Working Diagnosis:
Reverse humeral avulsion of the glenohumeral ligament(rHAGL)

Treatment:
He was placed in sling for one week. Treatmeents to follow included physical therapy followed by a sport specific rehabilitation program over 12 weeks.

Outcome:
He was followed-up with MSK US 4 weeks post injury which documented interval healing of the injury site. After completion of rehabilitation, he returned to full, asymptomatic activity at 12 weeks.

Author's Comments:
The inferior glenohumeral ligament (IGHL) is composed of an anterior and posterior band. The IGHL limits anterior and posterior humeral head translation with the arm in abduction. Uncommonly, the humeral attachment of the anterior IGHL may be traumatically avulsed during an anterior instability episode, producing a HAGL lesion (humeral avulsion of the glenohumeral ligament). Rarely, a posterior instability episode with the arm in hyperabduction may avulse the humeral attachment of the posterior IGHL, resulting in a reverse HAGL lesion (rHAGL). Recognition of the rare injury is important to avoid chronic pain and posterior instability symptoms. This case highlights the evaluation and management of a rHAGL lesion in a high school athlete following a water tubing injury. rHAGL is a rare injury that should be considered in the setting of suspected posterior instability, particularly following a traumatic abduction injury. Unrecognized rHAGL lesions can be a source of chronic posterior shoulder pain & occult instability. The current case demonstrates the complementary role of MRI and US to better assess the extent of structural damage to the teres minor and capsule, assisting in decision-making regarding treatment. The lack of complete teres minor disruption in conjunction with lack of sonographic evidence of posterior humeral head subluxation facilitated the decision to pursue non-operative management.

Editor's Comments:
1. In the presentation, consider characterizing any reported dislocation event
2.In physical exam, avoid use of "ELE", and write out full. I am actually not entirely sure what the abreviation stands for
3. I would clarify "scarf maneuver", replacing with forced cross body adduction, if that is what you are implying.

References:
1. Bokor, Desmond, et al. Posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament. J Shoulder Elbow Surg. 2010. 19: 853-858.
2. Brown, Taylor, et al. Case Report: Reverse Humeral Avulsion Glenohumeral Ligament and Infraspinatus Rupture with Arthroscopic Repair. Am J Sports Medicine. 2007. Vol 35, No 12:2135-2139.
3. Castagna, A, et al. Posterior Humeral Avulsion of the Glenohumeral Ligament: A Clinical Review of 9 Cases. J Arthroscopic and Related Surgery. 2007. Vol 23, No 8: 809-815. 4. George, Michael, et al. H

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