Working Diagnosis:
After wide-field shoulder MRI was conducted, the athlete was diagnosed with a full avulsion of latissimus dorsi tendon from the humeral attachment.

Treatment:
The athlete underwent surgical repair with post-operative physical therapy.

Outcome:
The surgical repair was successful, and the patient worked with his athletic trainer/physical therapist on post-operative rehabilitation to achieve full pitching ability 9 months later.

Author's Comments:
With more emphasis on speed in baseball pitchers today, latissimus injuries are more common. Unfortunately, they remain a challenging diagnosis. One reason is non-specific physical examination findings. Our patient had a physical exam and right shoulder MR arthrogram that were largely unremarkable. Accurate diagnosis of latissimus tendon avulsion was only found with wide-field MRI of the right humerus because the shoulder MR arthrogram did not include the latissimus attachment to the humerus. It is therefore vital to consider imaging that reveals an upper arm injury as opposed to narrow imaging techniques revealing only shoulder pathology when suspicion of latissimus dorsi tendon injury is present.

Editor's Comments:
While this case highlights a surgical repair, a majority of latissimus dorsi tears in professional baseball players are treated conservatively (89%) with a more rapid return to sport (170 days +/- 169 days vs surgical return of 406 days +/- 146 days), and approximately 75% of all professional baseball players are able to return to sport in total (Erickson 2019).

While MRI is the gold standard in diagnosis, bedside ultrasound can be utilized in identifying injury to the latissimus dorsi muscle (Pedret 2011).

References:
1. Erickson, Brandon J., et al. "Performance and return to sport after latissimus dorsi and teres major tears among professional baseball pitchers." The American journal of sports medicine 47.5 (2019): 1090-1095.

2. Pedret, Carles, Ramon Balius, and Fernando Idoate. "Sonography and MRI of latissimus dorsi strain injury in four elite athletes." Skeletal radiology 40 (2011): 603-608.

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