Biomechanics and Management of HAGL Lesions in Anterior Instability

Desmond J Bokor, Yuval Arama

Volume 2 | Issue 1 | Jan – Apr 2017 | Page 36 -39

Author: Desmond J Bokor [1], Yuval Arama [1].

[1] Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia

Address of Correspondence

Dr. Desmond Bokor,
Suite 303, 2 Technology Place,Macquarie University. NSW. 2019, Sydney,Australia.


Humeral avulsion of the glenohumeral ligament is an uncommon but important cause for recurrent anterior instability of the shoulder. It is usually associated with high energy trauma in a slightly older male population with a hyperabduction/axial load mechanism. Associated damage can include avulsion of the glenoid labrum, rotator cuff tears, and bony damage. Diagnosis requires a high index of clinical suspicion, and MR arthrography performed 4-6 weeks post injury is the most reliable investigation. Care should be taken with MRI performed in the first week, as many of the lesions seen at this time will heal. Surgical repair is recommended for recurrent instability or if the patient requirements need them to have a stable shoulder. Repair can be performed using arthroscopic, minopen or full open techniques. Care should be taken when placing sutures through the capsule because of the proximity of the axillary nerve to the inferior capsular edge. Biomechanically, the capsule should be repaired to the medial humeral neck just below the chondral margin. Surgical outcomes are satisfactory in most series reported.
Keywords: Anterior instability, humeral avulsion of the glenohumeral ligament


1. Nicola T. Anterior dislocation of the shoulder: The role of the articular capsule. J Bone Joint Surg Am 1942;24:614-616.
2. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.
3. Bokor DJ, Conboy VB, Olson C. Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament. A review of 41 cases. J Bone Joint Surg Br 1998;81-B:93-96.
4. Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: The HAGL lesion. Am J Sports Med 2007;35(11):1960-1966.
5. Bui-Mansfield LT, Taylor DC, Uhorchak JM, Tenuta JJ. Humeral avulsions of the glenohumeral ligament: Imaging features and a review of the literature. AJR Am J Roentgenol 2002;179(3):649-655.
6. Field LD, Bokor DJ, Savoie FH. Humeral and glenoid detachment of the anterior inferior glenohumeral ligament: A cause of anterior shoulder instability. J Shoulder Elbow Surg1997;6:6-10.
7. Rhee YG, Cho NS. Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion. J Shoulder Elbow Surg2007;16:188-192.
8. Bach BR, Warren RF, Fronek J. Disruption of the lateral capsule of the shoulder. A cause of recurrent dislocation. J Bone Joint Surg Br 1988;70:274-276.
9. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63-A:1208-1217.
10. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC. Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10(2):187-197.
11. Norlin R Intraarticular pathology in acute, first-time anterior shoulder dislocation: An arthroscopic study. Arthroscopy 1993;9:546-549.
12. Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18(1):25-28.
13. Gagey O, Gagey N, Boisrenoult P, Hue E, Mazas F. Experimental study of dislocations of the scapulohumeral joint. Rev ChirOrthopReparatriceAppar Mot 1993;79:13-21.
14. Pouliart N, Gagey O. Simulated humeral avulsion of the glenohumeral ligaments: A new instability model. J Shoulder Elbow Surg2006;15:728-735.
15. George MS, Khazzam M, Kuhn JE. Humeral avulsion of glenohumeral ligaments. J Am AcadOrthopSurg2011;19:127-133.
16. Gagey OJ, Gagey N. The hyperabduction test. An assessment of the laxity of the inferior glenohumeral ligament. J Bone Joint Surg Br 2000;82-B:69-74.
17. Melvin JS, Mackenzie JD, Nacke E, Sennett BJ, Wells L. MRI of HAGL lesions: Four arthroscopically confirmed cases of false-positive diagnosis. AJR Am J Roentgenol2008;191:730-734.
18. Liavaag S, Stiris MG, Svenningsen S, Enger M, Pripp AH, Brox JI. Capsular lesions with glenohumeral ligament injuries in patients with primary shoulder dislocation: Magnetic resonance imaging and magnetic resonance arthrography evaluation. Scand J Med Sci Sports 2011;21:e291-e297.
19. O’Brien SJ, Neves MC, Arnoczky SP, Rozbruck SR, Dicarlo EF, Warren RF, et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;18:449-456.
20. Pouliart N, Gagey O. Reconciling arthroscopic and anatomic morphology of the humeral insertion of the inferior glenohumeral ligament. Arthroscopy 2005;21:979-984.
21. Southgate DF, Bokor DJ, Longo UG, Wallace AL, Bull AM. The effect of humeral avulsion of the glenohumeral ligaments and humeral repair site on joint laxity: A biomechanical study. Arthroscopy 2013;29(6):990-997.
22. Arciero RA, Mazzocca AD. Mini-open repair technique of HAGL (humeral avulsion of the glenohumeral ligament) lesion. Arthroscopy 2005;21:1152.
23. Bhatia DN, DeBeer JF, van Rooyen KS. The “subscapularis-sparing” approach: A new mini-open technique to repair a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2009;25:686-690.
24. Bhatia DN, DasGupta B. Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability. Knee Surg Sports TraumatolArthrosc2013;21:1603-1609.
25. Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2005;21:632.
26. Page RS, Bhatia DN. Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion: Anterior and posterior techniques. Tech Hand Up ExtremSurg 2009;13(2):98-103.
27. Richards DP, Burkhart SS. Arthroscopic humeral avulsion of the glenohumeral ligaments (HAGL) repair. Arthroscopy 2004;20 Suppl 2:134-141.
28. Spang JT, Karas SG. The HAGL lesion: An arthroscopic technique for repair of humeral avulsion of the glenohumeral ligaments. Arthroscopy 2005;21:498-502.
29. Bhatia DN, de Beer JF. The axillary pouch portal: A new posterior portal for visualization and instrumentation in the inferior ohumeral recess. Arthroscopy 2007;23:1241, e1-e5.

How to Cite this article:. Bokor DJ, Arama Y. Biomechanics and management of HAGL lesions in Anterior Instability. Asian Journal of Arthroscopy Jan – April 2017;1(2):36-39.

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