It was a wonderful and, I think, very fair and balanced presentation, Mike. That was fantastic. Next is, again, blessed to have everyone on the panel as friends. Brian Waterman is an absolute genius and, again, a patriot, war veteran. He's going to talk to us about two entities that I think are emerging in importance, Terry's Major and Latissimus Dorsey. Thanks, Brian. These are all great presentations. Thanks to all the attendees for showing up early on a Friday morning. I'm going to talk to you a little bit about these Lat and Terry's injuries, which is kind of an emerging diagnostic and treatment dilemma that we have in the high-performance athlete. My disclosures can be found online, none of which are relevant to the content of this talk. I will put a plug in for one of my mentors, Tony Romeo, who's really helped to shape my approach to this. Well, as J.K. mentioned, it's listed that this is an uncommon injury, but it may be more common than we think. This can really be a continuum of injury from high-grade muscle strains to frank avulsions. When we assess that, we really need to go back to the videotape and see what happened, but also just take a more holistic approach to their clinical examination. This is a patient of mine. You can see a 29-year-old former professional athlete who has a sports performance company and ultimately had a pop onset of pain while throwing 96 miles an hour. He ultimately has failed conservative treatment. You can see his physical exam, and you can see that loss of normal posterior axillary contour, which is a tip-off to something deeper. I will say that the MRI is not always the most conclusive. You can see trace edema. You can often appreciate the tendon, and what you want to look at is at the attachment side on the humerus, do you see that lat and teres extending all the way? What do you do? I think it boils down to an underlying appreciation of the anatomy. The latissimus, we know its origin insertion, but it really has a unique trajectory as it courses through that posterior axillary region, takes a 90-degree externally rotated turn, and then attaches right on the humerus with the teres. It's primary function, internal rotation, extension, and then also adduction. When you look at it in the throwing motion, it does control when the arm goes into layback, and you have this eccentric contraction, and you transition from that late cocking into early acceleration, and it's very intimately involved with this motion. You want to work on assessing where they experience pain, but you may also see this encountered with deceleration of the arm through the follow-through cycle. Again, the presentation can be acute, a chronic, or subacute in presentation, and it can manifest in much of the same way we see a lot of the throwing injuries, right? Loss in velocity, accuracy, and you can see pain that triggers in late cocking, but then propagates through the remainder of the throwing motion. You can see ecchymosis or overlying skin changes, you want to look at that contour loss, and you can see that represented in these images here. This MRI grading system has been very helpful, because I think traditionally we've been lumpers, and I think we need to be more splitters as it relates to these injury patterns, because management will be determined by the grade of injury. You can see, as you go from partial thickness, which are grade two, to these full thickness tears, and then also assessing whether it occurs at the myotendinous junction, or if it's intratendinous in nature, so kudos to Brandon Erickson and this group for pushing the envelope forward. Well, non-operative treatment has been our traditional stance, and this excellent study from Schickendance really helped to put it on the map as an injury entity. You can see 10 Major League Baseball athletes, there's a combination of isolated and combined injuries, but you can see in his report, 100% return to sport, with 90% of these occurring at three months. Why would you not do this? The caveats are, there was only one year follow-up, and there were no performance metrics when you look at these individuals, so more to follow. Another study from Nagda and colleagues, and you can see 16 Major League athletes, you can see there's a combination of avulsions and intramuscular strains, and so if you look at this, again, compelling data, 15 of 16 returning to their prior level of play, but you can see a trend towards a longer timeline to return among avulsions, and recurrence was notable, including one of the avulsions. So there's a mixed level of severity, and they did not measure retraction, which I think is an important determinant of recovery. So the question we have today is, is there a role for surgery? And I think much like many of these things, including the slap tear that Mike was talking about, you need to weigh the risks and benefits, especially in these elite athletes. Our charge is always to avoid surgery, but you can also make the problem worse by continuing to manage this conservatively and lose that soft tissue contour and healing potential. We do need to have an appreciation for the footprint anatomy, and this is kind of the dark nether regions of the shoulder. You don't see this very often. We encounter this with anatomic and reverse total shoulders, but we're not typically working too far medial on this aspect of the humerus, and so you really want to drill down the anatomy before attacking this surgically. And I'll run through a couple of the things that I've seen to be beneficial. In terms of the primary open repair, there's a variety of different constructs, but what it amounts to is you want to identify the tendon, freshen up those edges, make sure you get good control stitches in there, and however you want to reattach it is up to you. We have certainly evolved in our surgical technique much as was described initially. I used a two-incision approach. This is one of our first cases with it. I performed it in a beach chair position, two-incision, and then suture-anchor approach. I think this is very difficult to approach, often very tenuous in terms of the dissection and the quality of the skin contour. So we really have moved to more utilitarian posterior approach. You can see on that posterior axillary margin, we use an arm positioner, and I think it's key to think about the arm positioning. You want to make sure you have full unimpeded range of motion, and then when you orient the arm, you want to put it in inverted grip fashion so that you really can get maximal access to the footprint. And then buttons are great because they allow you a certain liberty in being able to get that down without getting that difficult-to-achieve angle. The surgical approach, you can see shown here, you want to identify that posterior brachial cutaneous nerve. You can isolate ultimately the lat and or teres. It's important to be careful with the neurovascular anatomy. You can see the radial and axillary nerve are very close in proximity, and so you want to be very familiar with that. I do not dissect that out routinely, but use finger palpation. J.K., we may need a transfusion after this case, so I apologize for the messiness of these images, but you can see us isolating this fairly significant tendon injury, and you can see us tensioning down these buttons, and the final construct is shown in the far right. These are your postoperative images. You can use two to three buttons at your discretion. Two has often been sufficient for me, and you want to, again, reproduce that externally rotated turn, so think about your orientation so that you recapitulate anatomy. As with everything from SLAP on through, the rehabilitation protocol is key, and I've been able to develop this protocol and work with some of my prior patients in order to inform that recovery from this injury pattern. Again, we have very limited data, but certainly sources for optimism. When you look at this 11-patient series that Dr. Romeo and my colleagues were able to generate, you can see eight elite pitchers. You can see a fairly variable timeline from injury, but you can see return to prior-level play, and we had that in all of our athletes, and again, a KJOC score and very low rates of pain. When you look at this from the MLB data, obviously a lot of variability and only a limited subset of individuals in the professional ranks, so when you compare this non-op to operative management, I don't know if we really have a consensus on what our baseball community is using to approach this, but again, you can see the operative players had no change in their performance metrics after surgery, and I think this is definitely one that we would consider in full-thickness tears. Another question comes up about the chronic tears and the myotendinous tears. This is a technique we developed using a dermal allograft in order to reconstitute and improve the reliability of our repair. I certainly don't think this is for everybody, but for those chronic and somewhat complex injuries, this may be an option, and you can see in this case, reestablishing a normal contour and initiation of return to throw. So the management algorithm, just in brief, these Latt and Terry's injuries are not overly uncommon, but you will see them. Most of these we will see are grade one and two in nature, and I think those could be managed with physical therapy, with a biologic adjunct, and conservative management. The primary prayer is probably indicated for those full-thickness and retracted tears, and then allograft reconstruction can be utilized for those more complex tears that have failed conservative treatment. Again, look for this in the early acceleration phase, in the late deceleration phase, and follow through. You can see with non-operative treatment, 90 to 94% return to prior level of play at an average of three months. Again, primary open repair can result in really excellent rates of return, 75 to 100% in our series, and selective reconstruction, again, for those chronic neglected cases, limited tendons dump, or inadequate tissue mobility. Thank you, and I look forward to the discussion.

Dr. Brian Waterman

Terry's Major

Latissimus Dorsey

diagnosing injuries

treating injuries