Advanced Imaging of the Glenohumeral Ligaments

Abstract

The glenohumeral ligaments (GHLs) are the most important passive stabilizers of the shoulder joint. Recognition of acute and chronic glenohumeral ligamentous lesions is very important in the preoperative work-up of shoulder instability and trauma. This article describes and depicts the normal anatomy of the GHLs and their appearance during arthroscopy and on MR and computed tomography arthrography (CTA). Pathologic findings of the superior, middle, and inferior GHLs are described and illustrated with MR and CTA and their corresponding intraoperative arthroscopic images. MR arthrography (MRA) is useful for direct visualization of all GHLs including most lesions of their intra-articular portion and associated capsulolabral pathologies. Sprains, midsubstance tears, avulsion, or fibrous infiltration of the GHL can be identified on MRA images using fast spin-echo sequences with and without fat saturation in the three planes. Although CTA is reputed to better depict associated bony and cartilage lesions, CTA allows only indirect evaluation of the GHLs by outlining their contour or showing contrast penetration. Normal variants may create pitfalls that one should be aware of. Signs of GHL pathology on imaging include: discontinuity, nonvisualization, changes in signal intensity (on MRA), contrast extravasation, contour irregularity, thickening, or waviness.

Keywords

superior - middle - inferior glenohumeral ligaments - shoulder instability - shoulder MRA - CTA - arthroscopy

• References

• 1 Pouliart N, Somers K, Eid S, Gagey O. Variations in the superior capsuloligamentous complex and description of a new ligament. J Shoulder Elbow Surg 2007; 16 (6) 821-836
• 2 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
• 3 Carlson CL. The “J” sign. Radiology 2004; 232 (3) 725-726
• 4 Chung CB, Sorenson S, Dwek JR, Resnick D. Humeral avulsion of the posterior band of the inferior glenohumeral ligament: MR arthrography and clinical correlation in 17 patients. AJR Am J Roentgenol 2004; 183 (2) 355-359
• 5 George MS, Khazzam M, Kuhn JE. Humeral avulsion of glenohumeral ligaments. J Am Acad Orthop Surg 2011; 19 (3) 127-133
• 6 Magee T. Prevalence of HAGL lesions and associated abnormalities on shoulder MR examination. Skeletal Radiol 2014; 43 (3) 307-313
• 7 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 Roentgenol 2008; 191 (3) 730-734
• 8 Tirman PF, Steinbach LS, Feller JF, Stauffer AE. Humeral avulsion of the anterior shoulder stabilizing structures after anterior shoulder dislocation: demonstration by MRI and MR arthrography. Skeletal Radiol 1996; 25 (8) 743-748
• 9 Steinbach LS. MRI of shoulder instability. Eur J Radiol 2008; 68 (1) 57-71
• 10 Yeh L, Kwak S, Kim YS , et al. Anterior labroligamentous structures of the glenohumeral joint: correlation of MR arthrography and anatomic dissection in cadavers. AJR Am J Roentgenol 1998; 171 (5) 1229-1236
• 11 Chung CB, Dwek JR, Cho GJ, Lektrakul N, Trudell D, Resnick D. Rotator cuff interval: evaluation with MR imaging and MR arthrography of the shoulder in 32 cadavers. J Comput Assist Tomogr 2000; 24 (5) 738-743
• 12 Petchprapa CN, Beltran LS, Jazrawi LM, Kwon YW, Babb JS, Recht MP. The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance. AJR Am J Roentgenol 2010; 195 (3) 567-576
• 13 Pouliart N, Gagey OJ. The arthroscopic view of the glenohumeral ligaments compared with anatomy: fold or fact?. J Shoulder Elbow Surg 2005; 14 (3) 324-328
• 14 Pouliart N, Somers K, Gagey O. Arthroscopic glenohumeral folds and microscopic glenohumeral ligaments: the fasciculus obliquus is the missing link. J Shoulder Elbow Surg 2008; 17 (3) 418-430
• 15 Chandnani VP, Gagliardi JA, Murnane TG , et al. Glenohumeral ligaments and shoulder capsular mechanism: evaluation with MR arthrography. Radiology 1995; 196 (1) 27-32
• 16 Palmer WE, Brown JH, Rosenthal DI. Labral-ligamentous complex of the shoulder: evaluation with MR arthrography. Radiology 1994; 190 (3) 645-651
• 17 Acid S, Le Corroller T, Aswad R, Pauly V, Champsaur P. Preoperative imaging of anterior shoulder instability: diagnostic effectiveness of MDCT arthrography and comparison with MR arthrography and arthroscopy. AJR Am J Roentgenol 2012; 198 (3) 661-667
• 18 Lecouvet FE, Simoni P, Koutaïssoff S, Vande Berg BC, Malghem J, Dubuc JE. Multidetector spiral CT arthrography of the shoulder. Clinical applications and limits, with MR arthrography and arthroscopic correlations. Eur J Radiol 2008; 68 (1) 120-136
• 19 Boulet C, De Maeseneer M, Pouliart N, De Mey J, Handelberg F, Shahabpour M. Magnetic resonance arthrography of glenohumeral lesions: anatomy and arthroscopically confirmed pathology. Can Assoc Radiol J 2012; 63 (2) 79-86
• 20 Coussement K, Pouliart N. Correlation of ArthroMRI, ArthroCT and arthroscopy for anterosuperior lesions of the glenohumeral joint [master's thesis]. Brussels, Belgium: Vrije Universiteit Brussel; 2012
• 21 De Maeseneer M, Van Roy F, Lenchik L , et al. CT and MR arthrography of the normal and pathologic anterosuperior labrum and labral-bicipital complex. Radiographics 2000; 20 (Spec No) S67-S81
• 22 De Maeseneer M, Van Roy P, Shahabpour M. Normal MR imaging anatomy of the rotator cuff tendons, glenoid fossa, labrum, and ligaments of the shoulder. Radiol Clin North Am 2006; 44 (4) 479-487 , vii
• 23 De Maeseneer M, Boulet C, Pouliart N , et al. Assessment of the long head of the biceps tendon of the shoulder with 3T magnetic resonance arthrography and CT arthrography. Eur J Radiol 2012; 81 (5) 934-939
• 24 Dekeyzer P, Pouliart N. Correlation of ArthroMRI, ArthroCT and arthroscopy for lesions of the glenohumeral joint [master's thesis]. Brussels, Belgium: Vrije Universiteit Brussel; 2013
• 25 Halma JJ, Eshuis R, Krebbers YM, Weits T, de Gast A. Interdisciplinary inter-observer agreement and accuracy of MR imaging of the shoulder with arthroscopic correlation. Arch Orthop Trauma Surg 2012; 132 (3) 311-320
• 26 Merila M, Leibecke T, Gehl HB , et al. The anterior glenohumeral joint capsule: macroscopic and MRI anatomy of the fasciculus obliquus or so-called ligamentum glenohumerale spirale. Eur Radiol 2004; 14 (8) 1421-1426
• 27 Neumann CH, Petersen SA, Jahnke Jr AH , et al. MRI in the evaluation of patients with suspected instability of the shoulder joint including a comparison with CT-arthrography. Rofo 1991; 154 (6) 593-600
• 28 Pouliart N, Coussement K, Boulet C, De Maeseneer M, Handelberg F, Shahabpour M. Anterosuperior shoulder instability: MRA and CTA against arthroscopically confirmed pathology. Paper presented at: the 8th ISAKOS Congress; 2013; Toronto, Canada
• 29 Sanders TG, Tirman PF, Linares R, Feller JF, Richardson R. The glenolabral articular disruption lesion: MR arthrography with arthroscopic correlation. AJR Am J Roentgenol 1999; 172 (1) 171-175
• 30 van der Veen HC, Collins JP, Rijk PC. Value of magnetic resonance arthrography in post-traumatic anterior shoulder instability prior to arthroscopy: a prospective evaluation of MRA versus arthroscopy. Arch Orthop Trauma Surg 2012; 132 (3) 371-375
• 31 Waldt S, Metz S, Burkart A , et al. Variants of the superior labrum and labro-bicipital complex: a comparative study of shoulder specimens using MR arthrography, multi-slice CT arthrography and anatomical dissection. Eur Radiol 2006; 16 (2) 451-458
• 32 Wischer TK, Bredella MA, Genant HK, Stoller DW, Bost FW, Tirman PF. Perthes lesion (a variant of the Bankart lesion): MR imaging and MR arthrographic findings with surgical correlation. AJR Am J Roentgenol 2002; 178 (1) 233-237
• 33 Neer II CS, Satterlee CC, Dalsey RM, Flatow EL. The anatomy and potential effects of contracture of the coracohumeral ligament. Clin Orthop Relat Res 1992; (280) 182-185
• 34 Dunham KS, Bencardino JT, Rokito AS. Anatomic variants and pitfalls of the labrum, glenoid cartilage, and glenohumeral ligaments. Magn Reson Imaging Clin N Am 2012; 20 (2) 213-228 , x
• 35 Werner A, Mueller T, Boehm D, Gohlke F. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. A histoanatomic study. Am J Sports Med 2000; 28 (1) 28-31
• 36 Di Giacomo G, Pouliart N, Costantini A, De Vita A. Atlas of Functional Shoulder Anatomy. Milan, Italy: Springer Verlag; 2008
• 37 Jost B, Koch PP, Gerber C. Anatomy and functional aspects of the rotator interval. J Shoulder Elbow Surg 2000; 9 (4) 336-341
• 38 Harryman II DT, Sidles JA, Harris SL, Matsen III FA. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992; 74 (1) 53-66
• 39 Itoi E, Berglund LJ, Grabowski JJ, Naggar L, Morrey BF, An KN. Superior-inferior stability of the shoulder: role of the coracohumeral ligament and the rotator interval capsule. Mayo Clin Proc 1998; 73 (6) 508-515
• 40 Tetro AM, Bauer G, Hollstien SB, Yamaguchi K. Arthroscopic release of the rotator interval and coracohumeral ligament: an anatomic study in cadavers. Arthroscopy 2002; 18 (2) 145-150
• 41 Rudez J, Zanetti M. Normal anatomy, variants and pitfalls on shoulder MRI. Eur J Radiol 2008; 68 (1) 25-35
• 42 Rafii M. Non-contrast MR imaging of the glenohumeral joint. Part I. Normal anatomy. Skeletal Radiol 2004; 33 (10) 551-560
• 43 Bigoni BJ, Chung CB. MR imaging of the rotator cuff interval. Magn Reson Imaging Clin N Am 2004; 12 (1) 61-73 , vi vi.
• 44 Krief OP. MRI of the rotator interval capsule. AJR Am J Roentgenol 2005; 184 (5) 1490-1494
• 45 Massengill AD, Seeger LL, Yao L , et al. Labrocapsular ligamentous complex of the shoulder: normal anatomy, anatomic variation, and pitfalls of MR imaging and MR arthrography. Radiographics 1994; 14 (6) 1211-1223
• 46 Sanders TG, Morrison WB, Miller MD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med 2000; 28 (3) 414-434
• 47 Pouliart N. Shoulder instability. Experimental model and related anatomy [PhD dissertation]. Brussels, Belgium: Vrije Universiteit Brussel; 2005
• 48 Park YH, Lee JY, Moon SH , et al. MR arthrography of the labral capsular ligamentous complex in the shoulder: imaging variations and pitfalls. AJR Am J Roentgenol 2000; 175 (3) 667-672
• 49 Beltran J, Bencardino J, Mellado J, Rosenberg ZS, Irish RD. MR arthrography of the shoulder: variants and pitfalls. Radiographics 1997; 17 (6) 1403-1412 ; discussion 1412–1415
• 50 Beltran J, Bencardino J, Padron M, Shankman S, Beltran L, Ozkarahan G. The middle glenohumeral ligament: normal anatomy, variants and pathology. Skeletal Radiol 2002; 31 (5) 253-262
• 51 Connell DA, Potter HG. Magnetic resonance evaluation of the labral capsular ligamentous complex: a pictorial review. Australas Radiol 1999; 43 (4) 419-426
• 52 DePalma A, Gallery G, Bennet G. Variational anatomy and degenerative lesions of the shoulder joint. Instr Course Lect 1949; 6: 255-281
• 53 Moseley H, Overgaard B. The anterior capsular mechanism in recurrent anterior dislocation of the shoulder. J Bone Joint Surg Br 1962; 44: 913-927
• 54 Steinbeck J, Liljenqvist U, Jerosch J. The anatomy of the glenohumeral ligamentous complex and its contribution to anterior shoulder stability. J Shoulder Elbow Surg 1998; 7 (2) 122-126
• 55 Tirman PF, Feller JF, Palmer WE, Carroll KW, Steinbach LS, Cox I. The Buford complex—a variation of normal shoulder anatomy: MR arthrographic imaging features. AJR Am J Roentgenol 1996; 166 (4) 869-873
• 56 Williams MM, Snyder SJ, Buford Jr D. The Buford complex—the “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy 1994; 10 (3) 241-247
• 57 Bencardino JT, Beltran J. MR imaging of the glenohumeral ligaments. Magn Reson Imaging Clin N Am 2004; 12 (1) 11-24 , v
• 58 Rowan KR, Keogh C, Andrews G, Cheong Y, Forster BB. Essentials of shoulder MR arthrography: a practical guide for the general radiologist. Clin Radiol 2004; 59 (4) 327-334
• 59 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; 18 (5) 449-456
• 60 Huber WP, Putz RV. Periarticular fiber system of the shoulder joint. Arthroscopy 1997; 13 (6) 680-691
• 61 Pouliart N, Gagey O. Reconciling arthroscopic and anatomic morphology of the humeral insertion of the inferior glenohumeral ligament. Arthroscopy 2005; 21 (8) 979-984
• 62 Ramirez Ruiz FA, Baranski Kaniak BC, Haghighi P, Trudell D, Resnick DL. High origin of the anterior band of the inferior glenohumeral ligament: MR arthrography with anatomic and histologic correlation in cadavers. Skeletal Radiol 2012; 41 (5) 525-530
• 63 Tuoheti Y, Itoi E, Minagawa H , et al. Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy 2005; 21 (10) 1242-1249
• 64 Palmer WE, Caslowitz PL, Chew FS. MR arthrography of the shoulder: normal intraarticular structures and common abnormalities. AJR Am J Roentgenol 1995; 164 (1) 141-146
• 65 Zlatkin MB, Bjorkengren AG, Gylys-Morin V, Resnick D, Sartoris DJ. Cross-sectional imaging of the capsular mechanism of the glenohumeral joint. AJR Am J Roentgenol 1988; 150 (1) 151-158
• 66 Neumann CH, Petersen SA, Jahnke AH. MR imaging of the labral-capsular complex: normal variations. AJR Am J Roentgenol 1991; 157 (5) 1015-1021
• 67 Cook TS, Stein JM, Simonson S, Kim W. Normal and variant anatomy of the shoulder on MRI. Magn Reson Imaging Clin N Am 2011; 19 (3) 581-594
• 68 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 (6) e291-e297
• 69 Ly JQ, Beall DP, Sanders TG. MR imaging of glenohumeral instability. AJR Am J Roentgenol 2003; 181 (1) 203-213
• 70 Omoumi P, Teixeira P, Lecouvet F, Chung CB. Glenohumeral joint instability. J Magn Reson Imaging 2011; 33 (1) 2-16
• 71 Peh WC. Magnetic resonance arthrography of the labral-ligamentous complex of the shoulder: an update. Ann Acad Med Singapore 2002; 31 (5) 614-620
• 72 Shankman S, Bencardino J, Beltran J. Glenohumeral instability: evaluation using MR arthrography of the shoulder. Skeletal Radiol 1999; 28 (7) 365-382
• 73 Schaeffeler C, Waldt S, Holzapfel K , et al. Lesions of the biceps pulley: diagnostic accuracy of MR arthrography of the shoulder and evaluation of previously described and new diagnostic signs. Radiology 2012; 264 (2) 504-513
• 74 Kim KC, Rhee KJ, Shin HD, Kim YM. Estimating the dimensions of the rotator interval with use of magnetic resonance arthrography. J Bone Joint Surg Am 2007; 89 (11) 2450-2455
• 75 Bigoni BJ, Chung CB. MR imaging of the rotator cuff interval. Radiol Clin North Am 2006; 44 (4) 525-536 , viii
• 76 Grainger AJ, Tirman PF, Elliott JM, Kingzett-Taylor A, Steinbach LS, Genant HK. MR anatomy of the subcoracoid bursa and the association of subcoracoid effusion with tears of the anterior rotator cuff and the rotator interval. AJR Am J Roentgenol 2000; 174 (5) 1377-1380
• 77 Vinson EN, Major NM, Higgins LD. Magnetic resonance imaging findings associated with surgically proven rotator interval lesions. Skeletal Radiol 2007; 36 (5) 405-410
• 78 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
• 79 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 1999; 81 (1) 93-96
• 80 Pouliart N, Gagey O. Simulated humeral avulsion of the glenohumeral ligaments: a new instability model. J Shoulder Elbow Surg 2006; 15 (6) 728-735
• 81 Stoller DW. MR arthrography of the glenohumeral joint. Radiol Clin North Am 1997; 35 (1) 97-116
• 82 Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995; 11 (5) 600-607
• 83 Chang EY, Hoenecke Jr HR, Fronek J, Huang BK, Chung CB. Humeral avulsions of the inferior glenohumeral ligament complex involving the axillary pouch in professional baseball players. Skeletal Radiol 2014; 43 (1) 35-41