Working Diagnosis:
Latissimus Dorsi full thickness tendon tear with retraction from its insertion site.

Treatment:
Leukocyte-rich platelet rich plasma injection into the latissimus dorsi tendon tear. Case Photo #1 Case Photo #2 . Followed by physical therapy then transitioned to an interval throwing program.

Outcome:
Following the procedure the patient underwent three months of physical therapy which included a supervised interval throwing program. The patient was then transitioned to a self guided interval throwing program with simulated pitching and increased throwing velocity with no issues. At three months post-procedure the athlete was able to return to sport related activity.

Author's Comments:
Latissimus Dorsi injuries are a unique challenge as they are often difficult to diagnose. When accessing the athlete special attention should be which phase of the throwing cycle elicits the pain symptoms. Latissimus Dorsi has an eccentric load placed on its tendon during the deceleration phase of overhead throwing; and is typically injured during this event. MRI is useful for diagnosis and potentially stratifying options for treatment. In this case we opted for non-operative management and successfully demonstrated a conservative approach to a grade IV latissimus dorsi tear in a baseball pitcher with ultrasound guided PRP and a gradual return to play rehabilitation program.

Editor's Comments:
Shoulder pain in throwing athletes can be difficult to diagnose and treat given the biomechanics and various structures involved. Latissimus Dorsi tendon pathology is an uncommon cause of shoulder pain in these athletes, however, not rare. A high index of suspicion is needed to diagnose and treat this condition as the current literature has suggested that the largest barrier to return to play is time to diagnosis. Additionally, I agree with the authors that non-operative treatment is typically the first line of treatment, however, no current consensus has been made between non-surgical or surgical intervention for tendon tears with retraction given more novelty to this case and outcome.

References:
Donohue, B.F., Lubitz, M.G., Kremchek. Sports injuries to the latissimus dorsi and teres major. American Journal of Sports Medicine 2017 (45): 2428-2435.
Schickendantz, M.S., Kaar, S.G., Meister, K., et. al. Latissimus dorsi and teres major tears in professional baseball pitchers: a case series. The American Journal of Sports Medicine 2009 (37): 2016-2020.
Erickson, B.J., Petronico, N., Romeo, A.A. Approach to latissimus dorsi and teres minor injuries in the baseball pitcher. Current Reviews in Musculoskeletal Medicine 2019 (12): 24-29.
Erickson, B.J., Chalmers, P., Potter, H., et al. “Magnetic Resonance Imaging Grading System for Tears of the Latissimus Dorsi and Teres Major.” Orthopaedic Journal of Sports Medicine, SAGE Publications, 4 Mar. 2019

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