1. The HAGL Lesion
2/10/2012
Blackpool Victoria
Hiren M Divecha (ST5)

2. Overview
1. Normal anatomy - stabilisers
2. Lesions associated with anterior dislocation
3. HAGL Lesion

3. Glenohumeral Stability
• The normal shoulder precisely constrains the humeral head
to the center of the glenoid cavity throughout most of the arc
of movement
• Laxity
– Asymptomatic, passive translation of the humeral head on the
glenoid (physiological) NOT associated with pain
• Instability
– Symptomatic pain/apprehension associated with excessive
translation of the humeral head during active motion

4. Normal Anatomy
1. Static stabilisers
1. Dynamic stabilisers

5. Static stabilisers
• Articular congruence & version
• Negative intracapsular pressure
• Adhesion-cohesion
• Labrum
• Capsulo-ligamentous structures:
– Coracohumeral ligament
– Glenohumeral ligaments

6. Glenoid Labrum
• Fibrocartilaginous ring
• Contributes 20% to GH stability
• 3 functions:
– “chock-block” effect ?
– increases surface contact area (deepens by 50%)
– attachment site for LHB & GH ligaments

7. Ligaments
• Coracohumeral ligament
– O = anterolateral coracoid process
– I = greater and lesser tuberosities, blends with capsule in
rotator interval
– ? Resists inferior translation. Tight in ER
• Glenohumeral ligaments
• (Coracoacromial ligament)

9. Modarresi S et al. AJR 2011;197:604-611

10. SGHL
• O = glenoid tubercle
• I = upper lesser tuberosity
• Limits inferior/ posterior transalation and ER (esp in
add)

11. MGHL
• O = superior glenoid and labrum
• I = medial lesser tuberosity
• Limits ant translation and ER (esp in 45 deg abd)

12. IGHL
• O= ant/post glenoid rim and labrum
• I= anatomic neck humerus
• Anterior band
– Limits ant trans in abd and ER
• Posterior band
– Limits post trans in flex and IR
• Both limit inferior translation at 45° abd

13. IGHL

14. Dynamic Stabilisers
• Rotator cuff muscles
• Deltoid
• Long head biceps tendon
• Scapulothoracic motion
• Co-ordinated contraction
• Concavity compression

17. The humeral head will
remained centred on
glenoid if:
•the glenoid and humeral
joint surfaces are
congruent
•the net humeral joint
reaction force is within
the effective glenoid arc

19. Lesions associated with Anterior
Dislocation
• Bankart
– Capsulo-ligamentous avulsion
– +/- bone
• Hill-Sachs
– Impaction # on posterior humeral head
• Humeral Avulsion of Glenohumeral Ligament
• ALPSA

22. Humeral Avulsion Glenohumeral Ligament
• IGHL can fail at 3 positions:
– Glenoid/ labrum
– Mid-substance
– Humeral insertion (least common)
• Avulsion of IGHL from humeral insertion
• <10% of shoulder instability
• Can occur with other lesions

26. Carlson C L Radiology 2004;232:725-726

27. Clinical
• Mechanism
– Hyperabduction & ER
• Pain, weakness, instability
• HIGH suspicion in prior failed stabilisations
• ROM, cuff strength
• Apprehension-relocation, load-shift tests

28. Imaging
• X-rays
– Concentric
– Hill-Sachs
– Bony Bankart
– Bony HAGL
• MRI arthrogram
– Best modality
– Coronal T2
– U-shaped pouch becomes J-shaped

29. Management
• Conservative
– Recurrent instability rate
unknown
– Young, athletic – prefer
surgical repair
• Surgical repair
– Arthroscopic
– Open

30. Outcome
• Limited to case series
• Most report no recurrent instability after repair
– Wolf (1995 Arthroscopy) – 6pts. 40 month
– Field (JESS 1997) – 5 pts. 26 month (HAGL + Bankart)
– Kon (2005 Arthroscopy) – 3 pts. 16 month

31. References
• George M et al. Humeral avulsion of glenohumeral
ligaments. JAAOS 2011; 19:127-33
• Melvin JS et al. MRI of HAGL Lesions: Four
arthroscopically confirmed cases of false-positive
diagnosis. AJR 2008; 191: 730-4
• www.shoulderdoc.co.uk