Posterior shoulder instability due to isolated reverse HAGL lesion in a young gymnast: A rare mechanism of injury and surgical technique

Repair of a Reverse Humeral Avulsion of the Glenohumeral Ligament and a Supraspinatus Tear in a Division I Collegiate Football Player: A Case Report

CASE

We present the case of a 21-year-old male, collegiate division I wide receiver, with a humeral avulsion of the posterior glenohumeral ligament (RHAGL) and near-full-thickness supraspinatus tear after falling on his outstretched arm. He returned to full collegiate participation with symptom resolution after arthroscopic repair of each tear.

CONCLUSION

This case report emphasizes the importance of imaging studies in the diagnosis of RHAGL and details a treatment approach that provided an excellent result in a young, active patient. This information will bring attention to these rare injuries and provides reference for providers who encounter patients with similar symptoms or pathology.

Imaging Posterior Instability of the Shoulder

Posterior instability of the shoulder is much less common than anterior instability with a clinical presentation that is often less obvious, making the diagnosis more challenging and more easily missed. We describe the imaging findings of posterior instability so the radiologist can make the diagnosis and provide a detailed description, enabling the surgeon to make more informed decisions regarding management and surgery.

Indications, management, and outcomes of humeral avulsions of the glenohumeral ligament: a systematic review

Purpose

To provide an updated overview of recent literature regarding the clinical indications, management, and outcomes of humeral avulsions of the glenohumeral ligament (HAGL) lesion.

Methods

Medline, Cochrane and Embase were systematically searched using keywords “humeral avulsion of the glenohumeral ligament” and others to identify studies reporting on management of HAGL lesions. Studies were double-screened and reviewed by two blinded authors according to selection criteria. Data was systematically extracted on the following topics: demographics, mechanism of injury, indication for treatment, treatment, post-operative complications, associated injuries, and outcomes including clinical outcome scores, clinical evaluations, and return to activity.

Results

There were 14 studies included that evaluated a total of 119 patients with HAGL lesions. In these studies, 69% of patients were male with a mean age of 24 years. Sports (23.5%) and fitness training (41.2%) were the most common injury mechanisms. Instability was the most common indication for treatment, followed by pain and recurrent dislocations. 85 associated lesions were reported, with non-descript labral tears (34.5%) and Bankart lesions (22.4%) being the most common. Out of patients treated, 117 of 119 patients were treated operatively, with 60 open and 57 arthroscopic procedures. A variety of clinical outcome scores showed postoperative functional shoulder improvement and 97% of patients were able to return to some level of activity.

Conclusions

HAGL lesions commonly present with associated injuries, necessitating a high clinical awareness of their presentation and management options to prevent undiagnosed lesions that can lead to persistent instability and pain. Surgical management yields good clinical outcomes.

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Critical Analysis Review

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Posterior humeral avulsions of the inferior glenohumeral ligament represent an increasingly recognized but likely underdiagnosed source of posterior shoulder instability and pain.

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Injuries are commonly reported in athletic individuals who have sustained injury by either traumatic or atraumatic mechanisms; the ligament is most susceptible to injury with the shoulder in flexion, adduction, and internal rotation.

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Posterior humeral avulsions of the glenohumeral ligament often occur in the setting of concurrent injuries to the posterior or inferior labrum.

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Diagnosis is often challenging due to nonspecific symptoms and physical examination findings; a magnetic resonance arthrogram generally is utilized to identify avulsion from the humeral attachment; however, a definitive diagnosis is often made at the time of arthroscopic evaluation.

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In patients with persistent discomfort and limitations following nonoperative management, operative fixation, primarily utilizing arthroscopic techniques, can be performed to restore motion and glenohumeral stability.

Humeral Avulsion of the Glenohumeral Ligament: Diagnosis and Management

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The most common type of humeral avulsion of the glenohumeral ligament (HAGL) is a purely ligamentous avulsion involving the anterior inferior glenohumeral ligament (IGHL), but other variants are seen, including posterior lesions and those with an osseous avulsion.

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A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity.

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HAGL lesions are most commonly seen in patients with anterior instability without a Bankart tear or in those with persistent symptoms despite having undergone a Bankart repair.

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Magnetic resonance imaging is the most sensitive imaging modality. An arthrogram is helpful with subacute and chronic lesions when the joint is not distended. Arthroscopy is the gold standard for diagnosis.

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While some have reported success with nonoperative management, surgical repair with either arthroscopic or open techniques has provided a high rate of successful outcomes; however, the literature is limited to mostly Level-IV and V evidence.