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\begin{document}

\title{Tear of latissimus dorsi and teres major in a high performing,
middle-aged, artistic gymnast: Diagnostic and classificational
challenges, and clinical result.}



\author[1]{Roar Pedersen}%
\author[2]{Kerstin Myhrvold}%
\author[3]{Ståle Myhrvold}%
\affil[1]{Unilabs Norway AS}%
\affil[2]{Nordre Follo Municipality}%
\affil[3]{Akershus University Hospital}%


\vspace{-1em}



  
  \date{May 23, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
A middle-aged female veteran artistic gymnast sustained an
avulsion-injury of the latissimus dorsi and teres major. The case
reveals unclarity in the current classification system and illustrates
how a non-operative approach, in opposition to interpretation of
recommended guidelines, was adequate for an excellent clinical outcome.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Acute shoulder injuries are common in female gymnasts, and uneven bars
is the dominating mechanism of injury\textsuperscript{1}. We present a
case report of a conjoined tendon avulsion of both the latissimus dorsi
(LD) and teres major (TM) muscles in a high-performance, middle-aged,
veteran artistic gymnast. The challenges associated with these types of
injuries are related to the complex anatomy, a potentially low degree of
clinical suspicion because of unfamiliarity with the diagnosis among
clinicians, and the fact that these injuries are not well visualized at
standard shoulder imaging.

The LD and TM muscles act as one muscle unit in a wide variety of
movements. The large LD muscle originates from the iliac crest\selectlanguage{ngerman}´s
posterior third, the sacrum, all lumbar vertebrae, the spinous processes
of vertebrae T7-T12, and sometimes from the 9\textsuperscript{th} to the
12\textsuperscript{th} rib and the inferior angle of the scapula. It is
oriented in a craniocaudal direction, dorso-laterally along the torso.
The TM muscle originates from the scapular inferior angle. It follows
the LD laterally and both muscles merge together to form a conjoined
tendon and insert into the bicipital groove at the proximal humerus
(Fig. 1a-c). The LD/TM muscle unit adducts, extends, and rotate the
humerus internally when the shoulder is abducted. An intact LD muscle is
mandatory for shoulder stability and plays a crucial role in stabilizing
the lower back and the sacroiliac joint together with the contralateral
gluteus maximus muscle during bodily motions like walking and
running\textsuperscript{2,3}. Together with the pectoralis major, the LD
and TM are the main adductors of the shoulder\textsuperscript{4}. A
sudden contraction, against resistance, from a hyper-abducted position
of the shoulder with the arm externally rotated and/or hyperextended can
cause injury to the LD/TM muscle bellies, avulsion from their origins,
or avulsion of the conjoined tendon insertion from the proximal humerus.
Due to the rarity of injury to the LD and/or the TM, the literature
mainly consists of case reports and case series of high-level
athletes\textsuperscript{5}. Latissimus dorsi tendon tears have been
reported in baseball, cricket, weightlifting, soccer, water-skiing,
wrestling, steer wrestling (rodeo event), cross-fit, and
tennis\textsuperscript{5-14}. Isolated teres major tendon tears have
been reported in baseball\textsuperscript{6,7}. Furthermore, reports of
a combined tear to both the LD and the TM tendons are, to the best of
our knowledge, restricted to baseball, golf, and
water-skiing\textsuperscript{6,7,15,16}. The incidence of LD tear seems
to be increasing and the injury is predominantly found in baseball
pitchers\textsuperscript{1}. Because baseball is a sport with variable
popularity around the world, injury to the LD/TM may be unfamiliar for
physicians and physiotherapists in health care systems outside the
Americas and South Asia. Consequently, the diagnosis may be overlooked,
even in high quality health care countries. A clear classification
system will be helpful when orthopaedic surgeons with limited knowledge
of these injuries are consulted for treatment
recommendations\textsuperscript{17}.

\textbf{Case History:}

The patient is a 45-year-old female gymnast, active and participating in
national and international competitions for veterans. As a child and
youth, she was actively competing on national level, outside the
national team. Around her thirties, the gymnastics were resumed for four
years before paused due to pregnancies, and again resumed at the age of
40, but on a veteran level with approximately five hours weekly
training. She is a medical doctor, healthy with no relevant prior
injuries, non-smoker, and does not use medication. Before the injury,
she exercised two or three times a week with gymnastics and sometimes
with running or cross-country skiing. Two years prior to the injury she
had chronic right shoulder pain radiating along the proximal dorsal part
of the right upper arm which worsened after training sessions.

The patient was injured in September 2020 while doing subsequent glide
kips in the uneven bars. She experienced a snap in the right shoulder
area after the third repetition of sudden pull of the shoulder when
hanging by her arms. She initially felt no pain but had a sense that
something was missing in the dorsal musculature and the feeling of
reduced function and swelling (Fig. 2). She did not cool down the area
with ice, nor did she need analgesics. She was referred to MRI with the
question of a possible tear of a tendon in the right shoulder area. The
referrer suggested a tear of the triceps, teres major, or subscapularis
muscles. Clinical testing was difficult to perform in the sub-acute
setting because of pain evolving in the area.

Imaging was performed as described below, but no specific therapy, like
guided physiotherapy, was performed, and no surgical attempts were made.

After the injury, the patient continued to exercise twice a week but
avoided sudden movements, the uneven bars, climbing the ropes, and
pull-ups.

After two weeks, an apparent abnormal contour of the right posterior
axillary fold was visible (Fig. 3a). However, she could do push-ups and
``cross handstand -- roll forward'' on the balance beam. When hanging by
her arms, she was hanging obliquely ``like a banana'' with her legs
deviating to the left in the coronal plane, probably due to compensation
for reduced strength on her injured right side (Fig. 4a).

She continued exercising mainly by doing cross country skiing three
hours a week and some basic strength exercises at home. She experienced
reduced strength in the right upper arm when poling during the diagonal
stride in cross country skiing (i.e., extending the right shoulder
against resistance). The pain subsided a few weeks after the injury, but
she experienced a stretching sensation in the area, for instance, when
doing pull-ups.

After three weeks, she could do a handspring entry onto the vault board
and handstand on the balance beam (Fig. 4b).

After three months, she was able to walk on her hands, as she could
before the injury.

After six months of non-operative treatment with continuous but
self-guided tailored exercises, she had no pain, nor did she experience
any asymmetric strength, and she could climb the ropes all the way to
the ceiling (\textgreater{}10 meters above the floor) (Fig. 5). However,
the stretching sensations in the injured area persisted, and a contour
change was visible when doing pull-ups, but otherwise, no noticeable
sequelae (Fig. 6a and b).

\textbf{Imaging:}

The patient's right shoulder was scanned with magnetic resonance imaging
(MRI) ten months prior to the injury because of chronic shoulder pain
lasting for two years. At that point, the range of motion was normal.
The MRI study showed intact rotator cuff, but degenerative cystic
changes and bone marrow edema at the supraspinatus insertion were
believed to result of chronic tractional forces. In addition, there were
edematous changes at the posteroinferior part of the glenoid joint and
the inferior glenohumeral ligament, probably due to a soft tissue injury
to the capsule. The protocol covered the right proximal latissimus dorsi
and the teres major in the coronal and sagittal planes, but there were
no pathological changes in that area.

The patient was scanned again ten months later, one week post-injury.
The MRI was performed as a standard shoulder protocol with a proton
density fat-saturated sequence (PD fat sat) in all three planes, coronal
T2 and sagittal T1. However, the technician added ten more axial slices
because of soft tissue edema seen below the shoulder joint, covering 12
cm in the craniocaudal direction (standard coverage in the current
shoulder MRI protocol is 9 cm) (Fig. 7a and b).

The scanner used for these two first MRI scans was an older model (1.5T
GE Optima MR 360).

Despite some movement artifacts, the MRI showed extensive hematoma and
edema in the soft tissues medial and anterior to the right proximal
humerus, below the level of the subscapularis muscle and the axillary
neurovascular bundle. The hematoma continued dorsally between the muscle
belly of the proximal triceps laterally and the latissimus dorsi
medially. The hematoma along the humerus measured 5 x 3 x 1.5 cm, and in
this area a completely ruptured and avulsed tendon of the latissimus
dorsi was identified, retracted 1.5-2.5 cm from its original attachment.
The teres major, normally having a shorter tendinous attachment than the
latissimus dorsi, was partially torn at its insertion at the proximal
humerus. There was extensive edema in the bellies of both muscles near
the musculotendinous junction, particularly in the latissimus dorsi,
which had extensive muscle fiber defects and intramuscular hematoma
(Fig. 8a-d).

The right shoulder was imaged again on three additional occasions with a
1.5T Siemens Aera MRI scanner:

\begin{itemize}
\tightlist
\item
  Seven weeks post-injury the hematoma was largely resorbed, but a small
  amount of fluid along the now 4 cm retracted tendon of the latissimus
  dorsi remained. The attachment of the muscles to the humerus was not
  possible to identify, apart from probably a small remaining teres
  major component. (Fig. 9a and 9b)
\item
  Eleven weeks post-injury, some edema along the course of the teres
  major and latissimus dorsi was seen, but no hematoma. The ruptured end
  of the latissimus dorsi was, in both this and the previous scan,
  somewhat thickened and maybe scarred, and there was slight edema in
  the myotendinous junction (Fig. 10a-c). In contrast to the initial
  post-traumatic MRI, a subdeltoid bursitis and a partial rupture of the
  infraspinatus tendon attachment were visible.
\item
  Thirty-eight weeks post-injury, the hematoma and edema were completely
  resorbed. Some scar tissue had formed at the musculotendinous
  junction. Even though parts of the muscle could now be seen connecting
  to the humerus, the tendon and the distal muscle fibers were thin and
  slender compared to the left side and the imaging before the injury
  (Fig. 11a-d) (Fig. 12a and b (left side)).
\end{itemize}

\textbf{Discussion:}

Injury to the latissimus dorsi muscle is rare in non-baseball-athletes
and most often occurs after an acute traumatic event, typically as an
avulsion of the tendon rather than injury to the myotendinous
junction\textsuperscript{18}.

Standard imaging studies of the shoulder may not visualize injuries to
the latissimus dorsi, as its attachment could be in the periphery of the
chosen field of view. The referral should clearly state clinical
suspicion of latissimus dorsi injury to ensure that the correct area is
covered. In our case, there were both clinical suspicion and an alert
radiographer who added extra slices to the axial series to cover an area
of suspected soft-tissue edema. The oblique course of the latissimus
dorsi along the thoracic cage makes it often difficult, even with
adequate MRI imaging, to visualize a traumatized muscle and
tendon\textsuperscript{19}.

In the subsequent follow-up imaging examinations, we attempted to cover
more of the muscle belly, but at the price of somewhat reduced image
quality.

In the literature, treatment recommendations for LD/TM injuries are
predominantly based on younger male baseball pitchers treated
non-operatively or surgically.

Erickson and co-workers reported a return to sport rate of 75\% amongst
120 baseball pitchers from 2006 to 2011 with a latissimus dorsi / teres
major regardless of treatment (non-operative or surgical
treatment)\textsuperscript{20}. Interestingly, they found a shorter
recovery time to the same competition level in the non-operatively
treated pitchers compared to those who underwent surgery, which can be
explained by a more extensive injury in those receiving surgical
treatment. A grading system based on MRI is proposed by Erickson et
al.\textsuperscript{17}:

Grade I: Fluid tracking along latissimus dorsi / teres major Grade II:
Partial-thickness tear Grade III: Full-thickness tear,\selectlanguage{english} \textless{}\selectlanguage{english} 2~cm
of retraction A: Muscle is torn off the humerus. B: Tear is at the
musculotendinous junction. Grade IV: Full-thickness
tear,\selectlanguage{english} \textgreater{}\selectlanguage{english} 2~cm of retraction A: Muscle is torn off the
humerus. B: Tear is at the musculotendinous junction

Non-operative management of grade I and II injuries and surgical repair
in avulsion injuries in grade III and IV tears were recommended. In the
present case report, the injury was an avulsion of both latissimus dorsi
and the teres major, and the retraction of the LD tendon was
\textgreater{} 2 cm. According to the suggested treatment algorithm by
Erickson et al., our patient's injury may be classified as grade IV-A
which implies recommendation for surgical intervention. However, the
patient's choice of non-operative management with self-administered
early accelerated functional rehabilitation guided by the gradual reveal
of symptoms and limitations led to a full functional recovery with only
a negligible cosmetic sequel. The MRI findings of reduced thickness of
the muscle fibers on the right side compared to the uninjured left side
38 weeks post-injury suggest that the potential injury-related reduction
in strength of the teres major and latissimus dorsi muscles has been
compensated by biomechanical adjustments of motion pattern and/or
increased contribution from accessory muscles around the shoulder.

The classification system by Erickson et al. does not distinguish
between isolated tears to either the LD or the TM, and the conjoined
tendon as a whole. The current case demonstrates the need for a
clarification of the MRI classification system. A full thickness tear of
the LD with a retraction of more than 2 cm may be classified as a severe
(grade IV) injury which should be treated surgically according to
recommended guidelines\textsuperscript{17}. The successful non-operative
treatment of the patient in the current case may be explained by the
fact that a small string of the TM tendon remained in contact with its
bony attachment on the humerus despite the tear of the rest of the TM
and the whole LD with large retractions of more than 2 cm. We propose
that tears to the LD and TM tendons are graded as one conjoined tendon
tear and that a complete rupture of both the LD and the TM must be
present to classify the injury as a grade III or IV according to
Erickson et al. As exemplified by the injury in our female middle-aged
gymnast, this additional specification would have led to non-operative
treatment recommendations similar to the grade II injuries.

\textbf{Conclusion:}

Injuries to the latissimus dorsi and teres major are increasingly
reported in baseball pitchers. However, in most countries, baseball is
an uncommon sport, and the diagnosis may be challenging because of
unfamiliarity with the injury among patients and health care providers.
Our case illustrates that classification of these injuries should be
clarified to avoid unnecessary surgical treatment recommendations.
Several centimeters of retraction of the latissimus dorsi part of the
conjoined tendon combined with a sub-total avulsion of the teres major
part as in the present case report may be successively treated
non-operatively with excellent functional~results~and return to the same
level of gymnastic performance in less than six months post-injury.

\textbf{References:}

1. Hinds N, Angioi M, Birn-Jeffery A, Twycross-Lewis R. A systematic
review of shoulder injury prevalence, proportion, rate, type, onset,
severity, mechanism and risk factors in female artistic gymnasts. Phys
Ther Sport 2019;35:106-15.

2. Feeney DF, Capobianco RA, Montgomery JR, Morreale J, Grabowski AM,
Enoka RM. Individuals with sacroiliac joint dysfunction display
asymmetrical gait and a depressed synergy between muscles providing
sacroiliac joint force closure when walking. J Electromyogr Kinesiol
2018;43:95-103.

3. Hawkes DH, Khaiyat OA, Howard AJ, Kemp GJ, Frostick SP. Patterns of
muscle coordination during dynamic glenohumeral joint elevation: An EMG
study. PLoS One 2019;14:e0211800.

4. Marchetti PH, Uchida MC. Effects of the pullover exercise on the
pectoralis major and latissimus dorsi muscles as evaluated by EMG. J
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5. Pardiwala DN, Subbiah K, Rao N, Modi R. Latissimus Dorsi Tear in an
Olympics-Level Tennis Player: Case Report and Review of Literature.
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6. Schickendantz MS, Kaar SG, Meister K, Lund P, Beverley L. Latissimus
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7. Nagda SH, Cohen SB, Noonan TJ, Raasch WG, Ciccotti MG, Yocum LA.
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8. Naidu KS, James T, Rotstein AH, Balster SM, Hoy GA. Latissimus Dorsi
and Teres Major Tendon Avulsions in Cricketers: A Case Series and
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9. Gregory JM, Harwood DP, Sherman SL, Romeo AA. Surgical repair of a
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10. Fysentzou C. Rehabilitation after a grade III latissimus dorsi tear
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11. Henry JC, Scerpella TA. Acute traumatic tear of the latissimus dorsi
tendon from its insertion. A case report. Am J Sports Med 2000;28:577-9.

12. Hapa O, Wijdicks CA, LaPrade RF, Braman JP. Out of the ring and into
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Arthrosc 2008;16:1146-50.

13. Hiemstra LA, Butterwick D, Cooke M, Walker RE. Surgical management
of latissimus dorsi rupture in a steer wrestler. Clin J Sport Med
2007;17:316-8.

14. Holschen M, Korting M, Steinbeck J, Witt KA. Traumatic Tear of the
Latissimus Dorsi Tendon in a CrossFit Athlete: Surgical Management. J
Orthop Case Rep 2019;9:82-6.

15. 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;26:847-9.

16. Ahmad AN, Hankins DA, Wascher DC. Simultaneous Bilateral Latissimus
Dorsi Tendon Ruptures: A Case Report. JBJS Case Connect 2021;11.

17. Erickson BJ, Chalmers PN, Potter HG, Altchek DW, Romeo AA. Magnetic
Resonance Imaging Grading System for Tears of the Latissimus Dorsi and
Teres Major. Orthop J Sports Med 2019;7:2325967119826548.

18. Friedman MV, Stensby JD, Hillen TJ, Demertzis JL, Keener JD.
Traumatic Tear of the Latissimus Dorsi Myotendinous Junction: Case
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19. Acute Musculotendinous Tears of the Latissimus Dorsi and Teres
Major. Radsource, 2011.
at\emph{https://radsource.us/acute-musculotendinous-tears/} .)

20. Erickson BJ, Chalmers PN, D'Angelo J, Ma K, Romeo AA. Performance
and Return to Sport After Latissimus Dorsi and Teres Major Tears Among
Professional Baseball Pitchers. Am J Sports Med 2019;47:1090-5.

Figure legends:

\textbf{Fig. 1a-c.} Schematic drawings of the shoulder region in a
posterior (1a) and anterior (1b) view shows the latissimus dorsi (LD)
muscle curving along the thoracic wall and inserting on to the humerus
together with the teres major (TM). Partially resected views of the
following structures: Pectoralis major (PM); Long head of the biceps
(LHB); Short head of the biceps (SHB); Coracobrachialis (CB). Images by
Michael Stadnick, courtesy of Radsource (\emph{www.radsource.us}). Fig.
1c: Schematic drawing of the tendon attachments on the proximal humerus.
Courtesy of Dr Nabil Jomaah.

\textbf{Fig. 2.} Day of injury. The arrow indicates the area of
swelling, tenderness, and pain.

\textbf{Fig. 3.} Two weeks post-injury. Arrow indicates abnormal contour
of the posterior axillary fold on the right side caused by retraction of
the teres major and latissimus dorsi muscles from the humeral insertion.

\textbf{Fig. 4a and b.} Fig. 4a: Three weeks post-injury. The image
shows the patient hanging from the upper bar of the uneven bars device
where she inferred her injury three weeks previously. Note the
involuntary compensatory deviation of the legs towards the left,
uninjured side -- like a ``banana''. Fig. 4b: Three weeks post-injury
performing handstand on the balance beam.

\textbf{Fig. 5.} Six months post-injury the patient demonstrates
``climbing the ropes''. Arrow indicates injured right side.

\textbf{Fig. 6a and b.} Fig. 6a: Six months post-injury. The patient
reports to have regained her pre-injury strength and performs the same
number of pull-ups as before the injury. The arrow indicates the
abnormal contour of the posterior axillary fold. Fig. 6b shows
negligible cosmetic sequela six months post-injury.

\textbf{Fig. 7a and b} . Coronal PD fatsat in a study (7a) performed
before the injury, showing a common placement of transverse slices in a
regular shoulder MRI exam. The latissimus dorsi (star) and its proximal
insertion (arrow) are not covered sufficiently by the axial slices
(lines 1-22). Coronal T2 one week post-injury (7b) was performed by an
experienced radiographer who extended the imaging of axial slices to
cover the injured area along the humerus.

\textbf{Fig. 8a-d.} Axial PD fatsat (8a), coronal T2 (8b), sagittal PD
fatsat in a medial position (8c) and a more lateral position along the
humerus (8d) show a total rupture of the latissimus dorsi with
retraction, muscle edema, and a large hematoma between the tendon stump
and the humerus. It is difficult to identify the teres major tendon, and
we assume that this muscle is also ruptured.

\textbf{Fig. 9a and b.} Seven weeks post-injury. The hematoma is largely
absorbed, but a small amount of fluid along the retracted tendon is
seen. Fig. 9a: Coronal PD fatsat. Arrow points to the retracted tendon,
and lateral to the tendon a small amount of fluid/hematoma is seen.
Coracoid process (proc cor); subscapularis muscle belly (subscap). Fig.
9b: Sagittal PD fatsat. The circle captures the retracted tendon with
surrounding soft tissue edema.

\textbf{Fig. 10a-c.} Eleven weeks post-injury. Fig. 10a: Axial PD
fatsat, shows the still thickened proximal end of the latissimus dorsi
and slight surrounding edema (arrow). Fig. 10b: Coronal PD fatsat, also
shows the proximal tendon of the latissimus dorsi, retracted and with
some surrounding edema (arrow). Fig. 10c: Coronal STIR with extended
field of view, shows the proximal end of the latissimus dorsi.

\textbf{Fig. 11a-d} . Thirty-eight weeks post-injury. The hematoma and
edema are completely absorbed. The muscle seems to have reattached to
the humerus, and there is some residual scar tissue at the
musculotendinous junction. Fig. 11a: Coronal T2. The tendon can be seen
as a slender structure all the way to its former insertion (arrows).
Fig. 11b: Sagittal T1. Part of the muscle is close to its humeral
insertion indicated by the circle. Compare with previous Fig. 8d. Fig.
11c: Axial PD fatsat. Scar tissue at the musculotendinous junction
indicated by the circle. Fig. 11d: Axial PD fatsat. The latissimus dorsi
indicated by the star is reconnected to the humerus by reattachment of
muscle tissue as indicated by the arrows.

\textbf{Fig. 12a-b.} Normal left side. Fig. 12a: Coronal T2. Compare
latissimus dorsi indicated by the star, with fig. 11a. Fig. 12b:
Sagittal T1. Compare latissimus dorsi indicated by the circle, with 11b.\selectlanguage{english}
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