A 20-year-old patient with a history of traumatic anteroinferior dislocation and episodes of subluxation of the right shoulder, was referred to the Orthopaedic department because of persistent nonspecific pain and shoulder dysfunction.
A 20-year-old patient with a history of traumatic anterioinferior dislocation and episodes of subluxation of the right shoulder, with persistent nonspecific symptoms underwent radiological evaluation. Primarily, anteroposterior plain radiography in external and internal rotation of the arm, was obtained. An old Hill-Sachs defect and a bony-Bankart lesion were depicted (Fig. 1). Evaluation of patient’s shoulder with MR arthrogram was essential.
Under fluoroscopic guidance, 12cc of diluted Gadolinium was injected intra- articularly. After the injection of the contrast media, leakage along the shaft of the humerus was detected. That was an indication of a torn inferior capsule (Fig. 2)
MR arthrogram was performed in axial, sagittal and coronal planes. Coronal T1W FS images reveal a J-shaped appearance of the IGHL, the "J" sign of a HAGL lesion with concomitant extravasation of the contrast media. A Bankart lesion, and interruption of continuity of IGHL and a Hill-Sachs defect can be seen in the axial plane (Fig. 3)
Humeral avulsion of the inferior glenohumeral ligament (HAGL) is an infrequent cause of shoulder instability. This lesion occurs when the inferior glenohumeral ligament avulses from the inferior humeral neck and often is combined with other shoulder pathology such as labral tear, Hill-Sachs lesion, rotator cuff tear, specifically the subscapularis tendon or anterior capsule, which makes the diagnosis of HAGL a real challenge[1, 2]. The combination with a bony Bankart is rare and leads to isolation of the anterior band of the IGHL, called a “floating AIGHL”.
IGHL labral complex tear usually involves injury to the anterior band, although posterior avulsion of the inferior glenohumeral ligament has been described. Failure of this ligament has been shown to occur at three sites: at the glenoid origin (40%), an intrasubstance tear (35%), and at the point of insertion on the humerus (25%)[4].
The cause of HAGL lesion is usually a traumatic injury with the arm in hyperabduction and external rotation which usually leads to shoulder dislocation.
The complaints at the time of presentation are nonspecific, such as weakness, pain or dysfunction of the shoulder[1].
It is very difficult to diagnose HAGL lesion on plain radiographs, unless there is a bony HAGL lesion (BHAGL) which appears as a fleck of bone inferior to the anatomic neck of the humerus[1, 2, 4].
MRI is the imaging modality of choice for the assessment of a suspected HAGL lesion. In order to identify the humeral detachment of the IGHL, the use of MR arthrography is usually necessary [3]. Increased signal intensity and thickening of the inferior capsule, extravasation of joint fluid across the humeral detachment and a J-shaped anterior band of the inferior glenohumeral ligament (J sign), in stead of the normal U shaped appearance, are the main MRI findings that can lead to the diagnosis of HAGL lesion. Nevertheless, arthroscopy is the gold standard for diagnosis[2, 3, 4]. In our patient a classic Hill Sachs defect and bony Bankart are combined with a HAGL. Due to the isolation of the anterior band , this lesion has been described as a “floating AIGL”[5]. However, granulation tissue at the glenoid site indicates the spontaneous repair in longer standing disease.
Treatment of HAGL lesions is mainly surgical and can be performed either arthroscopically with suture anchors to reposition IGHL to its insertion or by open repair via a deltopectoral approach[1]. The shoulder instability in our patient has not yet been repaired.
Floating AIGHL.
1. X-ray Findings: The anteroposterior shoulder X-ray shows a mild compressive change on the posterolateral aspect of the humeral head, suggesting a possible Hill-Sachs lesion. The anteroinferior rim of the glenoid exhibits irregular or deficient bone, consistent with a bony Bankart lesion.
2. Arthrography or MRI Findings: MRI reveals an avulsion of the inferior glenohumeral ligament (IGHL) at its humeral attachment site, referred to as Humeral Avulsion of the Glenohumeral Ligament (HAGL). Because of the coexisting bony Bankart lesion and Hill-Sachs lesion, the detached anterior-inferior glenohumeral ligament appears “floating” (also termed “floating AIGHL”). In addition, some images demonstrate granulation tissue formation at the anteroinferior rim of the glenoid, suggesting possible spontaneous repair.
All of the above diagnoses align with this patient’s history of trauma, contracture, and recurrent shoulder instability. Among them, HAGL can be challenging to identify on imaging, but MRI arthrography clearly demonstrates an avulsion at the humeral attachment, making it a critical finding.
Considering the clinical history (recurrent subluxations and instability following trauma) and the imaging findings (bony Bankart lesion, Hill-Sachs lesion, and avulsion of the IGHL at its humeral attachment), the most likely final diagnosis is anterior-inferior instability of the right shoulder, with HAGL, accompanied by bony Bankart and Hill-Sachs lesions.
1. Treatment Strategies:
· Surgical Repair: For a confirmed HAGL and bony Bankart lesion, surgery is generally recommended. Under arthroscopy, techniques such as suture anchors or direct repair can be employed to reattach the IGHL to its humeral insertion or repair the glenoid defect. If necessary, additional procedures may be done to address the Bankart and Hill-Sachs lesions to prevent future recurrent dislocations.
· Conservative Treatment: If shoulder instability is mild or the patient is not currently a surgical candidate, conservative management — including immobilization and muscle-strengthening exercises — may be considered. However, in younger, more active individuals with recurrent episodes of shoulder instability, surgical intervention often offers better outcomes.
2. Rehabilitation and Exercise Prescription (Example Using the FITT-VP Principle):
· Early Rehabilitation (Weeks 1-4): The primary goal is to protect the repaired area and avoid re-injury. Under professional guidance, initiate passive range of motion (PROM) within a safe range. Use appropriate shoulder support devices to limit excessive abduction and external rotation.
· Mid Rehabilitation (Weeks 4-8): Gradually introduce active range of motion (AROM) exercises, such as external/internal rotation with light resistance bands. The aim is to strengthen the rotator cuff and surrounding shoulder musculature. Training frequency can be 3-4 sessions per week, each lasting 20-30 minutes.
· Late Strengthening (Weeks 8-12): Progressively increase resistance training and muscle-strengthening exercises, such as push-ups (starting with wall push-ups and progressing to floor push-ups), dumbbell abduction, forward raises, and rowing motions. Adjust the intensity and total volume based on pain and functional recovery, maintaining 3-4 training sessions per week.
· Advanced Training and Return to Activity (Week 12 and Beyond): Once clinical evaluations confirm adequate joint stability and muscle strength, gradually resume regular training and sports activities. Core stability and whole-body coordination exercises, such as planks, balance training, and throwing drills (starting with a light ball and progressing to normal weight), should be integrated. Continue monitoring shoulder function and pain closely.
· Individualization & Safety Precautions: In patients whose bony or soft tissues have not fully healed, exercise range and resistance should be strictly controlled, with shoulder braces or external fixation if needed. If notable pain, swelling, or persistent nighttime discomfort occurs, consult a physician promptly and adjust the rehabilitation plan accordingly.
Disclaimer:
This report is based on the current imaging and provided patient history and is for reference only. It does not replace an in-person consultation or individualized treatment advice from a professional physician. If you have any questions or develop new symptoms, please consult a specialist and follow their medical guidance.
Floating AIGHL.
