Humeral avulsion of the glenohumeral ligament

Dr Ayush Goel and A.Prof Frank Gaillard◉ et al.

Humeral avulsion of the glenohumeral ligament, is not surprisingly abbreviated toHAGL lesion. As the name suggests, there is avulsion of the inferior glenohumeral ligament (IGHL) from its humeral insertion. It can be associated with a bony avulsion fracture in which case it is referred to (again not surprisingly) as bony humeral avulsion of the glenohumeral ligament (BHAGL lesion).

Epidemiology

HAGL is much more frequent in young men engaged in contact sports.

Clinical presentation

Clinical presentation is usually with a history shoulder dislocation. Anterior shoulder pain, apprehension in abduction and lateral rotation, subjective instability and crepitus are noted on examination. 

Pathology

HAGL most often results from anterior shoulder dislocation due to forced hyperabduction and external rotation of the arm.

Radiographic features

MRI is the modality of choice for assessment of HAGL, especially as the finding may be difficult to diagnose on arthroscopy. Typical findings include:

• avulsion of the IGHL from the proximal humerus
  • it is important to note that failure of the IGHL is more frequent at it's insertion at the glenoid (40%) or mid-substance (35%), with only 25% tearing at the humerus
• retraction of the IGHL (so called J sign): the normal U-shaped inferior glenohumeral recess is disrupted 2
• other findings associated with anterior shoulder dislocation are found in 65% cases2
  • subscapularis tear
  • Hill-Sachs lesion
  • Bankart lesion and/or anterior labrum injuries

Treatment and prognosis

Shoulder instability as a result of HAGL lesions is reported to occur in ~5% (range 2-10%) 2.

The degree of instability and presence of other associated injuries determines whether surgical repair is required.

Differential diagnosis

• IGHL tears other than at the humeral insertion 2
  • 40% at the glenoid
  • 35% mid-substance
• adhesive capsulitis

Reference