The Spiral Glenohumeral Ligament: An Open and Arthroscopic Anatomy Study

doi:10.1016/j.arthro.2007.12.009

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 24, Issue 11, November 2008, Pages 1271-1276

https://doi.org/10.1016/j.arthro.2007.12.009 Get rights and content

Purpose

The purpose of this study was to visualize arthroscopically and to describe the micro- and macroscopic anatomy of the poorly known ligament of the anterior capsule of the glenohumeral joint: the so-called ligamentum glenohumerale spirale (spiral GHL).

Methods

Twenty-two fresh shoulder joints were dissected, and the anatomy of the anterior capsular structures (the spiral GHL, the middle glenohumeral ligament [MGHL], and the anterior band as well as the axillary part of the inferior glenohumeral ligament [AIGHL and AxIGHL, respectively]) was investigated. For arthroscopic visualization, 30 prospective arthroscopic clinical cases and 19 retrospective video clips of the patients who had an arthroscopic shoulder procedure with a normal subscapularis tendon, labrum, and anterior joint capsule were evaluated.

Results

The spiral GHL and the AxIGHL were present in all 22 shoulder specimens. The AIGHL was not recognizable on the extra-articular side of the joint capsule. The MGHL was absent in 3 shoulder specimens (13.6%). Arthroscopically, the spiral GHL was found in 22 (44.9%), the MGHL in 43 (87.8%), and the AIGHL in 46 (93.9%) of the cases. The spiral GHL arose from the infraglenoid tubercle and the triceps tendon and inserted together with subscapularis tendon onto the lesser tubercle of the humerus.

Conclusions

Our results suggest that extra-articular structure of the spiral GHL is consistently recognizable, the upper part of which can be arthroscopically identified.

Clinical Relevance

Advanced anatomic knowledge of the spiral GHL helps the clinician better understand the normal anatomy of the shoulder joint and also helps to differiantiate it from pathologic findings of the patient. The biomechanical importance of the spiral GHL and its connection with shoulder pathology remains to be determined in futher studies.

Section snippets

Gross Anatomic Dissection and Histology

Twenty-two fresh shoulder joints with intact joint structures (11 right and 11 left shoulders; 12 male and 10 female; age range, 61 to 90 years) were investigated. Soft tissues, clavicle, and shoulder girdle muscles were removed from the shoulder specimens. The extra-articular part of the long head of the biceps tendon within the intertubercular groove was preserved. The muscles and tendons of the rotator cuff were separated from the joint capsule with scissors by blunt and sharp dissection.

Gross Anatomy

The oblique ascending capsular ligament in the superficial layer of the anterior shoulder joint capsule—the spiral GHL—was clearly visible in all 22 shoulder specimens. It arose as a distinct band from the infraglenoid tubercle and from the long head of the triceps brachii muscle tendon (Fig 2A). After crossing the underlying IGHL and establishing a tight connection with the MGHL, it fused laterally with the postero-cranial surface of the subscapularis tendon. The spiral GHL and the

Discussion

Our study describes the arthroscopic appearance as well as gross and microscopic anatomy of the relatively unknown glenohumeral joint structure, the so-called spiral GHL.

According to a currently accepted opinion, the GHLs are constant and discrete thickenings of the joint capsule.¹⁴ As such, the anterior capsular ligaments are best visible from the inside of the shoulder joint, as shown in contemporary anatomy textbooks3, 4 and clinical studies.5, 6, 7 Besides this well known description, a

Conclusions

The results of this anatomic study suggest that extra-articular structure of the spiral GHL is consistently recognizable and the upper part of the spiral GHL can be arthroscopically identified. Further biomechanical and clinical studies are needed to clarify its clinical importance.

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Cited by (15)

Anterior glenohumeral capsular ligament reconstruction with hamstring autograft for internal impingement with anterior instability of the shoulder in baseball players: preliminary surgical outcomes
2022, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
We considered that AGCR would prevent hyperangulation and anterior translation through the effect of the graft along the MGHL, inferior glenohumeral ligament (IGHL), and SSC. Turkel et al.56 reported that the subscapularis, MGHL, and anterosuperior fibers of the IGHL provided anterior stability; the medial end of the MGHL blended with the periosteum on the anterior aspect of the scapular neck, and the lateral end of the MGHL attached firmly to the subscapularis tendon.14,24,39,48,55 Although the role of the MGHL during the throwing motion has not been clarified, these previous studies predict that in theory, the MGHL could act as the key stabilizer for anterior instability.
Shoulder pain and dysfunction are common in baseball players, and although “internal impingement” is recognized as one of the most common pathologies of shoulder dysfunction, the optimal surgical treatment for internal impingement with anterior instability of the shoulder remains controversial. This study evaluated baseball players' preliminary outcomes following anterior glenohumeral capsular ligament reconstruction for internal impingement with anterior instability of the shoulder.
Twelve baseball players (all male; mean age, 20.5 ± 2.2 years) with internal impingement and anterior instability managed via anterior glenohumeral capsular ligament reconstruction were examined. The mean follow-up period was 25.3 ± 4.6 months. Anterior glenohumeral capsular ligament reconstruction was performed with a knee hamstring autograft for balanced stability and laxity with two major targets: to prevent hyperangulation and translation in horizontal abduction and to mimic the individual arm cocking position at the final decision of tension. Preoperative and final follow-up evaluations were performed using Jobe's postoperative grading system; the Kerlan–Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score; Disabilities of the Arm, Shoulder and Hand sports module; plain radiographs; and magnetic resonance imaging.
Jobe's postoperative grading system score, the Kerlan–Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score, and the Disabilities of the Arm, Shoulder and Hand sports module score improved significantly from 20.4 ± 12.2, 28.4 ± 8.3, and 80.2 ± 11.1 points preoperatively to 88.8 ± 13.6, 80.8 ± 7.7, and 22.4 ± 18.7 points postoperatively, respectively (P < .001, .0025, <0.001, respectively). Both clinical and imaging evaluations revealed improved internal impingement with anterior instability after anterior glenohumeral capsular ligament reconstruction. The mean external rotation at abduction significantly decreased from 113° preoperatively to 104° postoperatively. At follow-up, 10 of the 12 athletes (83.3%) returned to their prior competitive level. Plain radiographs and magnetic resonance imaging revealed no obvious loosening of the graft or screws.
Anterior glenohumeral capsular ligament reconstruction resulted in preferable clinical outcomes for young baseball players who experienced pain during the throwing motion. Stabilization of the glenohumeral joint with autografting of the knee hamstring may thus represent a solution for internal impingement with anterior instability in overhead throwing athletes.
Permeable spaces between glenohumeral ligaments as potential gateways for rapid regional anesthesia of the shoulder
2022, Annals of Anatomy
Citation Excerpt :
Another general limitation of this study is the fact that the sex ratio of the cadavers in which injections were performed is strongly skewed towards females, due to availability issues. This shortcoming may be relevant to our findings, as there is some degree of dimorphism in glenoid anatomy (Merrill et al., 2008; Mathews et al., 2017). However, we didn’t observe any differences in structure and patterns of GHLs between sexes in our samples (Table I).
Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.
Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: A Call for Further Quantitative Studies
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Kask et al.9 addressed the relation between the sGHL and mGHL on the glenoid, stating “the sGHL is intimately connected to the mGHL and is partially covered by it.” Similarly to the authors of other studies,11,21 Ide et al. described attenuated variants: 17.9% of specimens possessed a cord-like mGHL, and 1.2% had a Buford complex (Table 3). Nine studies reported on the glenoid attachment of the aIGHL.8,11,15-21
To perform a systematic review of the glenohumeral ligament anatomic attachments on the glenoid and humeral neck.
A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase from 1980 to present. The inclusion criteria were as follows: cadaveric or clinical anatomic studies that qualitatively or quantitatively described the glenoid and humeral attachments of the glenohumeral ligaments in the English-language literature. Imaging and animal studies, editorial articles, and surveys were excluded from this study.
The 15 included studies analyzed a total of 983 shoulders. Only 5 studies reported quantitative measurements. The most common glenoid superior glenohumeral ligament attachment described was in the anterolateral region of the supraglenoid tubercle and was inserting on the humerus in close vicinity to the subscapularis tendon insertion. The superior labrum and lesser tuberosity were the most commonly reported middle glenohumeral ligament attachments. The inferior glenohumeral ligament was most commonly described to attach between the 2- and 4-o’clock positions of the glenoid and distally near the surgical neck of the humerus.
There were limited quantitative data on the attachments of the glenohumeral ligaments. Although the literature was discordant, the most common descriptions of the attachments were as follows: The anterolateral region of the supraglenoid tubercle, the superior labrum, and the glenoid (between the 2- and 4-o’clock positions) were the medial attachments for the superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament, respectively. Laterally, they inserted on the humerus in close vicinity to the subscapularis tendon insertion, on the lesser tuberosity, and near the surgical neck of the humerus, respectively.
The glenohumeral ligaments are important anatomic structures contributing to the dynamic stability of the glenohumeral joint. Further detailed quantitative descriptions of their attachments are required for truly anatomically based repairs.
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: Supported by the Estonian Science Foundation (Grant No. 5991) and by Estonian Science Financing (Project No. 2130).

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Original ArticleThe Spiral Glenohumeral Ligament: An Open and Arthroscopic Anatomy Study

Purpose

Methods

Results

Conclusions

Clinical Relevance

Section snippets

Gross Anatomic Dissection and Histology

Gross Anatomy

Discussion

Conclusions

Arthroscopy

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Ann Anat

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

The pathophysiology of shoulder instability

Am J Sports Med

Grant's atlas of anatomy

Original Article
The Spiral Glenohumeral Ligament: An Open and Arthroscopic Anatomy Study