Sunday, June 6, 2010

Jujitsu and a Shoulder Injury

Photo by icantcu

Hand-to-hand, testosterone-fueled combat has existed for centuries. As long as violence, power, and sex exist (and I see no signs of them going away soon), fighting will thrive. Boxing and ultimate cage fighting are the more recent variations of an ancient drive to display power and conquer the other.

Jujitsu, a form of hand-to-hand mayhem, is a Japanese martial art style that emphasizes pins, joint locks, and throws. This sport can cause significant torque forces on the body, and lead to injury.

In this case, a twenty-six year old male experienced an upper body injury two weeks ago during jujitsu. He had torso pain and a clinical exam notable for glenohumeral instability. An MR arthrogram of the shoulder was obtained to clarify the extent and nature of his injuries.

An oblique coronal intermediate-weighted image from an MR arthrogram depicts a tear of the latissimus dorsi and teres major tendons (red arrows), with increased fluid (yellow arrow) adjacent to the torn tendons:

An oblique sagittal T2 fatsat image demonstrates the torn, retracted latissimus dorsi (red arrow) and teres major (green arrow) tendons. Also seen is a paralabral cyst (yellow arrow) adjacent to the posterior labrum. There is fluid in the joint (blue arrow) related to the MR arthrogram:

The pectoralis major, latissimus dorsi, and teres major tendons all insert on the humerus, next to one another. A good mnemonic for the pattern of insertion is "lady between two majors", with "lady" = latissimus dorsi (red line) and "major" = pec major (blue line) and teres major (green line):

Sagittal images from a normal patient (medial to lateral) illustrate the anatomy of latissimus dorsi (red arrows) and teres major (green arrows).

(click on image to enlarge)

The teres major tendon is smaller and more compact than the tendon of the latissimus dorsi. The quadrilateral space (Q) is found between the teres minor (blue arrows) and teres major (green arrows) muscles. T = long head of the triceps
Oblique axial intermediate images through the upper arm of our injured patient better demonstrate the torn, retracted latissimus dorsi (red arrows) and teres major (green arrows) tendons.

(click on image to enlarge)

Note the intact pectoralis major (pink arrow) tendon, as well fluid (yellow arrow) at the expected insertion site of the latissimus dorsi and teres major tendons. The footprint of the latissimus dorsi and teres major tendons is "naked".

For comparison, consider these oblique axial images from a normal patient (superior to inferior), showing the intact latissimus dorsi (red arrows) and teres major (green arrows) tendons at their insertion. The intact pectoralis major (pink arrow) tendon is also seen:

In addition to tears of the latissimus dorsi and teres major, this patient had a posterior labral tear (red arrow) and an associated paralabral cyst (yellow arrows), additional information provided by the MR arthrogram:

Tears of the latissimus dorsi and teres major are uncommon injuries, usually seen in competitive athletes, such as baseball pitchers (Leland et al., J. Shoulder Elbow Surg.18, e1-e5, 2009). The clinical signs and symptoms for both injuries are similar (Schickendantz et al., AJSM 37, 2016-2020, 2009).Typical management is non-operative, as operative intervention does not seem to improve outcome (although published studies are small in number and limited in study design). Tears or reactive tendinosis of the latissimus dorsi tendon at its insertion may present as a pseudotumor (Anderson et al., AJR 185, 1145-1151, 2005).

It is important to note that these injuries will often be seen only at the edge of the field-of-view of a standard shoulder MRI (or completely missed). Thus, if this injury is suspected clinically, it is a good idea to alert the radiologist, so that the anatomic coverage of the examination can be increased (as was done in this case).

Vic David MD