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Role of Middle Glenohumeral Ligament in External Shoulder Rotation

Open AccessPublished:November 11, 2022DOI:https://doi.org/10.1016/j.jseint.2022.10.013

      Abstract

      Backgroun

      The middle glenohumeral ligament (MGHL) is one of the three ligaments that stabilize the anterior capsule of the shoulder. Recent work suggests that it inserts distally into the deep layer of the subscapularis tendon. The role of the MGHL remains debated. The hypothesis of this study was that the MGHL plays a significant functional role in limiting external rotation of the shoulder while allowing a wide range of motion through its distal insertion into the subscapularis rather than directly onto the humerus.

      Methods

      In a cadaveric study performed on 20 shoulders (10 subjects), the MGHL and the other anterior structures of the shoulder were successively cut according to a standardized protocol. At each stage, the external rotation range of the shoulder was measured with the arm at the side (ER1) and in 90° abduction (ER2) using a goniometer. After dissection, the structure of the MGHL and its distal insertion were analyzed.

      Results

      Cutting the MGHL led to significant increases in ER1 but not in ER2. Shoulder range of motion in ER1 increased on average by 15 ± 5° (p < 0.001) after cutting the MGHL and by 21 ± 11° (p < 0.001) after subscapularis peel. The range of motion in ER2 increased by 3 ± 4° (p = 0.048) after cutting the MGHL, by 4 ± 6° (p = 0.02) after subscapularis peel and by 25 ± 8° (p < 0.001) after cutting the inferior glenohumeral ligament. The MGHL was present in all dissected shoulders. It was leaf-like in 12 cases, cord-like in 6 cases and had a vestigial appearance in 2 cases. The distal insertion was in all cases in the deep layer of the subscapularis in a thickening of the anterior capsule in the superior part of the muscle, except for two cases in which the tendinous part of the subscapularis was also involved.

      Conclusion

      The MGHL limited shoulder external rotation by a similar amount as the subscapularis muscle. Further studies are required to understand the clinical relevance of these findings, notably for the treatment of shoulder stiffness.

      Keywords

      The middle glenohumeral ligament (MGHL) stabilizes the anterior part of the shoulder capsule along with the superior and inferior glenohumeral ligaments (SGHL and IGHL). The MGHL is classically described as inserting proximally on the anterosuperior part of the glenoid labrum and distally on the lesser tuberosity.
      • Dekker T.J.
      • Aman Z.S.
      • Peebles L.A.
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      • Chahla J.
      • Millett P.J.
      • et al.
      Quantitative and Qualitative Analyses of the Glenohumeral Ligaments: An Anatomic Study.
      ,

      Netter F. Upper Limb. In: Atlas of Human Anatomy. Elsevier Masson; 2019. p. 402–470. (ISBN No. 978-2-294-08042-5)

      ,

      Rouvière H, Delmas A. Articulations du membre supérieur. In: Anatomie humaine. Descriptive, topographique et fonctionnelle. Tome 3 Membres. Elsevier Masson; 2002. p. 41–89. (ISBN No. 978-2-294-00393-6)

      ,
      • Steinbeck J.
      • Liljenqvist U.
      • Jerosch J.
      The anatomy of the glenohumeral ligamentous complex and its contribution to anterior shoulder stability.
      Recent in-vivo arthroscopic observations have offered a more precise description of the MGHL’s anatomy, and suggest that it inserts distally into the deep layer of the subscapularis tendon, rather than on the humerus.
      • Bächler J.
      • Bergman S.
      • Lancigu R.
      • Hubert L.
      • Ropars M.
      • Rony L.
      Arthroscopic anatomy of the middle glenohumeral ligament. A series of 300 cases.
      ,
      • Collotte P.
      • Nové-Josserand L.
      Arthroscopic anatomy of the middle glenohumeral ligament.
      ,
      • Kaptan A.Y.
      • Özer M.
      • Alim E.
      • Perçin A.
      • Ayanoğlu T.
      • Öztürk B.Y.
      • et al.
      The middle glenohumeral ligament: a classification based on arthroscopic evaluation.
      These studies also highlight the variability of its structure and of its distal insertion.
      • Bächler J.
      • Bergman S.
      • Lancigu R.
      • Hubert L.
      • Ropars M.
      • Rony L.
      Arthroscopic anatomy of the middle glenohumeral ligament. A series of 300 cases.
      ,
      • Collotte P.
      • Nové-Josserand L.
      Arthroscopic anatomy of the middle glenohumeral ligament.
      ,
      • Kaptan A.Y.
      • Özer M.
      • Alim E.
      • Perçin A.
      • Ayanoğlu T.
      • Öztürk B.Y.
      • et al.
      The middle glenohumeral ligament: a classification based on arthroscopic evaluation.
      Whereas the role of the IGHL is well established in anterior glenohumeral instability,
      • Burkart A.C.
      • Debski R.E.
      Anatomy and Function of the Glenohumeral Ligaments in Anterior Shoulder Instability.
      ,
      • Felli L.
      • Biglieni L.
      • Fiore M.
      • Coviello M.
      • Borri R.
      • Cutulo M.
      Functional study of glenohumeral ligaments.
      ,
      • O’Connell P.W.
      • Nuber G.W.
      • Mileski R.A.
      • Lautenschlager E.
      The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.
      ,
      • Turkel S.J.
      • Panio M.W.
      • Marshall J.L.
      • Girgis F.G.
      Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
      the MGHL’s function remains unclear.
      • Burkart A.C.
      • Debski R.E.
      Anatomy and Function of the Glenohumeral Ligaments in Anterior Shoulder Instability.
      ,
      • Turkel S.J.
      • Panio M.W.
      • Marshall J.L.
      • Girgis F.G.
      Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
      Some studies suggest it contributes to the anterior stability of the shoulder,
      • Burkart A.C.
      • Debski R.E.
      Anatomy and Function of the Glenohumeral Ligaments in Anterior Shoulder Instability.
      ,
      • Felli L.
      • Biglieni L.
      • Fiore M.
      • Coviello M.
      • Borri R.
      • Cutulo M.
      Functional study of glenohumeral ligaments.
      ,
      • O’Connell P.W.
      • Nuber G.W.
      • Mileski R.A.
      • Lautenschlager E.
      The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.
      ,
      • Turkel S.J.
      • Panio M.W.
      • Marshall J.L.
      • Girgis F.G.
      Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
      whereas others highlight its role in limiting external rotation.
      • Ferrari D.A.
      Capsular ligaments of the shoulder: Anatomical and functional study of the anterior superior capsule.
      ,
      • Kuhn J.E.
      • Huston L.J.
      • Soslowsky L.J.
      • Shyr Y.
      • Blasier R.B.
      External rotation of the glenohumeral joint: Ligament restraints and muscle effects in the neutral and abducted positions.
      ,
      • O’Connell P.W.
      • Nuber G.W.
      • Mileski R.A.
      • Lautenschlager E.
      The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.
      ,
      • Terry G.C.
      • Hammon D.
      • France P.
      • Norwood L.A.
      The stabilizing function of passive shoulder restraints.
      ,
      • Turkel S.J.
      • Panio M.W.
      • Marshall J.L.
      • Girgis F.G.
      Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
      The hypothesis of this study was that the MGHL plays a significant limiting role in external shoulder rotation, while nevertheless allowing a considerable range of motion through the lack of a direct insertion on the humerus. Our main objective was to quantify the effect of the MGHL in external shoulder rotation. The secondary objectives were to describe the distal insertion and the structure of the MGHL.

      Material and Methods

      The study was approved by the local ethics committee (Conseil d’Orientation Scientifique Ramsay Santé, approval number 00010835, 18 November 2021).
      Twenty fresh (non-frozen, non-embalmed) cadaveric shoulders from 10 whole body cadavers were dissected in September and October 2021 by three surgeons (AW, TD, MB). Shoulders with severe glenohumeral arthritis, scaring suggestive of surgery, a callus consistent with traumatic injury or a subscapular tear were excluded.
      A protocol was established to investigate the role of the MGHL in external shoulder rotation, with the primary aim of evaluating the effect of isolated section of the MGHL on external rotation. The cadavers were taken out of cold storage (3°C) at least 30 min before dissection to limit the effect of temperature on joint range of motion. The shoulders were gently mobilized to eliminate any residual cadaveric stiffness.
      The subjects were placed in the beach chair position at 45°. A first set of range of motion measurements was performed before dissection. The dissections followed the usual steps of an anterior deltopectoral approach to the glenohumeral joint:
      • -
        Step 1: skin incision and dissection of soft tissue through a deltopectoral approach.
      • -
        Step 2: a 1 cm incision in the cranial part of the pectoralis major tendon.
      • -
        Step 3: identification of the long head of the biceps tendon in the bicipital groove and extra-articular tenotomy;
      • -
        Step 4: subscapularis exposure, opening of the rotator interval, identification and protection of the MGHL and resection of the rotator interval, including the coracohumeral ligament, up to the glenoid cavity, including the SGHL.
      • -
        Step 5: positioning of a double bent Hohmann retractor in the glenohumeral joint to retract the humeral head backward; identification of the MGHL from its medial insertion on the glenoid fossa to its lateral insertion, and sectioning of the MGHL in contact with the glenoid.
      • -
        Step 6: subscapularis peel; elevation of the subscapularis (including the anterior capsule) by peeling it away from the lesser tuberosity, starting from the bicipital groove. Identification of the plane between the subscapularis muscle and the IGHL, to avoid damaging the latter.
      • -
        Step 7: sectioning of the IGHL in contact with the glenoid. IGHL cut in full, from front to back, up to and including the posterior band, under visual control.
      Ranges of motion in external rotation were measured manually at each step using a goniometer with the arm at the side (ER1) and in 90° abduction (ER2), at the maximum rotational range without anterior glenohumeral instability (subluxation or dislocation). Measurements were rounded to the nearest 5°. The measurements were performed by two investigators in a blinded manner and the average value was taken.
      At the end of each dissection, the MGHL and the distal extremity of the subscapularis were removed by sectioning the subscapularis at the level of the glenoid neck and the structure of the MGHL and its distal insertion site were analyzed (Figure 1). The most cranial insertion point was measured with respect to the superior and inferior borders of the subscapularis and the most lateral insertion point was measured with respect to the lesser tuberosity. The structure of the MGHL was described using Collote et al’s classification
      • Collotte P.
      • Nové-Josserand L.
      Arthroscopic anatomy of the middle glenohumeral ligament.
      as either leaf-like (if only one border was identifiable), cord-like (if both borders were identifiable) or vestigial.
      Figure thumbnail gr1
      Figure 1Photograph of an anatomical specimen removed at the end of the dissection process: distal subscapularis (SSC) muscle with middle glenohumeral ligament (MGHL).

      Statistical analysis

      Continuous variables are reported as mean and standard deviation (SD). Univariate analyses were performed with paired t-tests if the data were normally distributed, and Wilcoxon signed-rank tests otherwise. Differences were considered statistically significant at p < .05. All analyses were performed online using EasyMedStat (version 3.13; www.easymedstat.com; EasyMedStat, Levallois-Perret, France).

      Results

      Eight of the subjects were female and two were male. The mean age at death was 86 years (range, 72–98 years). Rotator cuff tears was observed in ten shoulders: five superior (supraspinatus) tears and five posterosuperior (supra- and infraspinatus) tears. The long head of the biceps tendon was in the bicipital groove in all cases.

      External rotation

      The main results of the study are summarized in Table I (full sets of measurements in Supplemental Tables SI and SII). There was no significant difference in terms of initial ER1 values between shoulders with and without cuff tears (45° vs 49°, respectively). The measured values of ER1 and ER2 before dissection and in the first two steps (skin incision and subcutaneous dissection, and partial section of the pectoralis major) were identical in all cases. Increases in ER1 and ER2 were observed from steps 3 and 4 onward (Tables I).
      Table IChanges in external rotation with arm at the side (ER1) and in 90° abduction (ER2) after each stage of capsular release
      DissectionPM incisionLHB sectionRI and SGHL sectionMGHL sectionSSC sectionIGHL section
      170°70°70°85°100°100°
      240°40°40°50°80°80°
      345°45°45°70°90°90°
      445°50°50°60°90°90°
      540°50°50°75°90°90°
      645°45°60°75°90°90°
      745°45°65°80°90°90°
      860°60°60°80°90°90°
      930°30°35°50°85°85°
      1030°30°35°45°90°90°
      1150°50°50°60°75°75°
      1250°50°55°65°80°80°
      1340°40°60°70°90°90°
      1440°40°40°50°70°70°
      1550°50°50°70°80°80°
      1650°50°50°65°80°80°
      1740°40°40°50°85°85°
      1840°40°40°50°85°85°
      1960°60°60°80°90°90°
      2060°60°65°80°90°90°
      Mean ± SD47 ± 10°47 ± 10°51 ± 11°66 ± 13°86 ± 7°86 ± 7°
      Results are reported as mean ± standard deviation (SD); PM: pectoralis major; LHB: long head of biceps; RI: rotator interval; SGHL: superior glenohumeral ligament; MGHL: middle glenohumeral ligament; SSC: subscapularis; IGHL: inferior glenohumeral ligament.
      The range of motion in ER1 (with the arm at the side) increased in 7/20 shoulders and by 4° ± 7° on average (p = 0.02) after rotator cuff interval and SGHL section, and in all shoulders by 15 ± 5° (p < 0.001) after MGHL section (Figure 2; Table I). After subscapularis peel, the range of motion in ER1 increased in all shoulders and by 21 ± 11° on average (p < 0.001). Inferior gleno-humeral ligament section had no effect on ER1 (Table I).
      Figure thumbnail gr2
      Figure 2Box plot of the increase in external rotation range of the shoulder with the arm at the side after section of the middle glenohumeral ligament (MGHL) and of the subscapularis (SSC), in degrees (°). The difference between the two mean values is of borderline significance (paired t-test, p = 0.07).
      The range of motion in ER2 (arm in 90° abduction) did not increase after rotator cuff interval and SGHL section, increased in 5/20 shoulders, by 3 ± 4° on average (p = 0.02) after MGHL section, increased in 7/20 shoulders, by 4 ± 6° on average (p = 0.01) after subscapularis peel, and increased in all shoulders, by 25 ± 8° on average (p < 0.001), after IGHL section (Table I). Anterior dislocation or subluxation was systematically observed after subscapularis peel in maximal ER1, and anteroinferior dislocation was observed in all cases after IGHL section in maximal ER2. The instability was due to cam impingement of the greater tuberosity with the superior rim of the glenoid.

      Anatomical description

      The MGHL was present in all shoulders. Its structure was classified as leaf-like in 12 cases, cord-like in 6 cases and vestigial in 2 cases. A clear distal insertion into the deep layer of the subscapularis in a horizontal thickening of the capsule was observed in all cases. The insertion site was in the upper third or half of the subscapularis muscle, without involving the tendon, in 18/20 cases, and involved the subscapularis muscle and tendon in 2/20 cases.

      Discussion

      In this group of 10 fresh cadavers, sectioning the MGHL increased the external rotation range of the shoulder with the arm at the side by 15° on average, but there was no clinically significant increase in external rotation range with the arm in 90° abduction. This supports the hypothesis that the MGHL limits external shoulder rotation, particularly when the arm is placed at the side. In this position, the two main anatomical structures that limit external rotation, are the MGHL and the subscapularis. In 90° abduction, external rotation is only limited by the IGHL.
      The effects of MGHL section on shoulder instability and external rotation range have previously been investigated by Turkel et al
      • Turkel S.J.
      • Panio M.W.
      • Marshall J.L.
      • Girgis F.G.
      Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
      . The smaller increases observed by these authors (+5° on average with the arm at the side, +8° on average in 45° abduction, and +1° on average in 90° abduction) can be explained by their sectioning of the subscapularis muscle before measurements at an unspecified level, the subscapularis and the MGHL interacting closely as described above. They interpreted the increases as being mainly due to the section of the IGHL, and described the MGHL as being mostly taut with the arm at the side and in 45° abduction. In their cadaveric biomechanical study, Kuhn et al were the first to specifically assess the involvement of the anterior glenohumeral ligaments in limiting external rotation.
      • Kuhn J.E.
      • Huston L.J.
      • Soslowsky L.J.
      • Shyr Y.
      • Blasier R.B.
      External rotation of the glenohumeral joint: Ligament restraints and muscle effects in the neutral and abducted positions.
      They found that external rotation (ER1 and ER2) was mainly limited by the IGHL, with only limited involvement of the SGHL and MGHL (evaluated together). Whereas our results suggest likewise that ER2 is mainly limited by the IGHL (ER2 increased by 25° on average after IGHL section), they also indicate, in disagreement with Kuhn et al,
      • Kuhn J.E.
      • Huston L.J.
      • Soslowsky L.J.
      • Shyr Y.
      • Blasier R.B.
      External rotation of the glenohumeral joint: Ligament restraints and muscle effects in the neutral and abducted positions.
      that the MGHL significantly limits external rotation with the arm at the side while the IGHL does not. Our results are in keeping with those reported by Ferrari,
      • Ferrari D.A.
      Capsular ligaments of the shoulder: Anatomical and functional study of the anterior superior capsule.
      O’Connell et al,
      • O’Connell P.W.
      • Nuber G.W.
      • Mileski R.A.
      • Lautenschlager E.
      The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.
      and Terry et al,
      • Terry G.C.
      • Hammon D.
      • France P.
      • Norwood L.A.
      The stabilizing function of passive shoulder restraints.
      that the MGHL limits external shoulder rotation with the arm at the side and in moderate abduction (mainly up to 45°).
      • Ferrari D.A.
      Capsular ligaments of the shoulder: Anatomical and functional study of the anterior superior capsule.
      ,
      • O’Connell P.W.
      • Nuber G.W.
      • Mileski R.A.
      • Lautenschlager E.
      The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.
      ,
      • Terry G.C.
      • Hammon D.
      • France P.
      • Norwood L.A.
      The stabilizing function of passive shoulder restraints.
      More generally in the literature,
      • Ferrari D.A.
      Capsular ligaments of the shoulder: Anatomical and functional study of the anterior superior capsule.
      ,
      • Kuhn J.E.
      • Huston L.J.
      • Soslowsky L.J.
      • Shyr Y.
      • Blasier R.B.
      External rotation of the glenohumeral joint: Ligament restraints and muscle effects in the neutral and abducted positions.
      ,
      • O’Connell P.W.
      • Nuber G.W.
      • Mileski R.A.
      • Lautenschlager E.
      The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.
      ,
      • Terry G.C.
      • Hammon D.
      • France P.
      • Norwood L.A.
      The stabilizing function of passive shoulder restraints.
      ,
      • Turkel S.J.
      • Panio M.W.
      • Marshall J.L.
      • Girgis F.G.
      Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
      while all authors do not agree on the level of involvement of the MGHL, the general consensus is that it limits external rotation with the arm at the side and at low abduction angles.
      Anatomically speaking, we observed in all cases that the MGHL inserted distally on the articular side of the subscapularis rather than directly onto the lesser tuberosity,

      Pouliat N. Anterior and inferior glenohuméral capsuloligamentous complex. In: Di Giacomo G, Pouliart N, Costantini A, De Vita A, editors. Atlas of functional shoulder anatomy. Milan: Springer Verlag Italia; 2008. (ISBN No. 978-88-470-0759-8)

      merging almost perpendicularly with the horizontal fibers of the anterior capsule that define the fasciculus obliquus. Our results therefore differ from other macroscopic studies that report an insertion onto the humerus
      • Dekker T.J.
      • Aman Z.S.
      • Peebles L.A.
      • Storaci H.W.
      • Chahla J.
      • Millett P.J.
      • et al.
      Quantitative and Qualitative Analyses of the Glenohumeral Ligaments: An Anatomic Study.
      ,
      • Steinbeck J.
      • Liljenqvist U.
      • Jerosch J.
      The anatomy of the glenohumeral ligamentous complex and its contribution to anterior shoulder stability.
      but are in keeping with those that suggest that the distal insertion is into the deep layer of the subscapularis.
      • Bächler J.
      • Bergman S.
      • Lancigu R.
      • Hubert L.
      • Ropars M.
      • Rony L.
      Arthroscopic anatomy of the middle glenohumeral ligament. A series of 300 cases.
      ,
      • Collotte P.
      • Nové-Josserand L.
      Arthroscopic anatomy of the middle glenohumeral ligament.
      A histological study would be beneficial to confirm this relationship. We chose not to report the measured distances of the MGHL’s insertion points from the lateral borders of the subscapularis as these measurements were imprecise and poorly reproducible.
      The role of the MGHL in external shoulder rotation is clinically relevant information. External rotation is limited in frozen shoulder, in particular in cases of capsulitis with substantial anterior fibrosis involving the rotator interval and neighboring tissues.
      • Tsai M.-J.
      • Ho W.-P.
      • Chen C.-H.
      • Leu T.-H.
      • Chuang T.-Y.
      Arthroscopic extended rotator interval release for treating refractory adhesive capsulitis: A viewpoint of “mobilizing subscapularis.
      MGHL involvement in this pathology may limit external rotation. Hagiwara et al found that arthroscopic sectioning of the MGHL in cases of adhesive capsulitis was associated with statistically significant increases of +3° in ER1 and +2° in ER2.
      • Hagiwara Y.
      • Kanazawa K.
      • Ando A.
      • Sekiguchi T.
      • Koide M.
      • Yabe Y.
      • et al.
      Effects of joint capsular release on range of motion in patients with frozen shoulder.
      Meanwhile, Tipton et al have suggested arthroscopic sectioning of the MGHL to increase postoperative mobility in patients at risk of limited external rotation.
      • Tipton C.C.
      • Gilmer B.B.
      • Marvil S.
      • Lang S.
      • Unal K.
      • Guttmann D.
      An Arthroscopic Technique for Release of the Middle Glenohumeral Ligament and the Effect on External Rotation of the Shoulder.
      On the other hand, given the MGHL’s distal insertion into the subscapularis, the limiting role of the MGHL in ER1 must surely be intimately linked to the integrity of the subscapularis muscle. In massive, retracted subscapularis tears, the shoulder is clinically observed to be in excessive external rotation, a consequence of its no longer being restricted in this regard by the subscapularis and MGHL. In this situation, the MGHL loses its limiting effect on external rotation because its distal insertion is carried away by the retracted subscapularis. This mechanism is evidenced arthroscopically by the invisible MGHL sign, non-observation of the MGHL being indicative of a retracted subscapularis tear.
      • Chauvet T.
      • Haritinian E.
      • Baudin F.
      • Collotte P.
      • Nové-Josserand L.
      The Invisible MGHL Test: Diagnostic Value and Benefits for the Repair of Retracted Subscapularis Tears.
      ,
      • Nové-Josserand L.
      • Chauvet T.
      • Haritinian E.
      • Collotte P.
      • Merlini L.
      • Vieira T.D.
      The Middle Glenohumeral Ligament Test for the Diagnosis of Subscapularis Lesions.
      The fact the ER1 increases further after subscapularis peel (step 6) supports these clinical observations. The MGHL only restricts ER1 if the subscapularis muscle and tendon are intact.
      Anatomical and clinical observations provide a better understanding of the MGHL’s functions. The first is its restriction of external shoulder rotation with the arm at the side, as demonstrated biomechanically by the present study and clinically by excessive external rotation and capsulitis-type stiffness. The second role, supported by phylogenetic arguments, may be as a secondary stabilizer in cases of anterior instability.
      The strengths of this study lie in the precise analysis of the successive anatomical structures involved in controlling external shoulder rotation. The study is limited by its small size and cadaveric nature, while the old age and gender imbalance of the subjects means the findings need to be confirmed in the general population. Some subjects with superior and/or posterior rotator cuff tears were included because these tendons (supra- and infraspinatus) are not directly involved in external rotation. Finally, since subscapularis peel involved sectioning the anterior capsule, the effects of these two structures could not be evaluated independently. However, our results do provide useful information on the effects of not repairing the subscapularis or the anterior capsule in total shoulder arthroplasty.

      Conclusion

      The MGHL limits external shoulder rotation with the arm at the side. In these 20 cadaveric shoulders, sectioning the MGHL led to a significant mean increase of 15° in external rotation range with the arm at the side, but had no clinically significant effect on external rotation with the arm in 90° abduction. These observations support MGHL section, as proposed by some authors in the treatment of frozen shoulder, to improve mobility, particularly in external rotation.

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