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Ligaments & Soft Tissue

Glenohumeral and coracoclavicular ligamentous injuries, focusing on HAGL lesions and their role in anterior instability and preoperative diagnostic challenges.

Overview

Arthroscopic repair of pediatric anterior band inferior glenohumeral ligament L-shaped tears yields excellent short-term results with anatomic reconstruction [3]. In patients under 25 years of age, successful arthroscopic treatment of shoulder instability relies on correct patient selection and a surgical technique involving anterior and posterior capsular ligament repair with axillary retention [76]. For objective patellofemoral instability, isolated or associated medial patellofemoral ligament (MPFL) reconstruction using a bioactive synthetic ligament is a valid option that minimizes donor-site morbidity and associated complications [8]. Midterm follow-up results for this synthetic approach are comparable to autologous grafts [8].

Coracoclavicular (CC) ligament augmentation is highly recommended to improve short-term outcomes and decrease complications for Rockwood type V acromioclavicular (AC) separation treated by hook plate [9]. Combined anatomic reconstruction of both AC and CC ligaments using nylon tape provides an overall 88.2% satisfaction rate, a 94% radiologic reduction rate, and is associated with a low complication rate [15]. Augmented semitendinosus tendon grafts for CC ligament reconstruction result in excellent outcomes with full recovery of strength, minimal range of motion loss, and no clinical or radiographic loss of reduction [17]. A new technique for minimal-invasive CC ligament reconstruction serves as an alternative option for AC joint instability [30].

Future surgical approaches must systematically evaluate CC ligament-mediated vertical stability and AC ligament-mediated horizontal stability to optimize clinical outcomes [13]. Long-term outcomes beyond five years for dynamic anterior stabilization of the long head of the biceps are needed to define durability, and high-quality comparative or randomized trials are required to refine indications and position this technique within the broader algorithm for anterior shoulder instability management [10]. Indications for anterior cable reconstruction (ACR) for the shoulder superior capsule must be carefully considered, accounting for both anatomic and biomechanical rationales [20]. Regarding posterior instability, anchor placement does not seem to matter for clinical outcomes in anatomic capsular-labral reconstruction [27], and current cadaveric and clinical data do not support the recommendation that the posteroinferior labrum should not be repaired to the articular surface [27].

Anatomy & Pathophysiology

Ligamentous Structures

In healthy adult shoulders, ligamentous structures function as restraints at the extremes of motion rather than remaining fully elongated in many positions [4]. The coracoacromial ligament is critical for shoulder biomechanics, joint stability, and proprioception, with age-dependent changes in this ligament contributing to shoulder pathology [36]. Following AC joint dislocation, kinematic alterations may serve as a potential source of pain and dysfunction [37]. Regarding the rotator cuff and biceps, the long head of the biceps stabilizes the glenohumeral joint and counteracts humeral translation when the subscapularis or infraspinatus is compromised, yet it provides no stabilizing effect in simulated supraspinatus rotator cuff deficiency [43]. Additionally, the stabilizing function of the deltoid muscle assumes greater importance as shoulder instability increases [45].

Kinematics

Shoulder rotation involves a large range of anterior-posterior translation, indicating that motion is not a pure ball-in-socket mechanism [46]. During the simulated acceleration phase of throwing, anterior glenohumeral translation significantly increases as shoulder abduction decreases; consequently, lower abduction angles during the throwing motion may cause forceful internal impingement and decreased anterior stability [38]. While additional repair of a partial subscapularis tear combined with a supraspinatus tear does not affect external rotation or glenohumeral kinematics [41], the distances between coracoclavicular insertion points vary depending on both patient and shoulder positioning [42].

Classification

Coracohumeral Ligament: Histologic features indicate this structure is more capsular than ligamentous [1].

Coracoclavicular and Acromioclavicular Ligaments: The anatomic orientation of native coracoclavicular ligaments is highly variable in the sagittal plane [2]. In healthy adult shoulders, these ligamentous structures are not fully elongated in many positions but function as restraints at the extremes of motion [4]. Traumatic sections of the AC and trapezoid ligaments may lead to high-grade AC joint instability [16]. Reconstruction of the AC ligaments may be necessary for restoring physiological properties [6], and consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries [71]. The integrity of the CC and AC ligaments found on MRI impacts clinical and radiographic parameters [11]. Subject-specific computational models of acromioclavicular and coracoclavicular ligaments may be useful for analyzing and assessing biomechanical stability after various types of surgical reconstruction [54].

Coracoacromial Ligament: Five main types of coracoacromial ligaments were identified [52]. There is no statistical correlation found between coracoacromial ligament type and rotator cuff degeneration [52]. Two different coracoid attachments (anterior and posterior bundles) of the coracoacromial ligament were consistently identified in all specimens [72].

Pectoralis Major Tears: The requisite elements for classifying pectoralis major tears are timing, location, and extent of the tear [55]. Further subdividing categories of pectoralis major tears would not have clinical significance in treatment or outcome [55].

Superior Capsular Complex: This complex forms a suspension sling with anterior and posterior limbs that function similarly to the inferior glenohuminal ligament complex [60]. The posterior limb of the superior capsular complex restricts internal rotation [60].

Subscapularis Tendon: The anatomically exceptional ligament-to-tendon distal insertion of the MGHL into the subscapularis was histologically confirmed in all cases [14]. The subscapularis tendon is composed of 2 distinct fibrous layers [67]. The 2 distinct fibrous layers of the subscapularis tendon are arranged differently than those of the supraspinatus tendon [67].

Other Considerations: No specific classification systems (e.g., Gustilo-Anderson, AO/OTA) are defined in the provided evidence base for these soft tissue structures; the classification criteria are limited to the defining features listed above.

Clinical Presentation

The coracohumeral ligament exhibits histologic features that classify it as more capsular than ligamentous [1]. In healthy adult shoulders, ligamentous structures generally do not reach full elongation across many positions, functioning primarily as restraints at the extremes of motion [4]. The anatomical orientation of native coracoclavicular ligaments demonstrates high variability in the sagittal plane [2], while the integrity of the coracoclavicular and acromioclavicular ligaments on MRI directly impacts clinical and radiographic parameters [11].

Traumatic sections of the acromioclavicular and trapezoid ligaments may precipitate high-grade acromioclavicular joint instability [16]. Rupture of the quadriceps tendon represents an uncommon yet serious injury necessitating prompt diagnosis and early surgical management [19]. The synchondrosis of an os acromiale can be injured following trauma, though such events are rare [24].

Contracture of the deltoid muscle presents with pain, skin dimpling, palpable fibrous bands, and scapular winging [25]. Rare posterior humeral avulsion of the glenohumeral ligaments lesions require careful interpretation of MR arthrograms and thorough diagnostic arthroscopy for identification [21]. The arthroscopic approach offers a unique advantage in diagnosing and treating occult intra-articular pathology [23]. However, shoulder arthroscopy does not adequately visualize pathology of the long head of the biceps tendon [48].

Anatomically exceptional ligament-to-tendon distal insertion of the middle glenohumeral ligament into the subscapularis has been histologically confirmed in all cases [14].

Investigations

Plain radiography: Appropriate radiographic investigation, including axillary views, is required to evaluate fractures of an os acromiale associated with rupture of the coracoclavicular ligaments [24].

MRI: MRI is the optimal imaging modality for diagnosing humeral avulsion of the glenohumeral ligament (HAGL) lesions [7]. However, approximately one-third of HAGL lesions are missed on preoperative MRI [74]. Consistent detection of posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament requires focused review of appropriate MRI images [65]. The integrity of the coracoclavicular (CC) and acromioclavicular (AC) ligaments identified on MRI influences clinical and radiographic parameters [11].

Arthroscopy: Careful history and physical examination are critical in the diagnosis of HAGL lesions [7]. A high level of suspicion is essential during history acquisition, clinical examination, MRI arthrogram interpretation, and arthroscopic evaluation for HAGL lesions [70]. Thorough diagnostic arthroscopy is essential to identify posterior humeral avulsion of the glenohumeral ligaments [21]. Specifically, consistent detection of posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament requires specific assessment of the posterior capsule during arthroscopy [65]. The arthroscopic approach offers a unique advantage in diagnosing occult intra-articular pathology [23].

Other Considerations: The coracohumeral ligament is more capsular than ligamentous based on its histologic features [1]. The anatomic orientation of the native coracoclavicular ligaments is highly variable in the sagittal plane [2]. In healthy adult shoulders, ligamentous structures are not fully elongated in many positions but function as restraints at the extremes of motion [4]. Careful interpretation of MR arthrograms is essential to identify posterior humeral avulsion of the glenohumeral ligaments [21]. HAGL lesions are often missed during routine workup [70].

Treatment

Non-Operative

Nonsurgical treatment can resolve pain effectively and restore function in patients with SLAP tears or biceps lesions [68]. Published functional results of nonoperative treatment for isolated teres major ruptures are uniformly excellent [50]. At a minimum 5-year follow-up, patients with successful non-operative treatment for type III-V ACJ injuries achieved similar clinical outcomes compared to those who were converted to anatomic coracoclavicular ligament reconstruction [22]. Manipulation under anaesthetic is recommended for post-traumatic stiffness of the shoulder where conservative methods have failed [59].

Operative

Indications: Arthroscopic repair is indicated for an L-shaped tear of the anterior band of the inferior glenohumeral ligament complex in pediatric patients to achieve excellent short-term results with anatomic repair [3]. Isolated or associated MPFL reconstruction with a bioactive synthetic ligament is a valid option for surgical treatment of objective patellofemoral instability [8]. Rupture of the quadriceps tendon is an uncommon yet serious injury requiring prompt diagnosis and early surgical management [19]. Combined anatomic reconstruction of both AC and CC ligaments using nylon tape is indicated to address AC joint instability, providing overall 88.2% satisfaction [15]. The indications for anterior cable reconstruction need to be carefully considered and account for both anatomic and biomechanical rationales [20]. Type-specific operative repair of acute acromioclavicular ligament complex tears might be considered to promote biological healing [56].

Surgical Approach / Technique: Arthroscopic repair of posterior humeral avulsion of the glenohumeral ligament in recurrent anterior shoulder dislocations typically results in favorable clinical outcomes [53]. Stability was restored in noncollision athletes who underwent conjoined tendon transfer for traumatic anterior glenohumeral instability with large bony defects and anterior capsulolabral deficiency [51]. Anatomic acromioclavicular joint reconstruction using semitendinosus graft with internal bracing in chronic acromioclavicular joint dislocation allows for an anatomic, biological, and minimally invasive procedure [61]. The described technique for minimal-invasive coracoclavicular ligament reconstruction is an alternative option to reconstruct the CC ligaments in AC joint instability [30]. Future surgical approaches should systematically evaluate and address both CC ligament-mediated vertical stability and AC ligament-mediated horizontal stability to optimize clinical outcomes [13].

Implant Selection: MPFL reconstruction with a bioactive synthetic ligament minimizes donor-site morbidity and associated complications [8]. Midterm follow-up results of MPFL reconstruction with a bioactive synthetic ligament are comparable to autologous graft [8]. CC ligament augmentation is highly recommended to improve short-term outcomes and decrease complications for Rockwood type V AC separation treated by hook plate [9]. Combined anatomic reconstruction of both AC and CC ligaments using nylon tape provides 94% radiologic reduction [15]. Combined anatomic reconstruction of both AC and CC ligaments using nylon tape has a low complication rate [15]. LARS artificial ligament for reconstruction of the CC ligament can provide immediate stability [18]. LARS artificial ligament for reconstruction of the CC ligament allows early shoulder mobilization [18]. LARS artificial ligament for reconstruction of the CC ligament provides good functional results and few complications [18]. Outcome for coracoclavicular ligament reconstructions using augmented semitendinosus tendon grafts was excellent with full recovery of strength [17]. Outcome for coracoclavicular ligament reconstructions using augmented semitendinosus tendon grafts included minimal range of motion loss [17]. Outcome for coracoclavicular ligament reconstructions using augmented semitendinosus tendon grafts included no clinical or radiographic loss of reduction of the acromioclavicular joint [17].

Alignment / Balancing Strategy: Anchor placement does not seem to matter for clinical outcomes in posterior shoulder instability and anatomic capsular-labral reconstruction [27]. The recommendation that the posteroinferior labrum should not be repaired to the articular surface is not supported by cadaveric data or currently available clinical studies [27]. In the in vitro setting, reconstruction of the acromioclavicular ligament complex using dermal allograft demonstrated increased AC joint stability [57]. Type-specific operative repair of acute acromioclavicular ligament complex tears might lower rates of horizontal ACJ instability following acute ACJ reconstruction [56]. None of the described techniques for coracoclavicular ligament reconstruction provided equivalent rotational stability in all planes compared with the native state [31]. None of the described procedures for graft fixation at the coracoid process restores the kinematics of the native coracoclavicular ligaments [62].

Pain Management: No significant range-of-motion loss was observed in noncollision athletes who underwent conjoined tendon transfer for traumatic anterior glenohumeral instability with large bony defects and anterior capsulolabral deficiency [51]. Comparable subjective outcomes after surgical treatment of AC joint instability were reported for all modalities [49]. Relatively low unplanned reoperation rates were reported after surgical treatment of AC joint instability [49].

Adjuncts: Anatomic acromioclavicular joint reconstruction using semitendinosus graft with internal bracing in chronic acromioclavicular joint dislocation avoids some of the inconveniences described in other reports [61].

Other Considerations: A review offers a comprehensive overview of indications, surgical and nonoperative approaches, and associated outcomes for tears of the latissimus dorsi and teres major [5]. Operative treatment of isolated teres major ruptures is not recommended because the strength deficit could not be eliminated [50]. Long-term outcomes beyond five years and high-quality comparative or randomized trials are needed to define durability, refine indications, and position LHB-based dynamic anterior stabilization within the broader algorithm for anterior shoulder instability management [10]. The likelihood of returning to sports after arthroscopic repair of posterior humeral avulsion of the glenohumeral ligament in recurrent anterior shoulder dislocations remains uncertain [53]. Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [69].

Complications

Instability: Anatomic coracoclavicular ligament reconstructions using fixation buttons or tendon grafts demonstrate an overall complication rate of 27.1% (16/59), with medial tunnel placement identified as a significant factor in the risk for early failures [58][32]. To mitigate these risks, coracoclavicular ligament reconstruction using a hook plate with CC ligament augmentation is highly recommended to decrease complications for Rockwood type V AC separation [9]. Furthermore, the addition of acromioclavicular ligament reconstruction to coracoclavicular ligament reconstruction using synthetic tapes/grafts or allograft tissues without bone tunnels significantly diminishes complication rates [73]. Combined anatomic reconstruction of both acromioclavicular and coracoclavicular ligaments using nylon tape provides a low complication rate [15].

Other Considerations: LARS artificial ligament for coracoclavicular ligament reconstruction can provide immediate stability with few complications [18]. Isolated or associated medial patellofemoral ligament reconstruction with bioactive synthetic ligament minimizes donor-site morbidity and associated complications [8]. Clinical outcomes of reverse total shoulder arthroplasty at a minimum follow-up of 1 year were similar in high- and lower-risk groups regarding iatrogenic suprascapular neuropathy by screw violation [29]. Remodeling following chronic tendon tear leads to a degenerative replacement of muscle with connective tissue rather than an active infiltrative process [77]. Medialized repair may be useful in cases where anatomic bone-to-tendon repair would be difficult because of excessive tension of the repaired tendon and a torn tendon that does not reach the anatomic insertion [78].

Recovery

Light activity (weeks): Early mobilization is facilitated by specific reconstruction techniques; LARS artificial ligament for coracoclavicular reconstruction provides immediate stability allowing early shoulder mobilization [18]. For Rockwood type V acromioclavicular separations, hook plate fixation with coracoclavicular ligament augmentation is highly recommended to improve short-term outcomes and decrease complications [9]. Patients undergoing anatomic coracoclavicular ligament reconstruction must avoid medial tunnel placement errors, as this is a significant factor in the risk for early failures [32].

Full activity (months): Anatomic repair of an L-shaped tear of the anterior band of the inferior glenohumeral ligament complex leads to excellent short-term results [3]. Coracoclavicular ligament reconstruction using augmented semitendinosus tendon grafts results in excellent outcomes with full recovery of strength and minimal range of motion loss [17]. Isolated or associated medial patellofemoral ligament (MPFL) reconstruction with a bioactive synthetic ligament is a valid option for surgical treatment of objective patellofemoral instability, with midterm follow-up results comparable to autologous graft [8]. Coracoclavicular and acromioclavicular ligament reconstruction with a double-bundle semitendinosus autograft and cortical buttons for chronic acromioclavicular joint dislocations achieves significant improvement in shoulder function without complications related to clinical symptoms at a mean follow-up of 31.7 months [80].

Complete recovery / outcome plateau (months): Coracoclavicular reconstruction using a semitendinosus tendon graft provides satisfactory results in revision cases for chronic acromioclavicular joint dislocations by replicating the course of the original coracoclavicular ligaments [26]. Patients with successful non-operative treatment for type III to V acromioclavicular joint injuries achieve similar clinical outcomes at a minimum 5-year follow-up compared to those converted to anatomic coracoclavicular ligament reconstruction [22]. Medial capsule reefing in patellar instability results in significantly improved functional results from preoperative values at an intermediate follow-up of 72 months, with 90% of patients very satisfied with their functional result [66]. Delayed repair of isolated subscapularis tendon rupture is associated with less satisfactory results due to muscle atrophy and degeneration [79].

Rehabilitation protocol: The procedure for contracture of the deltoid muscle resolved pain, skin dimpling, palpable fibrous bands, and winging of the scapula with no infections or neuromuscular complications [25]. Clinical outcomes of reverse total shoulder arthroplasty at a minimum follow-up of 1 year were similar in high- and lower-risk groups regarding iatrogenic suprascapular neuropathy from baseplate screw penetration [29].

Functional milestones: MPFL reconstruction with a bioactive synthetic ligament minimizes donor-site morbidity and associated complications compared to autologous graft [8]. Long-term outcomes beyond five years and high-quality comparative or randomized trials are needed to define durability and refine indications for dynamic anterior stabilization of the long head of the biceps [10]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [64].

Other Considerations: No specific rehabilitation protocols, PROM trajectories, or return-to-work predictors are detailed in the provided evidence base beyond the functional outcomes and complication rates listed above.

Key Evidence

  • [L5] The coracohumeral ligament is more capsular than ligamentous based on its histologic features. (10.1016/j.jse.2008.07.012)
  • [L5] The anatomic orientation of the native coracoclavicular ligaments is highly variable in the sagittal plane. (10.1016/j.jse.2019.11.034)
  • [L4] The arthroscopic repair technique leads to excellent short-term results with anatomic repair. (10.1007/s00167-009-0740-1)
  • [L5] In healthy adult shoulders, ligamentous structures are not fully elongated in many positions but function as restraints at the extremes of motion. (10.1186/1749-799x-7-29)
  • [L5] This review offers a comprehensive overview of these uncommon injuries, including their indications, surgical and nonoperative approaches, and associated outcomes. (10.1016/j.xrrt.2025.05.015)
  • [L5] For restoring physiological properties, reconstruction of the AC ligaments may be necessary. (10.1177/0363546513484892)
  • [L5] Careful history and physical examination are critical in the diagnosis of HAGL lesions, with MRI being the best imaging study. (10.5435/00124635-201103000-00001)
  • [L4] Isolated or associated MPFL reconstruction with bioactive synthetic ligament is a valid option in surgical treatment of objective PF instability, with results at midterm follow-up comparable to autologous graft, thus minimizing donor-site morbidity and associated complications. (10.1007/s00167-014-2970-0)
  • [L3] Therefore, CC ligament augmentation is highly recommended to improve short-term outcomes and decrease complications for Rockwood type V AC separation treated by hook plate. (10.1186/s12891-020-03726-z)
  • [L4] Long-term outcomes beyond five years and high-quality comparative or randomized trials are needed to define durability, refine indications, and position LHB-based DAS within the broader algorithm for anterior shoulder instability management. (10.5397/cise.2025.00752)
  • [L1] The integrity of the CC and AC ligaments found on MRI has an impact on clinical and radiographic parameters. (10.1016/j.jse.2020.10.026)
  • [L5] Future surgical approaches should systematically evaluate and address both CC ligament-mediated vertical stability and AC ligament-mediated horizontal stability to optimize clinical outcomes. (10.5397/cise.2025.00843)
  • [L5] The anatomically exceptional ligament-to-tendon distal insertion of the MGHL into the subscapularis was histologically confirmed in all cases. (10.1016/j.jseint.2025.09.016)
  • [L4] Combined anatomic reconstruction of both AC and CC ligaments using nylon tape by the described technique provides overall 88.2% satisfaction, 94% radiologic reduction, and a low complication rate. (10.1016/j.arthro.2012.02.001)
  • [L5] Traumatic sections of the AC and trapezoid ligament may lead to high grade AC joint instability. (10.1186/s12891-022-05245-5)
  • [L4] Outcome for coracoclavicular ligament reconstructions using augmented semitendinosus tendon grafts was excellent with full recovery of strength, minimal range of motion loss, and no clinical or radiographic loss of reduction of the acromioclavicular joint. (10.1177/0363546507304715)
  • [L4] LARS artificial ligament for reconstruction of CC can provide immediate stability and allow early shoulder mobilization with good functional results and few complications. (10.1007/s00167-013-2582-0)
  • [L5] Rupture of the quadriceps tendon is an uncommon yet serious injury requiring prompt diagnosis and early surgical management. (10.5435/00124635-200305000-00006)
  • [Commentary] The indications for anterior cable reconstruction (ACR) need to be carefully considered and account for both anatomic and biomechanical rationales. (10.1016/j.arthro.2021.05.039)
  • [Case_report] Careful interpretation of MR arthrograms and thorough diagnostic arthroscopy are essential to identify this rare lesion. (10.1016/j.jse.2006.09.009)
  • [L4] At a minimum 5-year follow-up, patients with successful non-operative treatment for type III-V ACJ injuries achieved similar clinical outcomes compared to those who were converted to ACCR. (10.1007/s00167-020-06159-2)
  • [L1] The arthroscopic approach offers a unique advantage in diagnosing and treating occult intra-articular pathology. (10.1016/j.jse.2006.10.006)
  • [L4] This case highlights that the synchondrosis of an os acromiale can be injured following trauma, though rarely, and emphasizes the need for appropriate radiographic investigation including axillary views and a flexible surgical approach. (10.1016/j.jse.2008.02.012)
  • [L3] The procedure resolved pain, skin dimpling, palpable fibrous bands, and winging of the scapula, with no infections or neuromuscular complications. (10.2106/00004623-199802000-00010)
  • [L4] Coracoclavicular reconstruction using a semitendinosus tendon graft provides a satisfactory result in revision cases by replicating the course of the original coracoclavicular ligaments. (10.1016/j.jse.2006.10.009)
  • [Commentary] The recommendation that the posteroinferior labrum should not be repaired to the articular surface is not supported by the cadaveric data or currently available clinical studies, and anchor placement does not seem to matter for clinical outcomes. (10.1016/j.arthro.2020.08.022)
  • [L3] However, the clinical outcomes of RTSA at a minimum follow-up of 1 year were similar in the high- and lower-risk groups. (10.1016/j.jse.2021.10.024)
  • [L5] The results suggest that the described technique is an alternative option to reconstruct the CC ligaments in AC joint instability in a minimal-invasive technique. (10.1007/s00167-012-2041-3)
  • [L5] None of the described techniques provided equivalent rotational stability in all planes compared with the native state. (10.1016/j.arthro.2020.01.033)
  • [L4] Medial tunnel placement is a significant factor in risk for early failures when performing anatomic CC ligament reconstructions. (10.1177/0363546512465591)
  • [L5] The coracoacromial ligament plays an important role in shoulder biomechanics, joint stability, and proprioception, with age-dependent changes contributing to shoulder pathology. (10.1177/2325967117703398)
  • [L5] The kinematic changes could be a potential source of pain and dysfunction in the shoulder with AC joint dislocation. (10.1177/0363546512458571)
  • [L5] During the simulated acceleration phase of the throwing motion, anterior glenohumeral translation significantly increased as shoulder abduction decreased. (10.1016/j.jse.2017.12.029)
  • [L5] Additional repair of the partial subscapularis tear with supraspinatus tear did not affect external rotation or glenohumeral kinematics. (10.1016/j.jse.2013.09.015)
  • [L4] The distances between the coracoclavicular insertion points depend on both patient and shoulder positioning. (10.1177/0363546511423015)
  • [L5] Once the subscapularis or infraspinatus is affected by a simulated tear, the long head of the biceps has a stabilizing effect for the glenohumeral joint and counteracts humeral translation. (10.1016/j.arthro.2023.08.018)
  • [L5] The stabilizing function of the deltoid muscle takes on more importance as the shoulder becomes unstable. (10.1177/03635465030310031201)
  • [Abstract] This study shows that there is a large range of anterior-posterior translation during shoulder rotation, and thus not pure ball-in-socket motion suggested by prior experimental studies. (10.1016/j.jse.2007.02.102)
  • [L5] Pulling the tendon into the joint with a probe does not allow adequate visualization of common distal sites of pathology in either lateral decubitus or beach chair positions. (10.1016/j.jse.2016.12.060)
  • [L1] Comparable subjective outcomes after surgical treatment of AC joint instability were reported for all modalities, with relatively low unplanned reoperation rates. (10.1016/j.arthro.2018.01.016)
  • [L4] We do not recommend operative treatment of this injury because we could not eliminate the strength deficit and the published functional results of nonoperative treatment are uniformly excellent. (10.1016/j.jse.2011.10.014)
  • [L4] Stability was restored and no significant range-of-motion loss was observed in noncollision athletes who underwent conjoined tendon transfer. (10.1016/j.arthro.2017.06.044)
  • [L4] Five main types of coracoacromial ligaments were identified, with no statistical correlation found between the ligament type and rotator cuff degeneration. (10.1016/j.jse.2007.05.015)
  • [L4] While arthroscopic repair of this combination typically results in favorable clinical outcomes, the likelihood of returning to sports remains uncertain. (10.1016/j.jse.2025.04.020)
  • [L5] These models may also be useful for analyzing and assessing biomechanical stability after various types of surgical reconstruction. (10.1016/j.jse.2022.09.004)
  • [Letter] The authors believe that the requisite elements for classifying pectoralis major tears are timing, location, and extent of the tear, and that further subdividing these categories would not have clinical significance in treatment or outcome. (10.1016/j.jse.2013.03.001)
  • [L4] Type-specific operative repair of acute ACLC tears might promote biological healing and lower rates of horizontal ACJ instability following acute ACJ reconstruction. (10.1186/s12891-016-1240-3)
  • [L5] In the in vitro setting, this study demonstrated increased AC joint stability with the addition of an ACLC reconstruction using dermal allograft. (10.1016/j.arthro.2019.07.021)
  • [L4] Anatomic procedures to treat disrupted CC ligaments using either CFBs or TGs resulted in an overall complication rate of 27.1% (16/59). (10.1177/0363546513502459)
  • [L3] The authors recommend MUA in post-traumatic stiffness cases where conservative methods have failed. (10.1177/1758573217693974)
  • [L5] The superior capsular complex forms a suspension sling with anterior and posterior limbs that function similarly to the inferior glenohuminal ligament complex, with the posterior limb restricting internal rotation. (10.1016/j.jse.2007.02.138)
  • [L4] This technique seems to be especially advantageous as it allows for an anatomic, biological, and minimally invasive procedure while avoiding some of the inconveniences described in other reports. (10.1177/2325967121s00902)
  • [L5] None of the described procedures for graft fixation restores the kinematics of the native coracoclavicular ligaments. (10.1016/j.arthro.2012.08.026)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] Consistent detection requires focused review of appropriate MRI images and specific assessment of the posterior capsule during arthroscopy, with surgical repair accomplished either arthroscopically or through an open technique. (10.1016/j.jse.2010.01.026)
  • [L4] At an intermediate follow-up of 72 months, functional results were significantly improved from preoperative values and 90% of patients were very satisfied with their functional result. (10.1007/s00167-014-3027-0)
  • [L5] The subscapularis tendon is composed of 2 distinct fibrous layers, just like the supraspinatus tendon, but arranged differently. (10.1016/j.jse.2018.11.045)
  • [L4] HAGL lesions are often missed during routine workup, and a high level of suspicion is essential during history acquisition, clinical examination, MRI arthrogram interpretation, and arthroscopic evaluation. (10.1177/23259671211004968)
  • [L5] Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries. (10.1016/j.jse.2020.09.006)
  • [L5] Two different coracoid attachments (anterior and posterior bundles) of the coracoacromial ligament were consistently identified in all specimens. (10.1016/j.arthro.2017.11.033)
  • [L3] This cohort study shows that the addition of AC reconstruction to CC reconstruction using synthetic tapes/grafts or allograft tissues without bone tunnels significantly improves durable radiographic outcomes, diminishes complication rates, and improves reoperation rates. (10.1016/j.asmr.2020.10.009)
  • [L3] Approximately one-third of HAGL lesions were missed on preoperative MRI. (10.1177/23259671231206757)
  • [L4] The study demonstrates that correct patient selection and a surgical technique involving anterior and posterior capsular ligament repair with axillary retention are crucial factors for successful arthroscopic treatment in patients under 25 years of age. (10.1186/s13018-025-05546-0)
  • [L4] Remodeling following chronic tendon tear leads to a degenerative replacement of muscle with connective tissue rather than an active infiltrative process. (10.1016/j.jse.2016.07.070)
  • [L4] Medialized repair may be useful in cases in which anatomic bone-to-tendon repair would be difficult because of the excessive tension of the repaired tendon and a torn tendon that does not reach the anatomic insertion. (10.1016/j.jse.2016.11.007)
  • [L4] Delayed repair was associated with less satisfactory results due to muscle atrophy and degeneration. (10.2106/00004623-199607000-00005)
  • [L4] Patients who underwent the index procedure achieved significant improvement in shoulder function without complications related clinical symptom after a mean follow-up interval of 31.7 months. (10.1016/j.jse.2024.01.019)

See Also

References

[1] An anatomic and histologic study of the coracohumeral ligament. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.07.012

[2] Sagittal orientation of coracoclavicular ligament reconstruction affects the stability of surgical repair. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.034

[3] Arthroscopic repair of L‐shaped tear of the anterior band of the inferior glenohumeral ligament complex in a pediatric patient: a technical note. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0740-1

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[19] Quadriceps Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200305000-00006

[20] Editorial Commentary: Anterior Cable Reconstruction for the Shoulder Superior Capsule: Time for “Indication Rounds”. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.05.039

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[22] Conversion to anatomic coracoclavicular ligament reconstruction (ACCR) shows similar clinical outcomes compared to successful non‐operative treatment in chronic primary type III to V acromioclavicular joint injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06159-2

[23] Arthroscopic versus open distal clavicle excision: Comparative results at six months and one year from a randomized, prospective clinical trial. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.10.006

[24] Fracture of an os acromiale with associated rupture of the coracoclavicular ligaments. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.02.012

[25] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

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[27] Editorial Commentary: Posterior Shoulder Instability and Anatomic Capsular-Labral Reconstruction: Repair the Posterior Inferior Glenohumeral Ligament to the Glenoid Neck at the 7 O’Clock Position. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.08.022

[29] Three-dimensional analysis of baseplate screw penetration in reverse total shoulder arthroplasty: risk of iatrogenic suprascapular neuropathy by screw violation. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.10.024

[30] Biomechanics of a new technique for minimal‐invasive coracoclavicular ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2041-3

[31] Vertical and Rotational Stiffness of Coracoclavicular Ligament Reconstruction: A Biomechanical Study of 3 Different Techniques. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.01.033

[32] Clavicular Bone Tunnel Malposition Leads to Early Failures in Coracoclavicular Ligament Reconstructions. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512465591

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[37] The Function of the Acromioclavicular and Coracoclavicular Ligaments in Shoulder Motion. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512458571

[38] Lower shoulder abduction during throwing motion may cause forceful internal impingement and decreased anterior stability. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.12.029

[41] The influence of partial subscapularis tendon tears combined with supraspinatus tendon tears. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.09.015

[42] In Vivo Analysis of Coracoclavicular Ligament Kinematics During Shoulder Abduction. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511423015

[43] The Long Head of the Biceps Has a Stabilizing Effect on the Glenohumeral Joint in Simulated Infraspinatus or Subscapularis but Not Supraspinatus Rotator Cuff Deficiency: A Biomechanical Study. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.08.018

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[48] Shoulder arthroscopy does not adequately visualize pathology of the long head of biceps tendon. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.12.060

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[51] Conjoined Tendon Transfer for Traumatic Anterior Glenohumeral Instability in Patients With Large Bony Defects and Anterior Capsulolabral Deficiency. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.06.044

[52] The coracoacromial ligament: The morphology and relation to rotator cuff pathology. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.05.015

[53] Clinical outcomes following arthroscopic repair of posterior humeral avulsion of glenohumeral ligament in recurrent anterior shoulder dislocations. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.04.020

[54] Subject-specific computational modeling of acromioclavicular and coracoclavicular ligaments. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.09.004

[55] Response to the Letter to the Editor regarding: a systematic review and comprehensive classification of pectoralis major tears. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.03.001

[56] Injury patterns of the acromioclavicular ligament complex in acute acromioclavicular joint dislocations: a cross-sectional, fundamental study. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1240-3

[57] Reconstruction of the Acromioclavicular Ligament Complex Using Dermal Allograft: A Biomechanical Analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2019.07.021

[58] Complications After Anatomic Fixation and Reconstruction of the Coracoclavicular Ligaments. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513502459

[59] Management of post-traumatic stiffness of the shoulder following upper limb trauma with manipulation under anaesthetic. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217693974

[60] Variations in the superior capsuloligamentous complex and description of a new ligament. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.138

[61] Anatomic Acromioclavicular Joint Reconstruction Using Semitendinosus Graft with Internal Bracing in Chronic Acromioclavicular Joint Dislocation: Case Series. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00902

[62] Tendon Graft Fixation Sites at the Coracoid Process for Reconstruction of the Coracoclavicular Ligaments: A Kinematic Evaluation of Three Different Surgical Techniques. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.08.026

[64] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[65] Posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.01.026

[66] Medial capsule reefing in patellar instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3027-0

[67] Histologic characteristics of the subscapularis tendon from muscle to bone: reference to subscapularis lesions. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.045

[68] Chapter 78 Superior Labrum Anterior to Posterior Tears and Lesions of the Proximal Biceps Tendon. 2019.

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[71] Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.006

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[73] Better Radiographic Reduction and Lower Complication Rates With Combined Coracoclavicular and Acromioclavicular Ligament Reconstruction Than With Isolated Coracoclavicular Reconstruction. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2020.10.009

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[80] Coracoclavicular and acromioclavicular ligament reconstruction with a double-bundle semitendinosus autograft and cortical buttons for chronic acromioclavicular joint dislocations: clinical and imaging outcomes. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.01.019

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