Injury Extra (2005) 36, 386—388
www.elsevier.com/locate/inext
CASE REPORT
Latissimus dorsi tendon avulsion: 2 case reports
James Turner, Michael P.M. Stewart *
Department of Orthopaedics and Trauma, James Cook University Hospital, Marton Road,
Middlesbrough, Cleveland TS4 3BW, UK
Accepted 6 February 2005
Latissimus dorsi tendon avulsion is an extremely rare
injury, with only five previous cases reported in the
literature.1—5 Paucity of information on the injury
makes it difficult to give any firm recommendations
for operative or non-operative management. We
report two cases, both servicemen, with latissimus
tendon avulsion managed non-operatively.
Case reports
Case 1
A 27-year-old Army Officer on an assault course,
hanging from his dominant left arm, carrying 22 lb of
webbing and a 10 lb rifle felt a ‘tearing and popping’
sensation in association with severe pain in his left
axilla. He was unable to continue to climb ropes,
perform pull-ups or hang from bars. He had not
suffered previous shoulder injury; he was not taking
steroids or any other medication. Within 2 days of
injury he had developed extensive bruising on the
posterior aspect of his left arm, extending from the
axilla to the mid forearm (see Fig. 1). There was no
obvious swelling or oedema. He could perform a full
range of shoulder movements without pain and the
power was graded 5/5 for all muscle groups; how-
ever, on resisted shoulder extension, adduction and
internal rotation, he complained of pain and the
* Tel.: +44 1833 62866; fax: +44 1833 62850.
E-mail address: stewartmpm@clara.net
1572-3461/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2005.02.010
sensation of a tight band in the posterior fold of the
left axilla. On palpation of the posterior axillary
fold, there was a visible and palpable defect. The
muscle belly of latissimus dorsi was deficient later-
ally where a web of skin covered a thin cord of
tissue; on resisted contraction of latissimus dorsi in
shoulder extension, the cord tightened and was the
sight of acute pain. Clinically, the diagnosis was a
rupture involving the left latissimus dorsi tendon.
Radiographs showed no evidence of an avulsed bony
fragment, but ultrasound scan (USS) and magnetic
resonance images (MRI) (Fig. 2) demonstrated near
complete rupture of the tendon from its insertion on
the proximal humerus. Given the relatively good
strength of left shoulder girdle muscle groups,
and the limited reported evidence and experience
of the natural history of the injury, the decision was
made to treat the injury non-operatively.
At review, 12 months after the initial injury, the
Officer reported that he could perform six to eight
unaided pull-ups before pain in the back of the axilla
which he related to a thin cord of residual tissue
caused him to stop. He remained dissatisfied in so
far as he had not felt able to return to playing
contact sports because of residual pain and the
prospect of further damage to the injured shoulder.
Case 2
A 34-year-old Royal Marine Physical Training Instruc-
tor (PTI) experienced sudden weakness in his right
Latissimus dorsi tendon avulsion
Figure 1 Bruising and oedema over the postero-medial
aspect of the left arm 2 days after injury in Army Officer
with a ruptured latissimus dorsi tendon.
dominant shoulder after bowling a cricket ball. He
managed to bowl several more balls and complete
the over. There was no pain or history of a tearing
sensation; however, marked bruising soon became
evident down the medial aspect of his right arm and
the lateral aspect of his right trunk. He noted some
weakness in the shoulder in association with a soft
tissue mass in the right posterior axillary fold. Active
Figure 2 A T2 weighted magnetic resonance image in
the coronal plane demonstrates in the left shoulder the
latissimus dorsi muscle and tendon, with surrounding
oedema (bright signal) ruptured and almost completely
avulsed (arrow) from the proximal humeral shaft.
387
shoulder movements were normal. There was no
past medical history of relevance.
Within 3 months, he developed right sided ante-
rior shoulder pain whilst performing resisted flexion
of the joint. Weakness of the shoulder in extension
persisted. He deployed on exercise for 6 months and
although he managed to regain strength in the
shoulder, he experienced ongoing anterior shoulder
pain. On returning to the UK, he was reviewed by an
orthopaedic surgeon and underwent an USS, which
demonstrated in the post axillary fold an avulsed
tendon of latissimus dorsi. A conservative approach
was adopted; following a course of physiotherapy to
address a presumed secondary bicipital tendonitis,
the anterior shoulder pain quickly settled. At review
18 months after injury, he could perform pull-ups
and climb ropes without pain to a standard similar to
that prior to the accident. No pain or stretching
sensation was elicited on resisted shoulder exten-
sion.
Discussion
The latissimus dorsi muscle is a large triangular flat
muscle that arises from the lower six thoracic ver-
tebrae, the thoraco-lumbar fascia, the iliac crest
and lower three ribs sweeps upwards and converges
to form the lower border of the posterior wall of the
axilla, and end in a quadrilateral tendon about 7 cm
long inserted into the bicipital groove of the prox-
imal humerus. Functionally, the latissimus dorsi
muscle extends, adducts and medially rotates the
humerus. Acting with pectoralis major and teres
major, it brings the outstretched arm from above
the head to behind the back to pull the body upward
and forward in activities such as climbing, swimming
rowing and pulling.
Latissimus dorsi tendon avulsion is extremely rare
with only five other cases reported. Spinner et al.,5
reported a case of avulsion of the conjoined latissi-
mus dorsi and teres major tendons in a 38-year-old
male novice golfer who presented with shoulder
pain after an unusual amount of golf, but no specific
history of injury. The patient was treated non-
operatively and was able to resume full activities
within 1 month of injury. Henry and Scerpella3
described the case of a 42-year-old male competi-
tive water-skier who sustained an acute traumatic
humeral avulsion of the tendon. Early anatomic
repair was performed in an attempt to restore
optimal strength in a high demand shoulder. At 6
months after surgery, the patient demonstrated
near full muscle strength by isokinetic testing,
and he had returned to competition. Budoff and
Gordon1 described the case of an acute traumatic
388
avulsion in a 29-year-old professional body builder
who was climbing a ladder 15 ft above the ground
when he lost his balance. As he fell, he reached and
grabbed a rung of the ladder with his right hand; as
he dangled in mid air his shoulder abducted and he
felt a painful pop in his right axilla. The patient had
no illnesses and denied any history of steroid abuse.
The patient considered the residual altered contour
of his lateral chest wall unacceptable. At surgical
repair 4 weeks after injury, the authors noted a
pseudo sheath that ran laterally from the tendon’s
edge to its humeral insertion. At 4 months after
surgery, the patient’s chest wall contour was
restored and he resumed full strength training.
Livesey et al.4 reported on a 39-year-old semi-pro-
fessional rock climber who presented 2.5 years after
injury unable to resume climbing and in particular to
perform the extreme manoeuvre of a one-armed
pull-up. Pain was localised along a tenuous band of
tissue thought to represent either a remnant of
latissimus dorsi tendon or scar tissue. Surgical repair
was deemed necessary to restore power required for
climbing. At review 16 months after surgery, the
patient’s strength had improved but he had not
achieved his pre-injury level of climbing activity.
Butterwick et al.2 described successful conservative
management of a 35-year-old professional steer
wrestler who presented with a 19-day-old almost
complete rupture of latissimus dorsi tendon in asso-
ciation with partial tear of teres major, long head of
biceps and supraspinatus. Five months after injury,
the patient was competing successfully; he had
regained normal and pain free range of movement,
and he had no complaints.
The clue to diagnosis in most of the cases of
latissimus dorsi tendon rupture is the patient’s his-
tory of an acute traumatic event associated with
pain and a tearing or popping sensation in the axilla
in association with the development within days of
extensive bruising over the postero-medial aspect of
the arm. Usually, the mechanism of injury involves a
sudden overwhelming extension force on an out-
stretched arm; however, our Case 2 and that of
Spinner et al.5 occurred under relatively atraumatic
circumstances playing cricket and golf and cannot
be readily explained.
USS and, or MRI can be helpful to determine the
extent of the avulsion and any associated injuries.
While our cases suffered isolated avulsion injuries of
the latissimus dorsi tendon, others have reported
J. Turner, M.P.M. Stewart
associated injuries to pectoralis major, teres major
and the rotator cuff.5,2 Our Case 1 and two previous
reports describe pain arising from a residual cord of
tissue taught in contraction of the muscle and
thought to represent either a remnant of latissimus
dorsi tendon4 or pseudosheath.1
The paucity of information on latissimus dorsi
tendon avulsion makes it difficult to give any firm
recommendations for management. The injury may
be more prevalent, but cause little disability and go
unreported except in sportsmen where even a small
functional deficit in the shoulder is exposed. Our
experience would suggest that in terms of pain,
range of movement strength and function conser-
vative management of a rupture of the latissimus
dorsi tendon can produce a satisfactory result; how-
ever, full restoration of pre-injury status may not be
achieved for some involved in challenging overhead
shoulder activity.
Even those who have undertaken operative
repair have commented that scar tissue around
the tendon and a well muscled individual can make
for challenging surgery, which should only be
undertaken by those familiar with the anatomy
of the axilla.1,4 As an alternative to surgical repair,
particularly in the non acute phase with the pro-
spect of a difficult repair under some tension, we
believe that there may be a role for simple division
of a painful residual band of latissimus tendon or
scar tissue to enable the development of accessory
muscles involved in shoulder extension and
improve power.
References
1. Budoff JE, Gordon L. Surgical repair of a traumatic latissimus
dorsi avulsion: a case report. Am J Orthop 2000;29(8
(August)):638—9.
2. Butterwick DJ, Mohtadi NG, Meeuwisse WH, Frizzel JB. Rup-
ture of latissimus dorsi in an athlete. Clin J Sport Med 2003;
13(3 (May)):189—91.
3. 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 (July—August)):577—9.
4. Livesey JP, Brownson P, Wallace WA. Traumatic latissimus dorsi
tendon rupture. J Shoulder Elbow Surg 2002;11(6 (November—
December)):642—4.
5. Spinner RJ, Speer KP, Mallo WJ. Avulsion injury to the
conjoined tendons of the latissimus dorsi and teres major
muscles. Am J Sports Med 1998;26(6 (November—Decem-
ber)):847—9.