DOI:10.2214/AJR.04.1247
AJR 2005; 185:1145-1151
© American Roentgen Ray Society
Latissimus Dorsi Tendinosis and Tear: Imaging Features of a Pseudotumor of the Upper Limb in Five Patients
Suzanne E. Anderson1,
Ralph Hertel2,
James O. Johnston3,
Edouard Stauffer4,
Eva Leinweber1 and
Lynne S. Steinbach5
1 Department of Diagnostic, Interventional and Pediatric Radiology, University
Hospital of Bern, Inselspital, Freiburgstrasse, CH-3010 Bern,
Switzerland.
2 Department of Orthopedics, University Hospital of Bern, Inselspital, Bern,
Switzerland.
3 Orthopedic Oncology, The Permanent Medical Group, South San Francisco,
CA.
4 Department of Pathology, University Hospital of Bern, Inselspital, Bern,
Switzerland.
5 Department of Radiology, University of California, San Francisco, San
Francisco, CA.
Received August 6, 2004;
revised October 26, 2004;
Address correspondence to S. E. Anderson
(suzanne.anderson{at}bluewin.ch).
Abstract
OBJECTIVE. The objective of our study was to determine the imaging
appearances of a pseudotumor of the upper limb, latissimus dorsi tendinosis
and tear, in five patients and to correlate those imaging findings with
clinical history and histopathology.
CONCLUSION. Tears or reactive tendinosis of the latissimus dorsi
tendon at its insertion on the proximal humerus may present as a pseudotumor.
Awareness of the imaging findings may allow accurate diagnosis and
conservative management.
Introduction
The latissimus dorsi tendon may rarely be avulsed or may undergo
degeneration with the clinical and imaging appearances mimicking a tumor of
the proximal humerus. The tendon may occasionally undergo degeneration with
overuse, such as with playing volleyball, or may be acutely avulsed as a
result of rapid adduction of the arm from full elevation, such as with
slam-dunking a basketball. Both chronic and acute injuries to this tendon may
be mistaken for a tumor both clinically and on MRI. We present five such
cases.
Materials and Methods
Five patients presented between 1998 and 2002 with a provisional clinical
diagnosis of sarcoma of the upper limb for further imaging. There were four
males and one woman. The age range was 15 to 58 years (mean age, 34.8 years).
All patients were right hand dominant.
Available images, which included radiographs in five patients
(anteroposterior views of the proximal humerus including the shoulder joint
and oblique lateral views of the proximal humerus), CT scans in two patients,
technetium-99 methylene diphosphonate bone scintigraphy in two patients, and
MRI (n = 6) in five patients, were retrospectively reviewed by two
radiologists by consensus.
Radiographs and CT studies were reviewed for the location of bone fragment
avulsion, periosteal reaction or erosion, bone destruction, and presence of a
soft-tissue calcification or mass. Bone scintigraphy was reviewed for the
presence of focal radionuclide uptake.
MRI was performed on a 1.5-T unit (Signa, GE Healthcare) with the following
protocol: oblique sagittal and coronal STIR (TR range/TE range,
1,040–4,440/14–84), axial T1-weighting
(460–480/12–15), T2-weighting (4,000–5,160/46–84), and
STIR (5,300–5,340/13–30) sequences followed by fat-saturated IV
gadolinium–enhanced T1-weighted sequences in five of six patients in the
axial plane (560–600/12–14) and oblique coronal plane
(440–500/12–14). Axial T2-weighted and STIR sequences are part of
the routine tumor protocol, and contrast material was administered also as
part of the routine MRI tumor protocol. The T2-weighted images were obtained
using fast spin-echo technique and were not fat-suppressed. One patient
declined contrast administration. A standard shoulder coil was used for four
of five patients with one patient requiring the use of a standard torso coil
due to the large size of the associated muscle injury. One patient underwent
follow-up MRI 6 months after the initial MRI as part of clinical
follow-up.
MR images were reviewed by two musculoskeletal radiologists by consensus
for location and evidence of altered bone marrow signal intensity or bone
destruction; periosteal reaction at the latissimus dorsi tendon insertion
site, tendinosis, or tendon tear (defined as a discontinuity of the tendon
components); and adjacent soft-tissue reaction or mass. Tendon lesion was
defined as any thickening or irregularity to the normal contour of the tendon
or any altered signal intensity within the tendon. A bone or soft-tissue mass
was defined as a focal region with shape and volume that caused either
destruction or displacement of adjacent anatomic structures.
Imaging findings were correlated with intraoperative findings (n =
2), histopathologic findings (n = 2), and/or clinical and imaging
follow-up (n = 3) of 2–6 years, with an average of 3.8 years.
Additional clinical history was elicited such as sports and occupational
history to suggest a possible cause.
Results
All patients had upper limb shoulder girdle discomfort with mild pain on
downward movement of the upper limb. On palpation, diffuse pain was elicited
over the proximal medial humeral shaft. The right side was involved in four
patients and the left in one patient. Three patients were referred from the
orthopedic oncology service and one patient each from the sports medicine
clinic and from internal medicine. Results are summarized in
Table 1.
Three patients retrospectively had sports-related injuries. One 15-year-old
basketball enthusiast had an acute trauma from slam-dunking a basketball. His
sports medicine doctor was disturbed by the visible mass at the back of the
shoulder and ordered MRI for tumor staging. He did not consider that the
reported injury could be related to the tumor. One 17-year-old amateur
volleyball player, also a rollerblade-skating enthusiast, had a history of
several months of chronic discomfort that had increased after a period of
intensive training. He presented with pain in the region of pectoralis major
muscle. A 42-year-old patient had a sports history of gymnastics at the
Olympic level in vaulting associated with chronic pain and no other history of
trauma. He had chronic nonspecific shoulder pain with no history of trauma.
The other 42-year-old patient suffered several years of upper limb discomfort
not associated with any specific trauma or activity. The oldest patient, who
was 58 years old, recalled minor trauma from lifting heavy office furniture
several years earlier. Biochemical, hematologic, and infection screening
results were normal in all patients, with calcific, inflammatory, and
autoimmune disorders and myofascitis being excluded.
On radiographs, two patients had evidence of a small radiopacity adjacent
to the medial aspect of the humeral diaphysis, 8–10 cm caudal to the
superior surface of the humeral head, with one being evident on radiographs
obtained 9 years earlier at the time of the minor trauma from lifting office
furniture. In two patients, there was a small region of humeral cortical
erosion (Fig. 1A,
1B,
1C,
1D,
1E,
1F). CT showed focal erosion in
two patients, and bone scintigraphy showed focal radionuclide tracer uptake at
the insertion site corresponding to the latissimus dorsi insertion site on
MRI. Review of the patients' other radiographs showed no signs of soft-tissue
calcification.
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Fig. 1A —42-year-old woman referred from orthopedic oncology with
concern for sarcoma with typical imaging appearances of latissimus dorsi
tendon injury pseudotumor. Patient had experienced intermittent low-grade pain
over upper third of humeral shaft for several years. Oblique frontal
radiograph shows evidence of cortical erosion (arrowhead) and
calcification (arrow).
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Fig. 1B —42-year-old woman referred from orthopedic oncology with
concern for sarcoma with typical imaging appearances of latissimus dorsi
tendon injury pseudotumor. Patient had experienced intermittent low-grade pain
over upper third of humeral shaft for several years. Oblique image from bone
scan shows focal radionuclide uptake in proximal humerus (arrow).
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Fig. 1C —42-year-old woman referred from orthopedic oncology with
concern for sarcoma with typical imaging appearances of latissimus dorsi
tendon injury pseudotumor. Patient had experienced intermittent low-grade pain
over upper third of humeral shaft for several years. Axial T1-weighted MR
image shows low-signal-intensity periosteal, cortical, and intramedullary
reactions at site of origin of latissimus dorsi tendon (solid arrow)
and evidence of fatty atrophy within latissimus dorsi muscle (open
arrow).
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Fig. 1D —42-year-old woman referred from orthopedic oncology with
concern for sarcoma with typical imaging appearances of latissimus dorsi
tendon injury pseudotumor. Patient had experienced intermittent low-grade pain
over upper third of humeral shaft for several years. Axial contrast-enhanced
T1-weighted MR image shows enhancement within latissimus dorsi tendon
(arrow) at its insertion site and within cortex and adjacent bone
marrow.
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Fig. 1E —42-year-old woman referred from orthopedic oncology with
concern for sarcoma with typical imaging appearances of latissimus dorsi
tendon injury pseudotumor. Patient had experienced intermittent low-grade pain
over upper third of humeral shaft for several years. Oblique sagittal STIR
image shows radiographic correlate with cortical reaction (arrow) and
bone marrow reaction (arrowhead).
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Fig. 1F —42-year-old woman referred from orthopedic oncology with
concern for sarcoma with typical imaging appearances of latissimus dorsi
tendon injury pseudotumor. Patient had experienced intermittent low-grade pain
over upper third of humeral shaft for several years. Photomicrograph shows
dense reactive connective tissue (arrow) at tendon insertion site
consistent with tendinosis. There is evidence of bone remodeling
(arrowheads). (H and E, x10)
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MRI showed evidence of latissimus dorsi tendinosis in four of five patients
as thickening of the tendon with inhomogeneous signal intensity on all
sequences and irregularity to its contour (Fig.
1A,
1B,
1C,
1D,
1E,
1F). Three of these patients
had subtle morphologic changes of the pectoralis major tendon at its insertion
site, and one other patient had evidence of minor alteration within the
proximal portion of the teres major tendon with some altered signal intensity
on T2 and STIR sequences with some fatty atrophy within the proximal muscle.
There was an incomplete tear to the latissimus dorsi tendon in one patient
that occurred at its insertion associated with extensive tear and hemorrhage
within the latissimus dorsi and teres major muscles (Fig.
2A,
2B).
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Fig. 2A —15-year-old male basketball player with acute onset of pain
and mass formation after slam-dunking who was referred by his sports medicine
doctor for sarcoma review. Axial T1-weighted MR image shows extensive
increased signal intensity within latissimus dorsi muscle (arrows),
which is consistent with recent hemorrhage.
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Fig. 2B —15-year-old male basketball player with acute onset of pain
and mass formation after slam-dunking who was referred by his sports medicine
doctor for sarcoma review. Corresponding axial T2-weighted MR image shows
extensive partial tear of latissimus dorsi and teres major tendons (black
arrows) and muscle with hemorrhage (white arrow) more
posteriorly.
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In all cases, there was an adjacent cortical reaction and associated
characteristic small region of altered bone marrow signal intensity at the
level of the tendon insertion (Fig.
3). In four of five patients gadolinium-enhanced MR images showed
evidence of contrast enhancement within the latissimus dorsi tendon and within
the cortex at the insertion site, in nearby bone marrow, and in adjacent soft
tissues. There was no focal contrast enhancement to suggest a mass either
within soft tissues or bone. Contrast-enhanced images showed increased detail
of reaction within the cortex of the humerus at the insertion site of the
latissimus dorsi tendon, but did not alter the diagnosis.
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Fig. 3 —17-year-old male amateur volleyball player and rollerblade
enthusiast with upper limb discomfort. Sagittal STIR image shows typical
appearance of associated altered bone marrow signal intensity
(arrow).
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MRI excluded a tumor and allowed the diagnosis of a pseudotumor in all five
patients; however, surgery was performed for histopathologic confirmation in
two patients because of the concern of the orthopedic tumor surgeon. In both
cases, histopathology excluded a malignant tumor and infection. A diagnosis of
reactive tendinosis with reactive bone remodeling was made. Biopsy material
consisted of gray dense connective tissue with some adjacent cortex and
medullary bone measuring 3 x 5 cm in one patient and 1 x 1.5 cm in
the second patient. The process was found to be centered on the interface of
tendon and cortex. There was prominent osteoclastic activity but also focal
appositional new bone formation with a marked osteoblastic seam of reaction,
and in the center of the specimen, there was evidence of a small residual bone
fragment. In adjacent medullary bone, evidence of subtle fibrosis and of some
macrophages was seen. However, the dominant picture was that of a chronic
fibrotic reaction at the insertion site of the tendon with discontinuity of
the cortical bone surface reminiscent of, for example, plantar fascitis of the
calcaneus. The other four patients had clinical and radiographic follow-up
(one patient with a second MRI examination) for 2–6 years, with an
average of 3.8 years; a decrease in symptoms over time; and no evidence of
tumor development.
Discussion
Acute or chronic overuse of the latissimus dorsi tendon may be associated
with characteristic MRI findings that may mimic a tumor. These include
tendinosis or avulsion of the tendon with irregularity, thickening, and
altered signal intensity at its insertion on the proximal humerus that is
associated with cortical erosion and a small region of diffuse altered bone
marrow signal intensity. This lesion may be misidentified as a tumor if the
radiologist does not appreciate the anatomic association of the altered bone
marrow signal intensity and cortical reaction with the tendon abnormality.
The altered bone marrow findings may dominate the picture with the more
subtle tendon findings being overlooked. Radiologists are not routinely used
to looking at these tendons in this region of the shoulder girdle compared
with the rotator cuff and anterior shoulder girdle muscles. The overuse may be
associated with sporting activities such as basketball, volleyball, and
gymnastic vaulting, as was the case in our series, and golfing and water
skiing, as previously described in the sports medicine orthopedics literature
[1,
2]. There have been two case
reports regarding the MRI findings of latissimus dorsi tendon abnormalities in
the sports medicine literature
[1,
2]. One patient, a 38-year-old
male novice golfer with posterior shoulder pain after excessive playing, had
radiographs that showed a cortical defect in the proximal humerus and MRI
findings that revealed avulsion of the conjoined tendons of latissimus dorsi
and teres major [1]. The other
patient was a 42-year-old male competitive water-skier who presented with a
palpable tender mass in the right posterior axilla several days after a
water-skiing injury [2]. On
MRI, there was focal increased signal intensity on T2-weighting, approximately
2 cm in width, consistent with complete avulsion of the latissimus dorsi
tendon.
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Fig. 4A —Diagrams and images illustrate anatomy of latissimus dorsi
tendon and muscle. Diagram from anterior aspect shows insertions of pectoralis
major (1), latissimus dorsi (2), and teres major (3) tendons. Bone landmarks
include crista tuberculi majoris (arrow), crista tuberculi minoris
(arrowhead), and sulcus intertubercularis (asterisk).
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Fig. 4B —Diagrams and images illustrate anatomy of latissimus dorsi
tendon and muscle. Diagram of posterior aspect shows latissimus dorsi muscle
fibers (m), aponeurosis (a), and tendon insertion (2) with adjacent teres
major muscle and tendon insertion (3). Tendons of latissimus dorsi and teres
major pass posteriorly onto anteromedial aspect of humerus. Components of
large spanning latissimus dorsi muscle are evident. Transitional fibers (Tr)
pass toward L1 and L2 levels and supraspinous ligaments. Raphe fibers (R)
attach to lateral raphae of thoracolumbar fascia (Tf). Iliac fibers (IL)
attach to iliac crest (Ic).
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Fig. 4C —Diagrams and images illustrate anatomy of latissimus dorsi
tendon and muscle. Coronal localizer image with axial slice of 41-year-old
healthy female volunteer defines level of axial image for D.
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Fig. 4D —Diagrams and images illustrate anatomy of latissimus dorsi
tendon and muscle. Axial T1-weighted image of 41-year-old healthy female
volunteer depicts axial anatomy corresponding to line drawing of A with
tendon insertions of pectoralis major (1), latissimus dorsi (2), and teres
major (3).
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The latissimus dorsi muscle is a large fan-shaped muscle covering the
posterolateral aspect of the thorax with extensive attachments on the
thoracic, lumbar, and sacral spinous processes with a relatively short linear
tendon attachment to the proximal humerus
[3], as shown in Figure
4A,
4B,
4C,
4D. Mechanically it is a
powerful adductor and extensor of the shoulder. Large adduction forces applied
to the fan-shaped muscles are transferred to the short tendon inserting on the
proximal humerus. This is seen particularly with the arm in full elevation,
resulting in partial or complete tear of the tendon. Clinical histories
include slam dunking with a basketball, vaulting in gymnastics on a vault
table, and downward forceful movements used in volleyball.
Dissections of five cadaver and three fresh frozen human specimens have
shown that the latissimus dorsi tendon begins posteriorly and then curves
inferiorly and anteriorly around the teres major tendons to insert 1 cm
anteriorly to the teres major tendon, with the two tendons being joined to one
another just proximal to the separate insertion sites on the humerus
[4]. This anatomic feature and
the different intensities of injuries and mechanism of injury presumably
account for the slight variations in the MRI findings in our series. The
different intensities of injury and whether there was a single injury or
repetitive injury would also explain the associated injuries with the teres
major and pectoralis major tendons. Important neurovascular structures are
closely associated with the conjoined tendons of latissimus dorsi and teres
major including the axillary nerve and posterior humeral circumflex artery
superiorly and the radial nerve inferiorly
[4]. However, these structures
were not injured in the patients in our series, but it is prudent to review
these structures in patients with this injury.
Other tendon abnormalities of the upper limb have been described as
presenting as tumorlike lesions. Cortical desmoidlike lesions of the proximal
humerus have been described in gymnasts, "ringman's shoulder
lesion," associated with overuse of the pectoralis major tendon
[5]. Pectoralis major tendon
injuries mimicking tumors associated with soft-tissue calcifications have been
described [6] with
histopathologic evidence of degeneration of the tendon and nonspecific
calcifications. Both acute and chronic pectoralis major tendon abnormalities
have been shown to be well evaluated with MRI
[7,
8].
The latissimus dorsi tendon lesion is similar to the well-described
pectoralis major tendon lesion; however, the anatomic site is different with
the bone interface and tendon abnormalities being seen adjacent to the
proximal humerus in a more medial and posteromedial location. The latissimus
dorsi lesion may also be seen slightly more caudal than the pectoralis major
lesion. The muscle and adjacent soft-tissue abnormalities that may be
associated with the latissimus dorsi lesion are seen in the posterior upper
thorax and posterior upper limb region as opposed to the anterior chest wall,
as is found with pectoralis major lesions. Both normal and variant insertion
site bone pits of the deltoid muscle
[9] and chronic avulsive
injuries of the deltoid insertion in adolescents mimicking tumors
[10] have been described.
Soft-tissue calcifications in the upper limb and shoulder girdle region
associated with either trauma and avulsion
[11] or calcific deposition,
either hydroxyapatite or calcium pyrophosphate
[12], remain in the radiologic
differential diagnosis.
In conclusion, tears or reactive tendinosis of the latissimus dorsi tendon
at its insertion on the proximal humerus may present as a pseudotumor.
Awareness of the imaging findings may allow accurate diagnosis and
conservative management.
Acknowledgments
Thank you to Klaus Oberli for his anatomical medical illustrations, to
Marlese Kaelen for normal anatomy, to Karen Kohli for imaging support, and to
Susanne Furrer for final manuscript support.
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Abstract
Introduction
