CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 400, pp. 32–39
Anatomy and Function of the
Glenohumeral Ligaments in Anterior
Shoulder Instability
Downloaded from http://journals.lww.com/clinorthop by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 06/11/2021
Andreas C. Burkart, MD; and Richard E. Debski, PhD
The anatomy of the glenohumeral ligaments
has been shown to be complex and variable and
their function is highly dependent on the posi-
tion of the humerus with respect to the glenoid.
The superior glenohumeral ligament with the
coracohumeral ligament was shown to be an
important stabilizer in the inferior direction,
even though the coracohumeral ligament is much
more robust than the superior glenohumeral
ligament. The middle glenohumeral ligament
provides anterior stability at 45
and 60
ab-
duction whereas the inferior glenohumeral lig-
ament complex is the most important stabi-
lizer against anteroinferior shoulder dislocation.
Therefore, this component of the capsule is the
most frequently injured structure. An appro-
priate surgical procedure to repair the inferior
glenohumeral ligament complex after shoulder
dislocation must be considered. In addition, a
detached labrum can lead to recurrent anterior
instability and a compromised inferior gleno-
humeral ligament complex. However, addi-
tional capsular injury usually is necessary to al-
low anterior dislocation.
From the Musculoskeletal Research Center, Department
of Orthopaedic Surgery, University of Pittsburgh, Pitts-
burgh, PA.
Reprint requests to Richard E. Debski, PhD, Muscu-
loskeletal Research Center, Department of Orthopaedic
Surgery, University of Pittsburgh, P.O. Box 71199, Pitts-
burgh, PA 15213.
32
© 2002 Lippincott Williams & Wilkins, Inc.
Shoulder stability is dependent on many fac-
tors that can be separated into two categories:
active and passive. The active stabilizers (del-
toid, biceps, and rotator cuff muscles) and the
passive restraints (bony geometry,19 labrum,
capsule, and glenohumeral ligaments) con-
tribute during normal shoulder function. How-
ever, no one structure stabilizes the gleno-
humeral joint throughout the range of motion
(ROM).
The capsuloligamentous complex at the
glenohumeral joint first was described in 1829
and consists of the superior, middle, and infe-
rior glenohumeral ligaments and the coraco-
humeral ligament.13 The glenohumeral liga-
ments do not act as traditional ligaments that
carry a pure tensile force along their length
and become taut at varying positions of ab-
duction and humeral rotation. In addition,
the glenohumeral ligaments do not have the
strength characteristics of the ligaments at the
knee.43–45
After a traumatic episode, more than 97%
of patients with anterior shoulder instability
were found to have a Bankart lesion.23,25 This
lesion is defined as the detachment of the an-
terior and inferior glenohumeral capsule with
involvement of the anterior band of the infe-
rior glenohumeral ligament.2 Clinical and ex-
perimental findings suggest that this site is the
most common location of failure and typically
Number 400
July, 2002
includes the labral attachment to the gle-
noid.3,14,21,34 The initial lesion found after
shoulder dislocation also includes the periosteal
insertion of the labrum.1 Recurrent disloca-
tions can lead to detached capsular structures
and additional tissue damage.15 However, tear-
ing and avulsion from the humerus of the cap-
sule also can occur.1,6,12 Based on these findings,
the anterior band of the inferior glenohumeral
ligament is commonly accepted to be the pri-
mary anterior stabilizer of the glenohumeral
joint.40
Anatomy of the Glenohumeral Ligaments
Coracohumeral Ligament
The coracohumeral ligament originates from
the dorsolateral base of the coracoid process
and extends as two bands, blending with the
capsule, to the greater tuberosity and to the
lesser tuberosity with only a few fibers20 (Fig
1). Portions of the coracohumeral ligament
form a tunnel for the biceps tendon on the an-
terior side of the joint.11,20 The rotator interval,
the region of the capsule between the anterior
border of the supraspinatus and the superior
border of the subscapularis muscle, is rein-
forced by the coracohumeral ligament.20 This
Fig 1. An anterior view of a right shoulder is
shown. The coracohumeral ligament (CHL) is out-
lined as it travels from the coracoid process to its
insertions on the greater and lesser tuberosity.
Glenohumeral Ligaments and Anterior Instability 33
ligament also blends inferiorly with the supe-
rior glenohumeral ligament.
Superior Glenohumeral Ligament
The superior glenohumeral ligament originates
from the supraglenoid tubercle, just anterior to
the origin of the long head of the biceps, and
inserts on the humerus near the proximal tip of
the lesser tuberosity on the medial ridge of the
intertubercular groove (Figs 2, 3). It forms an
anterior cover around the long head of the bi-
ceps tendon.20 The superior glenohumeral lig-
ament also is part of the rotator interval.20 In
an anatomic study, the superior glenohumeral
ligament was missing in 6% of the specimens,
whereas in 17% of the specimens, the superior
glenohumeral ligament had a common origin
with the middle glenohumeral ligament at the
1 o’clock position on the glenoid labrum.38
Middle Glenohumeral Ligament
The origin of the middle glenohumeral liga-
ment is found on the supraglenoid tubercle and
anterosuperior region of the labrum between
the 1 and 3 o’clock positions38 (Figs 2, 3).
Therefore, the anatomy of the middle gleno-
humeral ligament is similar to the superior
Fig 2. A posterior view of a right shoulder is shown.
The superior glenohumeral ligament (SGHL), mid-
dle glenohumeral ligament (MGHL), anterior band
of the inferior glenohumeral ligament (AB-IGHL),
glenoid, and humeral head are labeled as each lig-
ament from its origin on the glenoid to its insertion
on the humerus.

34 Burkart and Debski
Fig 3. Anterior view of the humerus from a right
shoulder shows the insertion sites of the glenohum-
eral ligaments, marked with dark stain. SGHL 
superior glenohumeral ligament; MGHL  mid-
dle glenohumeral ligament; AB-IGHL  anterior
band of the inferior glenohumeral ligament
glenohumeral ligament. However, the fibers
of the middle glenohumeral ligament blend
with portions of the subscapularis tendon ap-
proximately 2 cm medial to its insertion on the
lesser tuberosity.40 The width and thickness of
this ligament has been found to be as much as
2 cm and 4 mm, respectively.
Inferior Glenohumeral Ligament Complex
The inferior glenohumeral ligament complex is
a hammocklike structure with anchor points on
the anterior and posterior sides of the glenoid
(Fig 4) and includes the anterosuperior, infe-
rior, and posteroinferior regions of the capsule.
The anterior band of the inferior glenohumeral
Fig 4. A lateral view shows a right shoulder with
the humeral head exposed. The anterior band of
the inferior glenohumeral ligament (AB-IGHL),
axillary pouch, and posterior band of the inferior
glenohumeral ligament (PB-IGHL) are shown.
Clinical Orthopaedics
and Related Research
ligament originates primarily from the anterior
labrum and attaches to the glenoid through two
separate mechanisms: (1) the collagen fibers di-
rectly attach to the glenoid labrum; and (2) col-
lagen fibers attach at an acute angle along the
neck of the glenoid and some fibers run parallel
to the surface and blend with the periosteum. At
the 3 o’clock location on the face of the glenoid,
the labral attachment of the anterior band of the
inferior glenohumeral ligament is similar to the
direct insertion of a tendon. At the 5 o’clock po-
sition, the insertion consists mainly of fibrous
tissue. The length, width, and thickness of the
anterior band of the inferior glenohumeral liga-
ment have been reported to be 37
2 mm, 13

1 mm, and 3
0 mm, respectively.26,27
The humeral insertion site of the anterior
band of the inferior glenohumeral ligament is
located on the inferior margin of the articular
surface and around the anatomic neck, below
the lesser tuberosity (Fig 3). Two distinct at-
tachments also can be observed on the
humeral side: (1) a collarlike insertion that at-
taches the entire complex to the articular edge
of the humeral head; and (2) a V-shaped at-
tachment with the anterior and posterior bands
attaching at the apex of the V, distal to the
edge of the articular cartilage.29 The axillary
pouch runs from the inferior 1⁄3 of the humeral
head to the inferior 2⁄3 of the anterior glenoid.
Histologically, the inferior glenohumeral
ligament complex consists of closely packed
collagen bundles, which tighten with abduc-
tion and external rotation of the glenohumeral
joint.29 In the midsubstance, the collagen bun-
dles are oriented in a radial fashion. However,
near the glenoid they change direction and
blend into the labrum circumferentially.14 The
posterior band of the inferior glenohumeral
ligament is the least commonly found portion
of this region and only could be identified in
63% of the specimens examined.14
Function of the Glenohumeral Ligaments
Coracohumeral Ligament and Superior
Glenohumeral Ligament Complex
Based on a selective sectioning study, the su-
perior glenohumeral ligament was found to be
Number 400
July, 2002 Glenohumeral Ligaments and Anterior Instability 35

an important inferior stabilizer of the adducted finding confirms the role of the superior gleno-
shoulder41 whereas the coracohumeral liga- humeral ligament in the adducted arm. Using
ment also has been shown to contribute to in- a computational model, the superior gleno-
ferior stability.5,20,32 In addition, these liga- humeral ligament was predicted to carry up to
ments limit external rotation of the adducted 71 N at the position of maximum anterior
arm.17,18,31 The superior glenohumeral liga- translation8,9 (Fig 5).
ment and anterior band of the coracohumeral
ligament also seem to be more important re- Middle Glenohumeral Ligament
straints up to 50 abduction and external rota- The middle glenohumeral ligament has been
tion. Furthermore, the posterior band of the shown to become taut at 45 abduction, 10
coracohumeral ligament elongates with inter- extension and external rotation.11,40 There-
nal rotation and adduction.33 fore, this ligament has been assumed to con-
While examining the tensile properties of the tribute to anterior stability. Using a robotic
superior glenohumeral ligament and coraco- and universal force moment sensor testing
humeral ligament, the coracohumeral ligament system, this hypothesis was confirmed by
was found to have twice the stiffness and three finding that the middle glenohumeral ligament
times the ultimate tensile load of the superior was the primary anterior stabilizer in anatomic
glenohumeral ligament.5 The coracohumeral rotation and adduction10 (Fig 6). The middle
ligament absorbed six times the amount of en- glenohumeral ligament carried force during
ergy to failure but only elongated 1.5 times as only anterior loading at 30, 60, and 90 ab-
much as the superior glenohumeral ligament. duction with the maximum force of 34 N be-
During these tests, all of the coracohumeral lig- ing achieved at 60 abduction.10 As the ab-
aments failed in the proximal ligament sub- duction angle was increased, the middle
stance whereas the superior glenohumeral liga-
ment failed in the distal ligament substance near
the insertion on the humerus. The cross-sec-
tional area of the coracohumeral ligament also
was significantly greater than that of the supe-
rior glenohumeral ligament at their midportions
(coracohumeral ligament 54
3 mm; superior
glenohumeral ligament 11
2 mm).5,43 The
cross-sectional area measured at the midpor-
tion of the coracohumeral ligament was ap-
proximately fivefold that of the superior gleno-
humeral ligament.
The in situ force distribution of the gleno-
humeral capsule and the resulting joint kine-
matics attributable to application of external
loads at different abduction angles have been
determined using a robotic and universal force
moment sensor testing system.10 The superior
glenohumeral ligament—coracohumeral liga-
ment complex carried force during anterior
loading (26
16 N at 0) at all abduction an- Fig 5. The surface geometry of the scapula and
gles and during posterior loading in anatomic humerus used in the computational model and
the glenohumeral ligaments are shown. SGHL 
rotation at 0 abduction. However, no forces superior glenohumeral ligament; MGHL  mid-
were detected in this complex during posterior dle glenohumeral ligament; AB-IGHL  anterior
loading at 30, 60 and 90 abduction. This band of the inferior glenohumeral ligament

36 Burkart and Debski
Fig 6. In situ force (mean
standard deviation)
in the glenohumeral ligaments with an anterior
load of 89 N applied to the glenohumeral joint is
shown. SGHL-CHL  superior glenohumeral
and coracohumeral ligament complex; MGHL 
middle glenohumeral ligament; AB-IGHL  ante-
rior band of the inferior glenohumeral ligament
glenohumeral ligament and inferior gleno-
humeral ligament become more important. Se-
lective sectioning of the middle glenohumeral
ligament resulted in increased translation at
the joint,35 and abducting the arm to 45 in-
creased the strain in the middle glenohumeral
ligament.31 Others showed that the contribu-
tion of the superior glenohumeral ligament to-
gether with the middle glenohumeral ligament
was similar to the inferior glenohumeral liga-
ment in abduction and external rotation, but
the contribution of the inferior glenohumeral
ligament becomes more important with in-
creasing external rotation.4,31 Based on these
observations, the overall function of the mid-
dle glenohumeral ligament could be summa-
rized as: (1) to support the arm; (2) to restrain
external rotation from 0 to 90 abduction; and
(3) to provide anterosuperior stability.
Inferior Glenohumeral Ligament Complex
Based on anatomic studies, the anterior band
of the inferior glenohumeral ligament spans
the midportion of the anterior glenohumeral
joint at 90 abduction and external rotation and
restrains anterior and inferior translation of the
humerus.36,40 Measurement of the in situ force
in the anterior band of the inferior gleno-
humeral ligament revealed that it carried force
Clinical Orthopaedics
and Related Research
at 60 and 90 (30
21 N) abduction and
reached a maximum at 90 abduction. A com-
putational model found that at 90 abduction
the anterior band of the inferior glenohumeral
ligament had the highest forces (45 N) during
anterior translation. However, during applica-
tion of a posterior load at all abduction angles,
the posterior band of the inferior gleno-
humeral ligament experienced only minimal
forces.9
At the neutral position (0 abduction and 30
horizontal extension), the anterior band of the
inferior glenohumeral ligament becomes the
primary stabilizer. Sectioning the anterior band
of the inferior glenohumeral ligament and the
anterior half of the axillary pouch resulted in
significant increases in anterior, posterior and
total translation at 30 and 0 flexion and ex-
tension.30 On the opposite side of the capsule,
the posterior band of the inferior glenohumeral
ligament is considered the primary stabilizer
with the arm in flexion and internal rotation,
providing posterior stability.28
Tensile testing of the inferior glenohumeral
ligament with the shoulder oriented in the clin-
ical apprehension position revealed that 66% of
the specimens failed at the glenoid attachment
site whereas 34% failed at the midsubstance and
humeral insertion.26,27 The failures at the gle-
noid attachment can be separated into two cate-
gories: (1) the labrum was avulsed from the gle-
noid bone (63%); and (2) the labrum remained
attached to the glenoid and the ligament alone
was avulsed, representing failure at the ligament-
to-labral junction (37%). In other studies, fail-
ure occurred at the glenoid insertion site, the lig-
ament midsubstance and the humeral insertion
site in 40%, 35%, and 25% of the specimens, re-
spectively.3,16,39 Before failing, all regions of
the inferior glenohumeral ligament experienced
a significant amount of strain.37 High strain rates
also increased the percentage of failures in the
midsubstance of the ligaments (54%) whereas
failures at the humeral insertion decreased sub-
stantially to 8%.39
The ultimate load of the anterior band of the
inferior glenohumeral ligament was not sig-
nificantly different when failure occurred ei-
Number 400
July, 2002
ther at the glenoid insertion (353
32 N), in
the midsubstance of the ligament (213
64 N)
or at the humeral insertion (250
28 N).26,27
The elongation at failure was greater with rup-
ture at the glenoid insertion site (9.1
0.5 mm)
than with failure at the midsubstance (6.4

0.3 mm) or the humeral insertion site (7.6

0.7 mm). However, the amount of irrecover-
able elongation was found to be 0.8 mm at the
glenoid insertion site, 0.2 mm in the midsub-
stance of the ligament, and 0.9 mm at the
humeral insertion site. The yield strain at the
glenoid insertion site (12%
1%) and humeral
insertion site (11%
1%) was larger than
midsubstance failure (5%
0%).26,27 There-
fore, permanent stretching of the anterior band
of the inferior glenohumeral ligament could
lead to an increase in length that never exceeds
4% strain.
The midsubstance strain reported in other
studies has been found to be between 9% and
11%.3,39 The elongation at failure of the bone-
ligament-bone complex reported by McMahon
and coworkers27 was only 6% although others
have reported a range of 24% to 30%.3,39 These
differences might be caused by the use of dif-
ferent strain rates and joint positions. The fail-
ure mode of the anterior band of the inferior
glenohumeral ligament also has been shown to
be age-dependent.22 In younger individuals,
disruption of the anterior band of the inferior
glenohumeral ligament occurred most fre-
quently at the glenoid insertion site, whereas in
older individuals, the midsubstance of the lig-
ament was the most common failure site. The
load at failure of the anterior band of the infe-
rior glenohumeral ligament was higher in the
younger group (164% of older group).22
The strain field in the inferior glenohumeral
ligament during anteroinferior subluxation of
the glenohumeral joint also has been exam-
ined.24 The maximum principal strains on the
glenoid side of the inferior glenohumeral liga-
ment were found to be significantly greater
than on the humeral side. However, the strain
fields were highly variable over the region
studied. The principal strain vectors tended to
be oriented diagonally across the region and
Glenohumeral Ligaments and Anterior Instability 37
did not correlate with any anatomic directions.
This finding supports the hypothesis that the
capsule functions as a membranous structure.
These experimental findings suggest that
patients with initial glenohumeral instability
have only a small irrecoverable elongation of
their capsuloligamentous structures so that
plication of the capsule, in addition to repair of
the Bankart lesion, may not be necessary. In
addition, repetitive episodes of subluxation or
dislocation with permanent stretching of the
anterior band of the inferior glenohumeral lig-
ament must be considered when determining
treatment options because they may lead to in-
creased soft tissue elongation. Furthermore,
even though healing may occur quickly after
injury to the capsule or its humeral attachment
site, the components of the capsule still could
be in an elongated state.
Glenohumeral Joint Capsule
Posterior dislocation of the glenohumeral joint
did not occur until the capsule was sectioned
from the 1 o’clock to 3 o’clock positions in ad-
dition to the entire posterior capsule.30,42 In
addition, sectioning of the posterior band of
the inferior glenohumeral ligament and the
posterior half of the axillary pouch resulted in
a significant increase in anterior, posterior,
and total translation at 30 flexion. Further-
more, sectioning the inferior capsule resulted
in a significant increase in total translation in
all humeral positions.30 The posterior capsule
does not have a significant role in anteropos-
terior stability.
The components of the capsule provide sig-
nificant contributions at 0 and 90 gleno-
humeral abduction in anatomic rotation. There-
fore, as the contribution of the capsule to
stability decreases at 30 and 60 abduction, the
amount of translation increases and the rotator
cuff ’s contribution to joint stability must in-
crease. The capsule also has been shown to
carry no force when the humeral head is cen-
tered in the glenoid with the humerus in
anatomic rotation.7–9
The function of the glenohumeral ligaments
is dependent on the position of the humerus

38 Burkart and Debski
with respect to the glenoid. The superior gleno-
humeral ligament and coracohumeral ligament
were shown to be important stabilizers in the
inferior direction from 0 to 50 abduction
whereas the middle glenohumeral ligament
provides anterior stability between 45 and 60
abduction. The inferior glenohumeral ligament
complex was found to be the most important
stabilizer against anteroinferior shoulder dislo-
cation and the most frequently injured compo-
nent of the capsule. After shoulder dislocation,
an appropriate surgical procedure to repair the
inferior glenohumeral ligament complex must
be considered. Repetitive episodes of subluxa-
tion or dislocation could be indications of a de-
tached labrum and a compromised inferior
glenohumeral ligament complex and injuries
to other capsular components.
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