Successful Nonoperative Management of HAGL (Humeral Avulsion of Glenohumeral Ligament) Lesion With Concurrent Axillary Nerve Injury in an Active-Duty US Navy SEAL
Humeral avulsion of the glenohumeral ligament (HAGL) is a lesion that has been recognized as a cause of recurrent shoulder instability. To our knowledge there are no reports of successful return to full function in young, competitive athletes or return to manual labor following nonoperative management of a HAGL lesion. A 26-year-old Navy SEAL was diagnosed with a HAGL injury, and associated traction injury of the axillary nerve as well as a partial tear of the rotator cuff. Operative intervention was recommended; however, due to issues with training and with inability to properly rehab with the axillary nerve injury, surgical plans were delayed. Interestingly, the patient demonstrated both clinical and radiographic magnetic resonance imaging healing of his lesion over an 18-month period. At 18 months the patient had returned to full active duty without pain or instability as a Navy SEAL.
When nerve continuity remains, functional recovery occurs after 3 to 6 months, or within weeks in some cases.18-20 Nerve injuries in continuity but with persistent, severe clinical deficits may require surgical exploration with subsequent neurolysis and/or repair.19-21 Our patient showed gradual axillary nerve recovery from a clinical standpoint. By 6 months after injury, despite continued muscle atrophy and decreased axillary nerve sensation, he had returned to full duty as a Navy SEAL. By 17 months, atrophy was markedly improved, and strength and ROM had subjectively returned, despite there being significant conduction amplitude losses, up to 50% of the contralateral side, on EMG testing.
This case represents a scenario in which likely initial surgical management was precluded by a concomitant injury, and the patient had a serendipitous outcome. It is possible the axillary neuropraxia and subsequent temporary deltoid dysfunction provided a unique environment that was conducive to the healing of the HAGL lesion. With classic Bankart lesions, many surgeons prefer to use aggressive early surgical treatment in first-time dislocators, especially elite athletes, in an attempt to avoid recurrent instability.22-26 However, some have suggested that initial immobilization after acute injury may lead to successful nonoperative management.27 Perhaps our case report raises the question as to whether a prolonged period of initial immobilization can prove successful in management of a HAGL lesion. Prospective studies comparing early surgical and nonoperative treatment of these challenging lesions are warranted.
We have reported a case of successful nonoperative management of a HAGL lesion in an active-duty Navy SEAL with concomitant shoulder injuries. This case could suggest that a trial of initial nonoperative management should be considered for injuries that involve a HAGL lesion when there are concerns about the patient’s ability to complete functional rehabilitation because of the combined injuries of the shoulder.
