Humeral avulsion of the glenohumeral ligament

Last revised by Henry Knipe on 06 Jul 2022

Humeral avulsion of the glenohumeral ligament (HAGL) is, as the name suggests, 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 as bony humeral avulsion of the glenohumeral ligament (BHAGL lesion).

Humeral avulsion of the glenohumeral ligament is much more frequent in young men engaged in contact sports. Prevalence of ~1.5% on MRIs performed for shoulder pain 6

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

Humeral avulsion of the glenohumeral ligament most often results from anterior shoulder dislocation due to forced hyperabduction and external rotation of the arm 6.

MRI is the modality of choice for the assessment of HAGL, especially as the finding may be difficult to diagnose on arthroscopy. It should be noted that HAGL can be difficult to diagnose on MRI 6. 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 its glenoid insertion (40%) or midsubstance (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

Shoulder instability as a result of HAGL lesions is reported to occur in ~5% (range 2-10%) 2. The degree of instability and the presence of other associated injuries determines whether surgical repair is required.

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