Posterior-Axillary-Fold Injury of Athletes
- Uncommon ruptures of the posterior-axillary-fold tendons at or near the humerus, from strain to complete avulsion; latissimus dorsi and teres major may tear together or separately
- Throwing/overhead athletes (classically pitchers) and water-skiers, through a sudden eccentric load with the arm abducted and externally rotated
- Acute posterior-axillary pain, bruising, a palpable defect and weakness of extension, adduction and internal rotation; MRI confirms the tear and shows which tendon and how far it has retracted
- 16 professional pitchers, 6 of them avulsions, all treated non-operatively: 15 of 16 (94%) returned to the same or higher level, at a mean 35.6 days to throwing and 61.9 days to pitching
- In that series 56% of injuries were season-ending, 13% recurred and 75% of players had a prior shoulder or elbow injury
- Repair gives good results when chosen (all professional pitchers back at the same level, performance unchanged) despite a mean 389 days from injury to surgery, so the case for early repair is unproven
- “The muscles of the posterior axillary fold extend, adduct and internally rotate the arm; latissimus is supplied by the thoracodorsal nerve, teres major by the lower subscapular nerve
- “MRI findings (which tendon, how far retracted) inform planning but do not settle treatment
- “A complete avulsion in an elite thrower is not by itself an indication to operate: non-operative treatment has the better-documented record in that population
- “The 'repair early before retraction' rule is borrowed from cuff and pectoralis surgery and is unproven here
Overview
Latissimus dorsi and teres major ruptures are uncommon tendon injuries at or near the humeral insertion. The two muscles form the posterior axillary fold and extend, adduct and internally rotate the arm. The injury spans a spectrum from strain or partial tear to complete avulsion, and the two tendons may tear together or separately.
Who and how. Throwing and overhead athletes and other high-demand athletes, classically baseball pitchers, and characteristically water-skiers. The tendon fails under a sudden eccentric or violent load on the contracting muscle, with the arm in abduction and external rotation.
Presentation. Acute posterior-axillary pain with bruising or ecchymosis, a palpable defect or asymmetry of the posterior axillary fold, and weakness of shoulder extension, adduction and internal rotation. In an athlete the functional complaint is loss of throwing or overhead power and velocity.
Diagnosis. The diagnosis is clinical, from the posterior-axillary defect and bruise and the sporting mechanism, and is confirmed by MRI, which also characterises the tear and its retraction.
The related injuries and principles sit on neighbouring pages. The analogous tendon rupture at the front of the axilla is pectoralis major rupture; the loading that produces this injury is set out in throwing biomechanics; the biology behind the repair-timing argument is in tendon healing; and the framework for clearing an athlete afterwards is return-to-sport criteria.
Anatomy: Two Insertions, Two Nerves, and the Neurovascular Danger
Origins and the fold. The latissimus dorsi has a broad origin: the thoracolumbar fascia and spinous processes from about T7 down, the iliac crest, the lower ribs and the inferior angle of the scapula. The teres major arises from the inferior angle and lower lateral border of the scapula. Their tendons together form the posterior axillary fold.
Two insertions. The latissimus dorsi tendon inserts into the floor of the intertubercular (bicipital) groove, and the teres major onto the medial lip (crest of the lesser tubercle) just medial to it. The latissimus tendon lies anterior and deep and spirals around the inferior border of teres major, which is why the two can tear together or separately, and why MRI is used to say which is involved.
Two nerves and a shared action. Each muscle has its own nerve from the posterior cord:
- Latissimus dorsi: thoracodorsal nerve (C6-8)
- Teres major: lower subscapular nerve (C5-6)
Both extend, adduct and internally rotate the humerus. The latissimus is also the "handcuff" or "crutch" muscle, depressing the raised arm.
The neurovascular danger. The axillary approach for repair passes near the radial nerve, the axillary nerve and posterior circumflex humeral vessels, and the thoracodorsal pedicle; this is the neurovascular risk behind the evidence's caveat that repair requires technical expertise. Anteriorly, the radial nerve and its branch to the long head of triceps cross the latissimus and teres major tendons near the axillary artery; posteriorly, the axillary nerve exits the quadrilateral space. Blind retraction is unsafe.
A band to release. An aponeurotic band links triceps and latissimus dorsi beside the teres major tendon. When mobilising a chronic retracted tendon, recognise restrictive bands and release them selectively.
MRI and Grading: Which Tendon, and How Far Retracted
What MRI shows. The tendon avulsed off its humeral footprint, with fluid or oedema and haematoma at the posterior axilla. MRI identifies whether the latissimus dorsi, the teres major or both are torn, and measures the retraction, the gap between the torn tendon end and the footprint (6 cm in the cited case).
Grading. A morphological grading describes the tear, with the suffix A denoting a humeral avulsion and B a myotendinous tear:
- Grade I: strain
- Grade II: partial tear
- Grade III: complete tear with less than 2 cm retraction
- Grade IV: complete tear with more than 2 cm retraction
No grading system for this injury has been validated, although the "grade IIIA" terminology is used in some reports, including the MRI below.
What it decides, and what it does not. Before deciding, MRI must answer which tendon(s) are involved and how far they have retracted, so report the tendon torn, the tear level and the measured retraction. Combined with the patient's demand, these findings determine whether and when to operate and inform surgical planning. They do not settle treatment on their own, as the pitcher cohorts below show.
Management: Demand Set Against the Tear
The decision. Management is debated and genuinely individualised, and the central judgement is the patient's functional demand set against the tear pattern. The key is shared decision-making with the athlete rather than a one-size-fits-all approach.
Non-operative treatment. Many of these injuries, partial tears and tears in recreational athletes, do well with rest, a structured rehabilitation programme and a graded return to activity, often with good functional recovery despite some residual deficit. The cohort evidence favours non-operative treatment even in elite throwers (next section).
Repair. Re-attachment of the avulsed tendon, for example through a single-incision axillary approach with suture anchors, produces good results when chosen. It is an option, not a demand-driven necessity, and the exposure runs past the neurovascular structures described under Anatomy.
What the Two Cohorts Show - and Why 'Repair the Elite Thrower' Overstates It
The intuitive rule is that a complete avulsion in a professional thrower must be repaired. The only cohort of professional baseball pitchers with these injuries says otherwise. Sixteen pitchers treated between 2002 and 2008, 6 with tendon avulsions and 10 with strains, were all managed non-operatively with rest, rehabilitation and a throwing programme, and 15 of 16 (94 percent) returned to the same or higher level of play. A complete avulsion is therefore not in itself an operative indication, and a candidate who says so without qualification is quoting a plausible principle rather than the data.
- Non-operative (Nagda, n=16 professional pitchers)
- 6 avulsions, 10 strains - all treated non-operatively
- Repair (Erickson, n=11; 7 professional pitchers)
- Complete tears selected for repair
- Non-operative (Nagda, n=16 professional pitchers)
- 15 of 16 (94 percent) same or higher
- Repair (Erickson, n=11; 7 professional pitchers)
- All professional pitchers returned to same level
- Non-operative (Nagda, n=16 professional pitchers)
- Not formally measured
- Repair (Erickson, n=11; 7 professional pitchers)
- No significant change in any pitching metric
- Non-operative (Nagda, n=16 professional pitchers)
- Mean 35.6 days to throwing, 61.9 to pitching
- Repair (Erickson, n=11; 7 professional pitchers)
- Mean 389 days from injury to repair; only 36 percent within 6 weeks
- Non-operative (Nagda, n=16 professional pitchers)
- 56 percent season-ending; 13 percent recurrence; 75 percent had prior shoulder or elbow injury
- Repair (Erickson, n=11; 7 professional pitchers)
- ASES 100, KJOC 89, VAS 0 in professional pitchers
What return costs. Almost all the pitchers eventually returned, yet nine of the 16 injuries were season-ending, and those who came back within the same season lost a mean 82.4 days in total. Three quarters (12 of 16) had a prior shoulder or elbow injury, so this is often a tendon failing in an already-damaged throwing shoulder rather than an isolated event.
Q: Is a delayed latissimus dorsi repair compromised by retraction and fatty atrophy, as in the rotator cuff?
A: The rule that repair must be early, before retraction, scarring and fatty atrophy, is borrowed from cuff and pectoralis-major repair and is not supported by the published repair series here. In those 11 repairs (7 professional and 1 collegiate pitcher among them) the mean interval from injury to surgery was 389 days, with only 36 percent operated within 6 weeks, and yet all professional pitchers returned to the same level with an ASES of 100, a KJOC of 89 and no significant change in any performance metric. Both series are small, retrospective and without a comparison group, so neither settles the operative-versus-non-operative question - but the honest position is that non-operative treatment has the better-documented record in elite throwers, repair produces good results when chosen, and urgency has not been demonstrated.
Mnemonics & Memory Aids
LATS
Hook:LATS: Latissimus (posterior axillary fold), Athletes (throwers/water-skiers), Tell-tale pain/bruise/defect (MRI), Start non-operative (94% of pro pitchers returned) - Surgery is an option.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A baseball pitcher develops sudden posterior axillary pain and bruising with weakness, and MRI shows a latissimus dorsi tendon avulsion. How do you decide management?”
What it is
- Uncommon rupture of latissimus dorsi (+/- teres major) tendon at the humeral insertion
- Posterior-axillary-fold muscles: extend, adduct, internally rotate the arm
- Spectrum: strain → partial tear → complete avulsion
Who & presentation
- Throwing/overhead and high-demand athletes; classically water-skiers (eccentric load)
- Acute posterior-axillary pain + bruising + palpable defect/asymmetry
- Weakness of extension/adduction/internal rotation; loss of throwing power
Diagnosis & management
- MRI: confirms tear, which tendon(s), degree of retraction
- Non-operative did well even in professionals: 16 pitchers, 6 avulsions, 94 percent same-or-higher level
- 56 percent season-ending; 13 percent recurrence; 75 percent had a prior shoulder or elbow injury
- Repair also gives good results (all pro pitchers returned, performance unchanged) despite mean 389 days to surgery - an option, not a necessity
Evidence & Key Studies
Latissimus dorsi tendon rupture repair in a high-demand athlete (single-incision axillary approach)
- Latissimus dorsi tendon rupture (with associated teres major partial tearing) occurred in a high-demand competitive athlete, causing shoulder weakness and impaired athletic/professional performance, with imaging confirming a complete rupture and retraction.
- Surgical repair (single-incision axillary approach with an all-suture-anchor tension-slide technique) achieved near-complete return to pre-injury function by 7 months.
- Surgical repair is an effective option for complete latissimus dorsi tendon ruptures in high-demand athletes, though it requires technical expertise (neurovascular risk).
Management and outcomes of latissimus dorsi and teres major injuries in professional baseball pitchers
- Retrospective case series of 16 professional baseball pitchers treated for a latissimus dorsi or teres major tear between 2002 and 2008, mean age 28.1 years, MRI-confirmed in all. The injuries comprised 6 tendon avulsions and 10 strains, and all 16 were treated non-operatively with rest, rehabilitation and a throwing programme.
- 15 of 16 (94 percent) returned to the same or higher level of play, at a mean of 35.6 days to throwing and 61.9 days to pitching. Nine of 16 (56 percent) were season-ending, and mean total time lost for those returning within the same season was 82.4 days.
- Two of 16 (13 percent) sustained a recurrence, and 75 percent (12 of 16) had a prior shoulder or elbow injury. The authors conclude that non-operative treatment is successful in allowing a return to high-level pitching - including in the avulsions. It is a small retrospective series with no operative comparison group.
Performance and return to sport in elite baseball players and recreational athletes following repair of the latissimus dorsi and teres major
- Eleven patients (mean age 29.9 years) undergoing latissimus dorsi and/or teres major repair with more than 12 months of follow-up; 73 percent were pitchers, of whom 7 were professional and 1 collegiate, and 86 percent underwent surgery on the dominant side.
- At final follow-up the mean visual analogue pain score was 0.7, the ASES score 100 and the KJOC score 93. Among professional pitchers, pain was 0, ASES 100 and KJOC 89; all returned to the same level of play, and no preoperative-to-postoperative performance metric differed significantly.
- Mean time from injury to repair was 389 days, with only 36 percent repaired within 6 weeks - so these good results were obtained despite substantial delay, which does not support an imperative to repair early. Eleven patients, retrospective, with no non-operative comparison group.
Latissimus dorsi tendon rupture (with teres major involvement) in a high-demand athlete causing weakness and impaired performance, and the effectiveness of surgical repair (single-incision axillary, suture-anchor) with good return to function, come from the cited Zogby report. The posterior-axillary-fold anatomy and function (extension/adduction/internal rotation), the throwing/overhead and water-skier mechanisms, the clinical presentation (pain/bruise/defect/weakness) and the role of MRI are standard, well-established teaching. The non-operative outcomes, the season-ending and recurrence proportions and the prior-injury figure come from the Nagda series of 16 professional pitchers; the repair outcomes and the 389-day mean interval to surgery from the Erickson series of 11 repairs. Both are small, retrospective and have no comparison group, so neither settles operative against non-operative treatment - and no randomised or comparative study exists. There is likewise no published incidence for this injury, no validated grading system despite the "grade IIIA" terminology used in some reports, no retraction threshold that mandates repair, and no evidence-based return-to-throwing protocol, so none is quoted here.