Glenohumeral ligament sprain

1. High-Yield Summary

• Core Pathology: Glenohumeral ligament sprains represent traumatic or repetitive microtraumatic disruption of the static capsuloligamentous restraints of the glenohumeral joint, most critically involving the inferior glenohumeral ligament complex (IGHLC).
• Failure Spectrum: Injury patterns range from interstitial Grade I and II micro-stretching to complete macroscopic rupture (Grade III), which includes midsubstance tears, glenoid labrocapsular avulsions (Bankart variants), and humeral avulsion of the glenohumeral ligaments (HAGL).
• Diagnostic Gold Standard: Magnetic resonance arthrography (MRA) is the imaging modality of choice; disruption of the lateral capsular insertion with extravasation of contrast into the medial axillary pouch produces the pathognomonic “J-sign” (conversion of the normal U-shaped capsular sling into a J-shaped dependent pouch).
• Management Algorithm: Grade I and II sprains respond successfully to nonoperative dynamic rehabilitation emphasizing rotator cuff and periscapular stabilization. Full-thickness Grade III tears with persistent symptomatic microinstability and confirmed HAGL lesions in active patients warrant anatomic operative repair (open or arthroscopic suture anchor re-fixation to the anatomical humeral neck).
• Critical Danger Zone: The axillary nerve courses intimately along the inferior border of the capsule within the quadrangular space, lying within 2 to 4 mm of the inferior glenoid rim at the 6 o’clock position and 10 to 12 mm from the humeral insertion, putting it at catastrophic risk during inferior capsular dissection and anchor placement.

2. Anatomy

The glenohumeral joint is an inherently unstable ball-and-socket articulation characterized by marked osseous incongruity, with the shallow glenoid fossa accommodating less than one-third of the hemispherical humeral head. Static stability is heavily dependent upon the labrocapsular envelope and discrete thickening zones termed the glenohumeral ligaments: the superior glenohumeral ligament (SGHL), the middle glenohumeral ligament (MGHL), and the inferior glenohumeral ligament complex (IGHLC).

Capsuloligamentous Anatomy and Restraints

• Superior Glenohumeral Ligament (SGHL): Originates from the anterosuperior glenoid rim and supraglenoid tubercle, closely associated with the long head of the biceps tendon origin. It courses laterally across the rotator interval to insert on the fovea capitis humeri just superior to the lesser tuberosity. The SGHL acts in synergy with the coracohumeral ligament to serve as the primary static restraint against inferior humeral translation in the adducted arm (0 degrees of abduction) and secondary restraint to posterior translation.
• Middle Glenohumeral Ligament (MGHL): Originates from the anterosuperior glenoid rim immediately inferior to the SGHL and courses obliquely across the subscapularis tendon footprint to insert into the anatomical neck medial to the lesser tuberosity. The MGHL is the principal static check to anterior translation in intermediate abduction (45 degrees) and external rotation. It exhibits notable anatomical variation, ranging from complete absence to a cord-like structure. When a cord-like MGHL occurs with an absent anterosuperior labrum, it defines the normal variant known as the Buford complex.
• Inferior Glenohumeral Ligament Complex (IGHLC) – Anterior Band: Originates between the 2 o’clock and 4 o’clock positions on the anterior-inferior glenoid labrum and inserts into the anterior-inferior anatomical neck of the humerus. It tightens in abduction and external rotation (ABER), preventing anterior translation at 90 degrees of abduction.
• Inferior Glenohumeral Ligament Complex (IGHLC) – Posterior Band: Originates between the 7 o’clock and 9 o’clock positions on the posterior-inferior glenoid labrum and inserts into the posterior-inferior anatomical neck. It tightens in abduction and internal rotation (ABIR), resisting posterior translation at 90 degrees of abduction.
• Inferior Glenohumeral Ligament Complex (IGHLC) – Axillary Pouch: The suspended, cradle-like inter-band capsular hammock that cushions and cradles the inferior humeral head, preventing inferior subluxation at 90 degrees of abduction.

Neurovascular Danger Zones

The primary neurovascular structure at risk is the axillary nerve. Emerging from the posterior cord of the brachial plexus (C5, C6), the axillary nerve traverses the quadrangular space bounded superiorly by the subscapularis and teres minor, inferiorly by the teres major, medially by the long head of the triceps, and laterally by the surgical neck of the humerus. At the 6 o’clock position on the glenoid rim, the nerve courses within 2 to 4 mm of the capsular reflection. Along the humeral neck, it lies approximately 10 to 12 mm inferior to the articular margin. In abduction and external rotation, the nerve is pulled taut and brought into direct proximity with the inferior capsule. Excessive inferior capsular retraction, blind electrocautery, or misplaced inferior suture anchors risk complete transection, incarceration, or debilitating traction neurapraxia causing deltoid and teres minor denervation.

The anterior humeral circumflex artery and its accompanying venae comitantes (“the three sisters”) run horizontally across the inferior border of the subscapularis tendon insertion. They serve as an anatomical landmark demarcating the transition between the subscapularis and the quadrangular space. Surgical dissection inferior to these vessels invites brisk, retracting hemorrhage that obscures the axillary nerve.

Internervous Plane and Critical Bony Landmarks

Open surgical exposure utilizes the deltopectoral interval, exploiting the internervous plane between the deltoid (innervated by the axillary nerve) and the pectoralis major (innervated by the medial and lateral pectoral nerves). Mobilizing the cephalic vein laterally preserves deltoid venous drainage. Critical deep osseous landmarks include the infraglenoid tubercle (origin of the long head of triceps brachii), the anterior-inferior glenoid rim, the bicipital groove, and the anatomical and surgical neck footprints of the humerus.

3. Pathogenesis

Glenohumeral ligament sprains develop through high-energy acute loading or repetitive microtraumatic attenuation. The primary mechanism of injury is forced abduction and external rotation (ABER), which places the anterior band of the IGHLC under peak mechanical strain. As the humeral head translates anteriorly against the static restraint of the anterior capsulolabral sling, the tensile load across the ligament fibers rises exponentially. If the applied energy exceeds the ultimate tensile strength of the collagenous architecture (approximately 400 to 500 N in young healthy tissue), structural failure ensues.

Biomechanical Failure Patterns

Failure can occur at three distinct anatomical zones across the glenohumeral capsular hammock:

• Glenoid-Side Failure (Bankart Lesion Spectrum): The most prevalent failure mode in traumatic anterior shoulder dislocations (~85% to 90%), characterized by avulsion of the anterior-inferior labrum and confluent IGHLC origin from the glenoid rim.
• Midsubstance Capsular Failure: Interstitial micro-tearing or macroscopic transverse rupture within the collagenous substance of the IGHLC. Plastic deformation occurs when loading surpasses the yield point without complete detachment from bone, yielding chronic capsular redundancy and elongation.
• Humeral-Side Avulsion (HAGL Lesion): The capsular insertion detaches directly from the anatomical neck of the humerus. This occurs in approximately 7.5% to 9.3% of anterior glenohumeral dislocations and up to 25% of recurrent instability cases devoid of Bankart pathology. In high-energy collision trauma, a bony fragment may be sheared from the humeral neck, creating a bony HAGL (BHAGL). In violent hyperabduction-internal rotation trauma, the posterior band can avulse, resulting in a reverse HAGL (RHAGL).
• Bipolar / Floating IGHLC: Concurrent avulsion on both the glenoid side (Bankart) and the humeral side (HAGL), leaving the inferior capsular sling completely unmoored and incompetent.

4. Natural History

Glenohumeral ligament sprains demonstrate an age- and activity-dependent clinical course. The condition predominates in active male athletes between the ages of 18 and 35 involved in contact sports (rugby, American football, ice hockey, wrestling) and high-velocity overhead sports (baseball, javelin, water polo).

Grade I and mild Grade II interstitial sprains treated promptly with functional rehabilitation have an excellent natural prognosis, with over 80% to 85% of patients achieving complete resolution of symptoms and returning to pre-injury performance levels. Conversely, complete Grade III disruptions, full-thickness midsubstance ruptures, and unrecognized HAGL lesions carry a high rate of chronic functional impairment. Without anatomic mechanical continuity, the unmoored capsule undergoes fibrotic retraction and fatty degeneration, failing to restore static stability.

If left untreated, full-thickness capsuloligamentous incompetence culminates in persistent anterior or multidirectional microinstability. Over time, excessive anterior and inferior translation of the humeral head imparts abnormal shear forces across the glenoid articular surface and labrum, accelerating secondary glenoid rim erosion. Chronic microinstability precipitates secondary rotator cuff fatigue, internal impingement in overhead throwers, and ultimately premature glenohumeral osteoarthritis (capsulorrhaphy or instability arthropathy).

5. Clinical Presentation

History

Patients typically present following an acute traumatic event involving forced abduction and external rotation, violent traction, or a direct blow to the shoulder. Throwing athletes frequently describe an insidious onset of deep joint aching accompanied by a sudden loss of throwing velocity, mechanical catching, or a transient “dead arm” sensation during the late cocking or early acceleration phase. Key clinical inquiries should establish:

• Exact mechanism of injury (e.g., hyperabduction, external rotation torque, direct axial blow, traction).
• Occurrence of frank dislocation requiring manual reduction versus transient subluxation with spontaneous reduction.
• Positions of mechanical vulnerability, particularly pain or apprehension in overhead abduction and external rotation.
• Associated paresthesias or numbness over the lateral deltoid patch, pointing to concurrent axillary nerve stretch.

Physical Exam

Physical examination requires systematic bilateral evaluation of passive range of motion, rotator cuff integrity, and specialized provocative maneuvers quantifying static and dynamic glenohumeral stability:

• Anterior Apprehension Test: With the patient supine, the arm is positioned in 90 degrees of abduction and gently externally rotated while the examiner supports the elbow. -> Positive Finding: Sensation of imminent joint dislocation, pain, or visible facial apprehension and muscular guarding [Sensitivity 72%–88%, Specificity 96%–99%].
• Jobe Relocation Test: Follows a positive apprehension test. The examiner applies a gentle posterior-directed translation force to the anterior humeral head. -> Positive Finding: Immediate cessation of apprehension and pain, allowing further external rotation [Sensitivity 81%–85%, Specificity 90%–98%].
• Surprise / Anterior Release Test: From the relocated position, the examiner abruptly releases the posterior stabilizing force. -> Positive Finding: Immediate recurrence of sharp anterior apprehension, pain, or forward translation of the humeral head [Sensitivity 64%–92%, Specificity 89%–99%].
• Sulcus Sign: With the patient seated and arm relaxed at the side, the examiner applies steady downward axial traction at the elbow at 0 degrees and 30 degrees of abduction. -> Positive Finding: Visible skin depression or “sulcus” beneath the lateral acromial border. Graded as 1+ (<1 cm), 2+ (1 to 2 cm), or 3+ (>2 cm), diagnostic of inferior capsular laxity and rotator interval incompetence [Sensitivity 72%–85%, Specificity 86%–93%].
• Load and Shift Test: The examiner stabilizes the clavicle and scapular spine with one hand, axially loads the humeral head into the glenoid fossa with the other, and translates the humerus anteriorly and posteriorly at 0 degrees and 45 degrees of abduction. -> Positive Finding: Asymmetric translation with soft or absent endpoint, graded based on translation to the glenoid rim (Grade I), over the rim with spontaneous reduction (Grade II), or over the rim without reduction (Grade III) [Sensitivity 65%–80%, Specificity 85%–92%].

6. Imaging and Diagnostic Studies

Diagnostic evaluation follows a hierarchical pathway starting with specialized radiographic projections and culminating in high-resolution contrast-enhanced magnetic resonance arthrography.

Plain Radiographs

Initial evaluation requires a dedicated shoulder trauma series:

• True Anteroposterior (Grashey View): Beam angled 35 to 45 degrees toward the scapular plane to visualize the joint space without glenohumeral overlap, assessing concentric reduction and joint space narrowing.
• Axillary Lateral View: Essential to confirm concentric articulation and exclude subtle posterior or anterior subluxation.
• West Point Axillary View: Prone view with 25 degrees caudal and 25 degrees medial beam angulation; highly sensitive for visualizing cortical avulsion or fracture of the anterior-inferior glenoid rim (bony Bankart).
• Stryker Notch View: Hand placed on top of the head with 10 degrees cephalad beam angulation; profiles the posterolateral margin of the humeral head to detect Hill-Sachs impaction defects.
• Internal Rotation AP: Profiles the medial surgical neck of the humerus, identifying cortical irregularity or fleck avulsion indicative of a Bony HAGL (BHAGL) lesion.

Magnetic Resonance Arthrography (MRA)

Direct magnetic resonance arthrography with intra-articular dilute gadolinium is the gold standard imaging modality for identifying capsuloligamentous disruption, exhibiting sensitivity exceeding 85% to 90% and specificity over 95% for HAGL lesions:

• The “J-Sign”: In a normal shoulder, the coronal oblique T1-weighted fat-suppressed sequence demonstrates the axillary pouch and IGHLC as an intact, symmetric, U-shaped sling originating from the glenoid and inserting on the humeral neck. When the humeral insertion avulses, the lateral limb drops inferiorly and retracts medially, transforming the classic “U” into a dependent “J-shaped” fluid pouch.
• Contrast Extravasation: Full-thickness capsular tears allow gadolinium contrast to extravasate along the medial surgical neck of the humerus, tracking into the subscapularis muscular belly or the axillary soft-tissue planes.
• Abduction and External Rotation (ABER) Sequence: Placing the shoulder in the ABER position tensions the anterior band of the IGHLC, elevating diagnostic sensitivity for subtle partial tears, labral peeling, and non-retracted insertional avulsions.
• Non-Arthrographic MRI Limitations: Conventional non-contrast MRI has inferior diagnostic accuracy for isolated capsular sprains and HAGL lesions, as the un-distended axillary pouch frequently collapses against the humeral neck, masking complete tears.

7. Classification

Glenohumeral ligament injuries are classified according to clinical severity grades and validated anatomical avulsion subtypes that directly guide surgical reconstruction.

8. Treatment

Medical / Nonoperative

Nonoperative treatment is the initial gold standard for Grade I and Grade II capsuloligamentous sprains, as well as selected Grade III midsubstance tears in low-demand, non-overhead athletic individuals.

• Acute Phase (Weeks 1 to 2): Brief sling immobilization for comfort and initial tissue healing. Immobilization should not exceed 10 to 14 days to prevent capsular contracture and disuse atrophy. Analgesics and scheduled non-steroidal anti-inflammatory drugs (NSAIDs) control reactive synovitis. Gentle pendulum exercises, active elbow and wrist motion, and passive shoulder range of motion within the pain-free zone (forward elevation <90 degrees, external rotation restricted to neutral) are initiated immediately.
• Intermediate Dynamic Recovery (Weeks 3 to 6): Progressive restoration of full active-assisted and active range of motion. Structured dynamic neuromuscular stabilization begins, focusing on the dynamic anterior stabilizers: subscapularis, infraspinatus, and teres minor. Rhythmic stabilization drills, isometric strengthening, and closed kinetic chain exercises enhance dynamic joint concavity compression.
• Advanced Functional Conditioning (Weeks 6 to 12+): High-level periscapular dynamic conditioning (serratus anterior, lower trapezius, rhomboids) to restore normal scapulohumeral rhythm. Integration of plyometrics, eccentric rotator cuff training, and proprioceptive neuromuscular facilitation (PNF) patterns. Overhead throwers progress through an interval throwing program once bilateral rotational symmetric strength exceeds 90%.
• Objective Failure Criteria: Persistent subjective instability, mechanical catching, recurrent subluxation episodes, or disabling anterior apprehension despite 12 to 16 weeks of structured, supervised rehabilitation.

Operative

The primary surgical goal is anatomic re-approximation of the torn capsuloligamentous complex directly to its native humeral footprint, restoring normal capsular volume and resting tension without over-constraining physiologic range of motion.

• Open Anatomic Repair: Considered the historical gold standard for HAGL lesions. Exposure is achieved through an anterior deltopectoral approach. To preserve subscapularis function, a horizontal split is performed in the lower third of the subscapularis tendon (subscapularis-sparing approach), or an L-shaped tenotomy leaving a 1 cm cuff of tendon on the lesser tuberosity for secure anatomic closure. The torn inferior capsular leaf is identified within the axillary pouch. The anatomical humeral neck is prepared to bleeding cortical bone with a burr or rasp. Two to three double-loaded suture anchors (3.0 to 4.5 mm) are inserted into the footprint. Suture limbs are passed in a horizontal mattress fashion through the retracted capsular edge and tied with the shoulder held in 30 degrees of abduction and 30 degrees of external rotation.
• Arthroscopic Anatomic Repair: A technically demanding procedure indicated for isolated HAGL lesions, particularly in young patients or when concurrent intra-articular pathology (e.g., SLAP tear, posterior labral tear) requires intervention. A 70-degree arthroscope placed through a high posterior portal or accessory Neviaser portal facilitates visualization down the axillary pouch to the inferior humeral neck. An accessory 5 o’clock or 7 o’clock low anterior-inferior trans-subscapularis portal is established under direct visualization. Suture anchors are placed onto the decorticated humeral neck, and specialized suture-passing instruments shuttled through the capsular leaf allow anatomic mattress knot fixation.

Indications & Contraindications

Indications for Operative Reconstruction:

• Documented full-thickness HAGL, RHAGL, or BHAGL lesion on MRA in active individuals or competitive athletes.
• Displaced Bony HAGL (BHAGL) fracture fragment with >2 mm displacement or articular involvement.
• Floating IGHLC lesion (concurrent Bankart and HAGL pathology).
• Grade III capsular rupture with persistent symptomatic microinstability failing 3 to 6 months of supervised rehabilitation.

Contraindications to Operative Intervention:

• Active glenohumeral sepsis or localized soft-tissue infection.
• Severe glenohumeral osteoarthritis (capsulorrhaphy or instability arthropathy with joint space obliteration; requires arthroplasty).
• Voluntary, non-traumatic multidirectional instability associated with behavioral disorders.
• Patient inability to adhere to postoperative protective immobilization and rehabilitation protocols.

9. Outcome

Clinical outcomes following anatomical repair of glenohumeral ligament disruptions and HAGL lesions demonstrate substantial, durable improvements in validated patient-reported outcome measures (PROMs):

• American Shoulder and Elbow Surgeons (ASES) Score: Mean scores improve significantly from preoperative baselines of 50 to 58 points to postoperative values of 88 to 94 points at long-term follow-up exceeding 5 to 10 years.
• Rowe Score for Instability: Increases from preoperative levels <45 points to postoperative levels of 86 to 92 points, indicating stable restoration of glenohumeral kinematics.
• Western Ontario Shoulder Instability Index (WOSI): Demonstrates marked normalization of quality-of-life and emotional stability scores, with average post-repair scores exceeding 85% of normal shoulder function.
• Return to Play (Nonoperative Sprains): Athletes return to sports between 4 and 8 weeks following full resolution of apprehension and restoration of symmetric kinetic chain strength.
• Return to Play (Operative Repairs): Collision athletes return to unrestricted contact at 6 to 9 months; overhead throwers return to competition at 9 to 12 months. Overall return to pre-injury athletic level ranges from 83% to 90%.
• Recurrence Rates: Anatomic open or arthroscopic suture anchor repair achieves a low recurrent instability rate (<5% to 8%). In contrast, nonoperative management of complete HAGL avulsions yields chronic recurrent subluxation and instability in over 50% to 70% of active individuals.

10. Complications

Complications are categorized chronologically into intraoperative, early postoperative, and late postoperative stages.

11. Pearls and Pitfalls

Navigating capsuloligamentous pathology requires careful intraoperative technique and vigilance against common diagnostic errors:

• Pearl: Systemic 70-Degree Axillary Pouch Inspection: During diagnostic arthroscopy for anterior instability, never conclude the procedure after finding a Bankart lesion. Systematically advance the 30-degree or 70-degree arthroscope inferiorly along the humeral neck into the axillary pouch while an assistant abducts and externally rotates the humerus. The normal humeral capsular reflection should attach cleanly to bone without fluid extravasation or exposed humeral cortical neck.
• Pearl: Subscapularis-Sparing Horizontal Split: In open HAGL repairs, an inferior horizontal split between the upper two-thirds and lower one-third of the subscapularis preserves the active internal rotation tendon and protects the anterior circumflex vessels. This approach reduces postoperative subscapularis atrophy and allows earlier rehabilitation.
• Pearl: Capsular Tensioning Parameters: When securing the capsular flap to the humeral neck, always fix and tie the sutures with the arm positioned in 30 degrees of abduction and 30 degrees of external rotation. Tensioning the capsule in complete internal rotation or adduction risks severe permanent external rotation contracture.
• Pitfall: Confusing the Buford Complex with Pathology: The Buford complex (a cord-like MGHL associated with an absent anterosuperior labrum) is an anatomical variant present in 1.5% to 6.5% of individuals. Anchoring this cord-like ligament to the anterior glenoid rim over-constrains the joint, producing painful loss of external rotation and early secondary osteoarthritis.
• Pitfall: Overlooking the Bipolar “Floating IGHLC”: Addressing only the anterior Bankart lesion while missing a concurrent HAGL tear leaves the inferior suspension hammock incompetent, ensuring persistent postoperative microinstability and early repair failure.

12. Controversy

Two primary areas of ongoing clinical debate involve the optimal surgical approach for HAGL repair and the management of capsular micro-laxity in overhead throwers.

Open Versus Arthroscopic HAGL Repair

Historically, open repair through a deltopectoral approach has been the gold standard, offering direct visualization of the humeral neck, straightforward anchor insertion, and direct protection of the axillary nerve. However, open surgery requires subscapularis violation (split or tenotomy) and carries risks of subscapularis dysfunction, postoperative stiffness, and anterior scar tissue. Proponents of arthroscopic repair emphasize complete preservation of the subscapularis, superior visualization of concomitant intra-articular pathology, and reduced postoperative pain. Conversely, arthroscopic repair has a steep learning curve, requires specialized low accessory portals (5 o’clock or 7 o’clock), and carries technical challenges in suture passing within a confined, fluid-distended axillary pouch. Recent systematic reviews demonstrate equivalent functional scores (ASES, Rowe) and low re-dislocation rates (<5%) between open and arthroscopic cohorts when performed by experienced shoulder surgeons.

Management of Capsular Strain and Micro-Laxity in Overhead Throwers

Elite overhead athletes frequently develop adaptive anterior capsular micro-laxity paired with posteroinferior capsular contracture (glenohumeral internal rotation deficit [GIRD]). Thermal capsulorrhaphy, widely utilized in the late 1990s to shrink attenuated capsular tissue, has been abandoned due to unacceptably high rates of recurrent failure, capsular necrosis, and chondrolysis. Modern consensus strongly mandates a minimum of 6 months of nonoperative kinetic chain rehabilitation (posterior capsular sleeper stretches, periscapular stabilization, and rotator cuff balancing). Operative capsular plication or rotator interval closure in throwers remains controversial, as over-tightening the anterior capsule eliminates the extreme external rotation required for competitive throwing velocity.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Longo UG, Rizzello G, Ciuffreda M et al. Humeral Avulsion of the Glenohumeral Ligaments: A Systematic Review. Arthroscopy. 2016. doi:10.1016/j.arthro.2016.03.009 [Level I: Systematic Review / Meta-Analysis]
• O’Brien SJ, Neves MC, Arnoczky SP et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med. 1990. doi:10.1177/036354659001800501 [Level IV: Clinical Case Series / Cohort Study]
• Warner JJ, Deng XH, Warren RF et al. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med. 1992. doi:10.1177/036354659202000608 [Level IV: Clinical Case Series / Cohort Study]
• Dannaway J, Raniga S, Bokor D. Long-term Outcomes After Open Repair of Humeral Avulsion of the Glenohumeral Ligament. Orthop J Sports Med. 2024. doi:10.1177/23259671241247544 [Level IV: Clinical Case Series / Cohort Study]
• Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007. doi:10.1177/0363546507301081 [Level I: Systematic Review / Meta-Analysis]

15. Master Class Pro-Tip

When evaluating recurrent anterior instability, the most critical technical pitfall is concluding diagnostic arthroscopy upon identifying an anterior Bankart lesion without thoroughly inspecting the humeral insertion of the inferior glenohumeral ligament complex. Drive the arthroscope down along the humeral neck into the axillary pouch while an assistant abducts and externally rotates the humerus. If the capsule does not insert smoothly onto the anatomical neck or if extravasation exposes bare cortical bone, an anterior HAGL lesion is present. In open repairs, split the lower third of the subscapularis horizontally rather than performing a complete tenotomy. This preserves upper tendon biology and keeps dissection safely superior to the anterior humeral circumflex vessels. Secure the capsular leaf to the humeral neck using double-loaded suture anchors placed at a 45-degree angle. Most crucially, tie the mattress sutures with the arm positioned in 30 degrees of abduction and 30 degrees of external rotation. Securing the capsule in internal rotation will cause severe permanent external rotation contracture and secondary posterior glenoid arthrosis.

Master Class Surgical Pearl: Glenohumeral Ligament Integrity