normal muscle size. Schickendantz et al6 reported that only 2 baseball pitchers in their series, both with isolated teres major injuries, required more than 3 months of shoulder rehabilitation prior to returning to play. One player did not return to full throwing velocity and retired at the completion of his season; he returned to play briefly at 6 months postinjury, but residual pain limited his throwing ability. One patient with combined teres major and latissimus dorsi injury was unable to return to pitching for 10 months.
Our patient was able to return to his preinjury athletic activity within 3 months of his initial injury, which is relatively consistent with previous reports.4,6,7 Interestingly, although several published cases have documented a lack of residual sequelae following nonoperative management of this injury,4,5,7 our objective strength measurements at 3 years postinjury demonstrated a loss of internal rotation strength of 37 kg with the arm in a 90°-abducted position. Given the comparable actions of the latissimus dorsi and the teres major, it is plausible that the larger latissimus dorsi muscle would compensate for any loss of function in the teres major in a recreational athlete. Although our patient was unable to subjectively perceive this difference in his usual sporting activities, were he participating in high-level athletics requiring forced internal rotation of the arm (eg, pitching), it is unclear if this difference may have become clinically significant.
We currently recommend initial nonoperative treatment of isolated teres major ruptures in recreational athletes, based on the favorable results of previously published reports as well as those of the present case.4,6,7 Although there are published reports of successful acute operative repairs of latissimus dorsi tendons in competitive athletes,12-14 the rare nature of isolated teres major injury makes it difficult to determine whether an operative approach may provide a more favorable outcome, or whether it may have a role in failed nonoperative cases. We hypothesize that nonoperative management is most often successful in the treatment of isolated teres major tears because of compensation by the stronger latissimus dorsi muscle.
This is the first report and longest follow-up of subjective and objective functional results after nonoperative management of an isolated teres major rupture. To establish the diagnosis, we recommend careful review of the mechanism of injury, direct palpation of the teres major insertion at the humerus, and observation for asymmetry of the teres major muscle at the inferior border of the scapula, especially with resisted adduction of the arm. Both axial and coronal T2-weighted MRIs should be inspected for tendon avulsion, peritendinous or intramuscular hematoma, and muscletendon retraction. Rehabilitation may include rotator cuff, periscapular, and latissimus muscle strengthening, with a gradual progression to resistance exercises and anticipated return to sports at 3 to 4 months postinjury. Although nonoperative treatment of isolated teres major injuries may be successful in returning a majority of patients to sports, patients should be advised of the potential for persistent objective weakness and periscapular muscle deformity.
- Curtis AS, Snyder SJ. Evaluation and treatment of biceps tendon pathology. Orthop Clin North Am. 1993; 24(1):33-43.
- Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle. An anatomic and clinical analysis. Am J Sports Med. 1992; 20(5):587-593.
- Maldjian C, Adam R, Oxberry B, Chew F, Kelly J. Isolated tear of the teres major: a waterskiing injury. J Comput Assist Tomogr. 2000; 24(4):594-595.
- Malcolm PN, Reinus WR, London SL. Magnetic resonance imaging appearance of teres major tendon injury in a baseball pitcher. Am J Sports Med. 1999; 27(1):98-100.
- Takase K. Isolated rupture of the teres major muscle. J Orthop Sports Phys Ther. 2008; 38(7):439.
- Schickendantz MS, Kaar SG, Meister K, Lund P, Beverley L. Latissimus dorsi and teres major tears in professional baseball pitchers: a case series. Am J Sports Med. 2009; 37(10):2016-2020.
- 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.
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- Murray MP, Gore DR, Gardner GM, Mollinger LA. Shoulder motion and muscle strength of normal men and women in two age groups. Clin Orthop Relat Res. 1985; (192):268-273.
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- Broome HL, Basmajian JV. The function of the teres major muscle: an electromyographic study. Anat Rec. 1971; 170(3):309-310.
- Levine JW, Savoie FH, III. Traumatic rupture of the latissimus dorsi. Orthopedics. 2008; 31(8):799-801.
- 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.
Mr Lester and Drs Boselli, Kim, and Ahmad are from the Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York.
Mr Lester and Drs Boselli, and Kim have no relevant financial relationships to disclose. Dr Ahmad is a consultant for Acumed, and receives research support from Arthrex.
Correspondence should be addressed to: Christopher S. Ahmad, MD, Columbia University Medical Center, 622 W 168th St PH-11, New York, NY 10032 (email@example.com).