The glenohumeral ligaments of the anterior aspect of the shoulder: anatomical patterning and morphometry

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Three distinct fascicles are usually described from the anterior surface of the shoulder joint: a superior glenohumeral ligament (SGHL); a middle glenohumeral ligament (MGHL) and an anteroinferior glenohumeral ligament (AIGHL). A remarkable interindividual variation has been reported, and there is a lack of consensus regarding terminology and quantitative measures of ligament attachments. A recent study provided a much-needed insight into the quantitative details of the glenohumeral ligament insertions. However, there is a lack of studies describing linear measurements (closer to real-life surgical anatomy) of glenohumeral ligamentous insertions according to their pattern. Hereby, we present a Thiel-based anatomical study describing proximal (glenoid) insertions of glenohumeral ligaments in 39 specimens. Only 43,5% of cases showed a canonical pattern of SGHL, MGHL, and AIGHL, with scapular insertions ranging from 0,28 to 1,58 cm for SGHL, 0,1–3,6 cm for MGHL, and 0,45 − 2,05 cm for AIGHL, frequently mixed between the labrum and the bony edge of the glenoid surface. Most cases show a single glenohumeral ligament inserted, usually in the labrum. A wide range of patterns regarding the number of insertions and their labral or bony nature is present in our sample. Overall, there are three different patterns of glenohumeral ligaments in the anterior aspect of the shoulder joint, with the canonical pattern (three ligaments) represented in less than half of the cases. The morphometric study of the glenohumeral ligaments should consider their pattern of distribution. Also, insertions vary between the labrum and the scapular bony articular surface.. rotator cuff shoulder glenohumeral anatomy ligament Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction The glenohumeral ligaments are key stabilizers of the glenohumeral joint. First described in the 19th century [ 1 – 5 ], there is no consensus about their detailed anatomy [ 2 – 4 ]. Overall, three distinct fascicles (Fig. 1A) are usually described from the anterior surface of the shoulder joint: a superior glenohumeral ligament (SGHL) that acts as a stabilizer in adduction and external rotation of the arm [ 5 ]; a middle glenohumeral ligament (MGHL) that stabilizes the shoulder in abduction and external rotation [ 6 – 7 ], and an anteroinferior glenohumeral ligament (AIGHL) that is a pure anterior stabilizer [ 8 ]. Furthermore, a posteroinferior glenohumeral ligament (PIGHL) and a coracohumeral ligament (CHL), which are not readily distinguishable from the anterior surface of the shoulder joint, do contribute to the vertical and posterior stabilization of the shoulder joint. The superior glenohumeral ligament (SGHL) has an origin at the tip of the glenoid cavity and/or from the supraglenoid tubercle, although there are authors that find additional attachments (see Fox et al., 2021 [ 9 ] for a comprehensive review and also [ 10 – 12 ]); in turn, MGHL originates in the supraglenoid tubercle and the glenoid neck immediately caudal to the insertion of the SGHL. The AIGHL is classically described as one of three fascicles on a broader complex that is almost continuously attached to the caudal half of the osseous labrum [ 9 ]. A remarkable interindividual variation has been reported, both from an extraarticular [ 2 , 4 ] and an intraarticular point of view [ 13 , 14 ]. Moreover, there is a lack of consensus regarding terminology and quantitative measures of ligament attachments. A recent study [ 3 ] provided much-needed insight into the quantitative details of glenohumeral ligament insertions. However, there is a lack of studies describing linear measurements (which are indeed more approximate to real-life surgical anatomy) of glenohumeral ligamentous insertions according to their pattern. Hereby, we present a Thiel-based anatomical study describing proximal (glenoid) insertions of glenohumeral ligaments. Materials and Methods Thirty-nine shoulders were used in this study (Table 1). Human tissue was obtained from volunteer body donors to the Applied Anatomy Laboratory at the Autonomous University of Madrid Department of Anatomy, Histology, and Neuroscience. Cadavers were subjected to transfemoral perfusion with 14.3 l of a water-based solution containing 3 g 3BO3, 30 ml ethylene glycol, 20 g NH4NO3, and 5 g KNO3, as well as 500 ml of another water-based solution, consisting of 20 ml ethylene glycol and 1 ml 4-Cl 3-methyl phenol [ 15 – 16 ]. Exclusion criteria included post-mortem lapses longer than 48 hours and a known history of shoulder pathology. After complete separation of the upper limb from the trunk using a band saw, all vasculonervous structures of the axilla were sectioned and rebutted. The subscapular muscle was dissected from the subscapular fossa until its myotendinous insertion in the humeral head was visible. This junction was very carefully dissected, as its cephalic limit follows the same direction as the SGHL. After visualization from the frontal aspect of the shoulder joint capsule, shoulders were assigned to one of three possible pat-terns according to the amount of glenohumeral ligaments: pattern 1 when three glenohumeral ligaments were identified (SGHL, MGHL and AIGHL), pattern 2 when a single ligament was found, and pattern 3 when two ligaments were identified [ 4 ]. When the identification of the ligament was unclear (particularly in pattern 3, see Results), any ligament inserting cephalic to 2 o`clock was considered SGHL, and any ligament inserted caudal to 4 o`clock was considered AIGHL. Any ligament with scapular insertions ranging between both (i.e, in the territory between 2 and 4 o`clock, but not exclusively) was considered MGHL. Afterwards, an LCD® Vernier digital caliper was used to measure the range of insertions of each possible ligament, both in the bone and in the labral cartilage. After measurements, transections through the articular line were performed to identify and correct possible overlaps between ligaments. Data were analyzed using Microsoft Excel and IBM SPSS Statistics 19. Only proximal (scapular/glenoid) insertions were registered in this study. Results Among the 39 cases studied, all of them showed at least one ligament, almost invariably covering the area between 2 and 3 o`clock regarding its scapular insertions. In 56% of cases (n = 22), an unambiguous SGHL was identified, inserted in the area immediately anterior to the supraglenoid tubercle, and its anterior aspect showed bony insertions. In 12.8% of cases (n = 5), the SGHL showed exclusively labral insertions. In 10,2% of cases (n = 4), a two-layered SGHL was identified with both superficial bony insertions and deep labral insertions. All cases but one showed a ligament with glenoid insertions covering the area around 3 o'clock and coinciding with the more anterior projection of the articular angle; therefore, all cases but one were deemed to have a MGHL. Osseous insertions of the MGHL were present in 38.4% of cases (n = 15), always in the articular angle and the border of the glenoid surface and extending anteriorly. Almost all cases (n = 37) were inserted in the labrum, meaning that the MGHL was a somewhat deeper structure than most of the GHLs. In 30.7% of cases, the MGHL was a double-layered structure with both bony and labral insertions encompassing almost its entire cephalocaudal length. In 7.69% of cases (n = 3, see D1, D14L, D16 in Supplementary Table 1), an almost purely labral MGHL was reinforced with a very thin cephalic fascicle of around 0.1 cm and inserted around 1 o`clock, probably corresponding with an amalgamated SGHL. Around 46% of cases (n = 18) showed, clearly in the anterior aspect of the shoulder joint, an AIGHL that was inserted in the osseous border of the anterior and inferior region of the glenoid, around the lateral edge of the glenoid neck or in the immediately underlying labral cartilage (n = 15, 38.4%, ). In 7.69% (n = 3) cases, there was a close apposition between superficial bony-inserted fascicles and deeper labral ones, forming a two-layered structure (see above), and no cases with a purely osseous insertion were identified, while 9 (23.07% overall) cases showed purely labral insertions. All results are recorded in Supplementary Table 1. Regarding the pattern, 30.8% of cases (n = 12) presented three ligaments (pattern 1, the ‘canonical’ one, Figs. 1A, 2A, 2B, 3), 38.8% of cases (n = 15) presented all GHLs amalgamated into one single ligamentous band (pattern 2, Figs. 1B, 2B, 4 and 5), and 30.8% (n = 12) presented two ligaments (pattern 3; Fig. 1C, 2C and 6). Although the protocol followed to record cases considered any ligament including the range from 2 to 4 o`clock as an MGHL, ligamentous fascicles cephalic to 2 o'clock were identified (either a true SGHL or a SGHL-like structure included in an MGHL) in 38 cases. The morphometrical analysis of the SGHL rendered a range of bony insertions between 0.28 and 1.58 cm (x̄=0.66 ± 0.31) and of labral insertions of 0.41 to 1.06 cm (x̄=0.69 ± 0.25). The MGHL showed bony insertions between 0.1 cm and 2.09 cm (x̄=1.14 ± 0.72) and, almost invariably, labral insertions that range from 0.47 and 3.60 cm (x̄=1.75 ± 0.73). The AIGHL showed bony insertions between 0.45 and 2.05 cm (x̄=0.96 ± 0.52) and labral insertions between 0.5 and 2.05 cm (x̄=1.06 ± 0.51). However, measures (see Supplementary Table 1) are dependent on the pattern of in-sertion. In pattern 1, where the three ligaments are identifiable from a frontal view of the shoulder, 83% of SGHLs showed bony insertions (range 0.28–1.58 cm; x̄=0.69 ± 0.38) and 25% of cases showed labral insertions (range 0.41–0.98 cm; x̄=0.66 ± 0.29). In pattern 1, almost all (91.6%) of the MGHL showed pure labral insertions (range 0.56–2.4 cm; x̄=1.2 ± 0.58), and bony insertions represented slightly smaller fascicles that were mostly discrete reinforcements of the main body of the ligament, present in 3 cases (25%; range 0.55–1.49 cm; x̄=1 ± 0.47). In AIGHLs, osseous insertions were present in 33.3% of cases (range 0.45–1.05 cm; x̄=0.85 ± 0.26), and 75% of cases showed labral insertions (range 0.5–1.88 cm; x̄=1.08 ± 0.49). In pattern two, all ligaments coalesced in a single band, which is universally inserted in the labrum (range 1.57–3.6 cm; x̄=2.19 ± 0.59); this band has osseous reinforcements in its upper border in up to half of the cases (53.3%) that probably represent remnants of a putative SGHL. These reinforcements range from thin connective bridges to true ligaments (range 0.1–2.09 cm; x̄=1.056 ± 0.87). Pat-tern 3 is assigned when only two ligaments are identifiable from an anterior view of a dissected shoulder joint. From all the shoulders classified as pattern 3, 75% showed a combination of a MGHL with a putative SGHL (see Fig. 1C) (range 0.4–2.5 cm for bony insertions and 0.42–2.5; for labral insertions) and the other 25% a combination of a MGHL + AIGHL or AIGHL + SGHL (range 0.47–2.05 cm for bony insertions and 0.58–2.05 for labral insertions, see also Fig. 1C). Based on its ‘clockface-defined’ insertions, no shoulder showed an absolute absence of MGHL except case D38. A Stu-dent t-test was performed to check whether the presence of a canonical (1) or non-canonical (2,3) pattern influenced the linear measurement of the insertion, which was the case for the labral insertion of the MGHL (t=-3.01, p = 0.06). Related to this result, the patterning also influences the perimeter of ligamentous insertion as seen from the anterior surface of the joint (t = 1.95, p = 0.068). Sex and laterality were unrelated to the patterning (χ²=1.17; sig.=0.55 and χ²=0.75; sig = 0.68, respectively). Sex and laterality did not show any statistically relevant relationship to the linear length of any set insertions. Discussion This study is a descriptive study in soft-embalmed cadavers that provides morphometrical data for the scapular insertions of the glenohumeral ligaments, except the posterior ligaments; GHLs are essential for shoulder stability and are frequently subject to traumatic injuries. Quantitative studies on the glenohumeral ligaments are rare [ 2 ], typically based on few cases [ 3 ] or focused on only one ligament [ 17 – 18 ]. Also, a few studies [ 13 , 19 ] describe regional variability in a systematized way, although this description is usually performed from an intra-articular point of view. However, arthroscopic patterns largely coincide with gross anatomical ones [ 4 ]. To our knowledge, this is both the first quantitative study of the glenohumeral ligaments in Thiel-embalmed cadavers (see also [ 20 ] for other studies using soft-embalming methods) and the first one considering the anatomical variability of the glenohumeral ligaments. Technical issues, nomenclature and embryological basis of the anatomical variability. The main shortcomings of this study are those inherent to cadaveric-based studies. The fixation method, although allowing a good separation between structures in the connective tissue [ 4 ], hampers the histological assessment of the ligaments described and, therefore, a more precise identification. Additionally, complete information about subtle clinical details that may indicate shoulder pathology is not readily accessible to researchers. In any case, our samples still belong to a real-world population, although probably age biased. The dissection protocol offers the advantage of having previously separated the upper limb from the trunk, which frees up joint movements and eases the identification of the GHLs. This task is unfeasible when the limb hangs in a neutral position [ 21 ]. Comparability to other studies The main findings of this study are the morphometrical data for the scapular insertions of the glenohumeral ligaments, related to their pattern of insertion. Despite the high prevalence and cost of shoulder pathology, these kinds of quantitative studies are scarce and remain relatively inconspicuous [ 2 ]. Our morphometrical data largely match the more recent ones [ 3 ], although measures in this work are linear ones that do not consider the curvature/perimeter of the glenoid rim or the labrum. Also, we have not measured the footprint of the ligamentous insertion. However, the data presented here remain in a comparable range and consider patterns diverging from the canonical one, which were not recorded in the aforementioned study, probably due to its reduced sample size. Regarding the SGHL, our findings point in the same direction as other studies that try to reconcile long-standing discrepancies regarding the origins of this fascicle [ 17 , 27 ], which has been described to be inserted both in the supraglenoid tubercle and the superior labrum at the 1 o’clock position. This difference is likely related to the double-layered nature of the glenohumeral ligaments (see Results and Fig. 7) and the fact that arthroscopic and gross anatomical studies describe different layers of the same structure [ 28 ]. According to the work of Kask and colleagues [ 28 ], oblique fibres of the superior glenohumeral ligament arise from the supraglenoid tubercle, and the direct fibres arise from the labral insertions. Results presented here reinforce the idea of two distinct fascicles of the SGHL and provide quantitative data for them. This can also be applied to the remaining GHLs, particularly to the MGHL, which is very frequently double-layered, showing almost invariably a deep, labral fascicle (Fig. 7). Based on its insertions (see Material and methods), we have very few cases of agenesia of the MGHL (2,5%), contrasting to recent series [ 29 ] and classical ones [ 22 ], which found a much larger percentage (see also [ 30 ]). Again, this discrepancy may be rooted in the chosen method of nomenclating the ligaments. Remarkably, we have also not found any case of Buford complex [ 18 , 31 ]. Likely, the leaf-like MGHL reported in many studies corresponds to our pattern 2, and the cord-like MGHL corresponds to the canonical pattern 1 [ 30 , 33 – 35 ], at least in our sample. More complicated are the findings related to the insertions of the AIGHL. First, we are limiting our description to the ligaments that are identifiable on the anterior surface of the shoulder joint and not considering the PIGHL, which is probably functionally intermingled with the AIGHL. Second, our data regarding its range of insertion provide a much more caudal position than many studies [ 14 , 17 , 18 ], although other studies, including some recent ones, challenge these descriptions [ 3 , 36 ]. Again, discrepancies may be rooted in the method employed for defining the ligaments. Clinical considerations. From a clinical and radiological perspective, measures of insertions and the double-layered structure (osseous + labral) of many of them are useful in the field of radiological assessment. Ligaments in the anterior aspect of the shoulder joint are frequently affected after trauma [ 37 ], producing a characteristic Bankart lesion, a consequence of the detachment of the anterior and inferior labrum and glenohumeral capsule, frequently involving the anteroinferior glenohumeral ligament. The direct repair of glenohumeral insertions is the main solution for many cases of post-traumatic shoulder instability [ 38 , 39 ]. However, our results point to the need to assess separately each glenohumeral ligament, as the set of insertions may be variable. Also, an anterior or even inferior instability may be a consequence of lesions of ligaments other than the AIGHL when patterns distinct than the canonical pattern 1 are present [ 40 ]. The presence of osseous insertions that do not necessarily match the set of labral insertions point to the need of careful radiological guidance before surgery and to the development of techniques based on a mixed intraarticular and extraarticular approaches. Conversely, the potential presence of duplicated labral-osseous insertions of all three anterior glenohumeral ligaments explains why lesions like the glenolabral articular disruption that imply tears and ruptures to the labrum may course without shoulder instability, if bony insertions are respected [ 9 , 23 , 41 ]. Also in this sense, the conjoined work of labral and osseous insertions may explain the rarity of scapular avulsions of the GHLs compared to humeral avulsions [ 42 ], and a possibly subtle clinical presentation of these lesions, like in the case of anterior ligamentous periosteal avulsions [ 43 – 45 ], leading to infradiagnosis. Conversely, insufficient repair (not repairing a putative MGHL along the AIGHL or not repairing the whole set of insertions) may lead to the recurrent occurrence of anterior shoulder stability following one single traumatic event [ 46 ]. Regarding the biomechanical consequences of lesions in patients with glenohumeral patterns distinct from the canonical one, more studies are needed. Conclusions There are three different patterns of glenohumeral ligaments in the anterior aspect of the shoulder joint, being the canonical pattern of a ‘superior’ plus ‘middle’ and ‘inferior’ ligaments represented in less than half of the cases. All glenohumeral ligaments show distinct, and not necessarily overlapping, sets of labral and bony insertions, with a length and relative position that depends on the pattern. Failing to recognize anatomical variability of the ligaments in the anterior aspect of the shoulder joint makes both descriptive studies and clinical classifications less consistent. Abbreviations The following abbreviations are used in this manuscript: GHL/GHLs, glenohumeral ligament/s; AIGHL, anteroinferior inferior glenohumeral ligament MGHL, middle glenohumeral ligament; SGHL, superior glenohumeral ligament; PGHL: posterior glenohumeral ligament; CHL: coracohumeral ligament; cgl: coracoglenoid ligament; LHBB: long head of the biceps brachii Declarations Author Contributions : Conceptualization EGA and MFP.; methodology, EGA.; investigation, EGA, IPS, EBB, AGP, CMC, LRY, MFP, data curation, EGA; writing, original draft preparation, EGA, EBB (illustration) writing, review and editing. All authors have read and agreed to the published version of the manuscript. Funding : This work is self-funded by the authors. Institutional Review Board Statement : All procedures described here were carried according to the Spanish law and the Helsinki Declaration and in the context of a body donation program approved by the respective boards of the University of La Laguna and the Autonomous University of Madrid, as well as part of a broader project that received approval by the local ethics committee (reg. CHUC_2023_11, 2023-02-23). Informed Consent Statement : Written informed consent has been obtained from the patient(s) to conduct research involving donated cadaveric material. Data Availability Statement : All data, including detailed photographical record of the dissections, are fully available on request to EGA or IPS. Most of the cadaveric material is still stored, although not completely preserved as further work has been developed in the same specimens. Acknowledgments : Authors are thankful to Francisco Clascá Cabré, from the Autonomous University of Madrid, for his invaluable work setting up and maintaining the Applied Anatomy Laboratory in its present form. Camino Braojos Rodríguez and Carolina Morallón-Chinchilla, from the same laboratory, made a significant contribution to tissue conservation. We are also grateful to Lorena Jiménez-Sánchez, now an independent researcher based in Edinburgh (Scotland, UK), for her contributions in the early steps of this project, in the form of illustrations and photographical records. The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase mankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude Conflicts of Interest : Artimes García-Parra was self-employed by MundoFisio, a private cabinet in El Hierro (Canary Islands) dedicate to physical therapy. Noé Liria-Martín was employed by Canarian Network of Pathology, a private pathology laboratory in Tenerife (Canary Islands). Mario Fajardo-Pérez was self- employed by UltraDissection, a company that offers practical courses on regional anesthesia. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. References Flood V (1830) Discovery of a new ligament of the shoulder joint. Lancet 13:672–673 Chahla J, Aman ZS, Godin JA, Cinque ME, Provencher MT, LaPrade RF (2019) Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: A Call for Further Quantitative Studies. 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Skeletal Radiol 43:35–41. https://doi.org/10.1007/s00256-013-1744-y Additional Declarations No competing interests reported. Supplementary Files Tablagelnohumerales.pptx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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6","display":"","copyAsset":false,"role":"figure","size":116441,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"EGAetalFig6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7783752/v1/c267fae904978ae9e36204ea.jpg"},{"id":94489226,"identity":"53c618f3-e560-423a-aea7-cd08979d29e8","added_by":"auto","created_at":"2025-10-27 17:03:51","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":161565,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"EGAetalFig7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7783752/v1/ff83845d9874322c9d70942a.jpg"},{"id":94558447,"identity":"89255e8b-4105-460c-867e-130d2fb1b258","added_by":"auto","created_at":"2025-10-28 18:00:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1418512,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7783752/v1/5ae4111b-bb46-4af0-a8a5-2ebb2e9a9f00.pdf"},{"id":94389009,"identity":"4c15a4e4-a277-4c32-ad95-8db5b28c48a7","added_by":"auto","created_at":"2025-10-27 13:51:20","extension":"pptx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":52654,"visible":true,"origin":"","legend":"","description":"","filename":"Tablagelnohumerales.pptx","url":"https://assets-eu.researchsquare.com/files/rs-7783752/v1/ec99b1f6b0e220bb2635668a.pptx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The glenohumeral ligaments of the anterior aspect of the shoulder: anatomical patterning and morphometry","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe glenohumeral ligaments are key stabilizers of the glenohumeral joint. First described in the 19th century [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], there is no consensus about their detailed anatomy [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Overall, three distinct fascicles (Fig.\u0026nbsp;1A) are usually described from the anterior surface of the shoulder joint: a superior glenohumeral ligament (SGHL) that acts as a stabilizer in adduction and external rotation of the arm [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; a middle glenohumeral ligament (MGHL) that stabilizes the shoulder in abduction and external rotation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and an anteroinferior glenohumeral ligament (AIGHL) that is a pure anterior stabilizer [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, a posteroinferior glenohumeral ligament (PIGHL) and a coracohumeral ligament (CHL), which are not readily distinguishable from the anterior surface of the shoulder joint, do contribute to the vertical and posterior stabilization of the shoulder joint. The superior glenohumeral ligament (SGHL) has an origin at the tip of the glenoid cavity and/or from the supraglenoid tubercle, although there are authors that find additional attachments (see Fox et al., 2021 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] for a comprehensive review and also [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]); in turn, MGHL originates in the supraglenoid tubercle and the glenoid neck immediately caudal to the insertion of the SGHL. The AIGHL is classically described as one of three fascicles on a broader complex that is almost continuously attached to the caudal half of the osseous labrum [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA remarkable interindividual variation has been reported, both from an extraarticular [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and an intraarticular point of view [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, there is a lack of consensus regarding terminology and quantitative measures of ligament attachments. A recent study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] provided much-needed insight into the quantitative details of glenohumeral ligament insertions. However, there is a lack of studies describing linear measurements (which are indeed more approximate to real-life surgical anatomy) of glenohumeral ligamentous insertions according to their pattern. Hereby, we present a Thiel-based anatomical study describing proximal (glenoid) insertions of glenohumeral ligaments.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThirty-nine shoulders were used in this study (Table\u0026nbsp;1). Human tissue was obtained from volunteer body donors to the Applied Anatomy Laboratory at the Autonomous University of Madrid Department of Anatomy, Histology, and Neuroscience. Cadavers were subjected to transfemoral perfusion with 14.3 l of a water-based solution containing 3 g 3BO3, 30 ml ethylene glycol, 20 g NH4NO3, and 5 g KNO3, as well as 500 ml of another water-based solution, consisting of 20 ml ethylene glycol and 1 ml 4-Cl 3-methyl phenol [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Exclusion criteria included post-mortem lapses longer than 48 hours and a known history of shoulder pathology.\u003c/p\u003e\u003cp\u003eAfter complete separation of the upper limb from the trunk using a band saw, all vasculonervous structures of the axilla were sectioned and rebutted. The subscapular muscle was dissected from the subscapular fossa until its myotendinous insertion in the humeral head was visible. This junction was very carefully dissected, as its cephalic limit follows the same direction as the SGHL. After visualization from the frontal aspect of the shoulder joint capsule, shoulders were assigned to one of three possible pat-terns according to the amount of glenohumeral ligaments: pattern 1 when three glenohumeral ligaments were identified (SGHL, MGHL and AIGHL), pattern 2 when a single ligament was found, and pattern 3 when two ligaments were identified [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. When the identification of the ligament was unclear (particularly in pattern 3, see Results), any ligament inserting cephalic to 2 o`clock was considered SGHL, and any ligament inserted caudal to 4 o`clock was considered AIGHL. Any ligament with scapular insertions ranging between both (i.e, in the territory between 2 and 4 o`clock, but not exclusively) was considered MGHL. Afterwards, an LCD\u0026reg; Vernier digital caliper was used to measure the range of insertions of each possible ligament, both in the bone and in the labral cartilage. After measurements, transections through the articular line were performed to identify and correct possible overlaps between ligaments. Data were analyzed using Microsoft Excel and IBM SPSS Statistics 19. Only proximal (scapular/glenoid) insertions were registered in this study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the 39 cases studied, all of them showed at least one ligament, almost invariably covering the area between 2 and 3 o`clock regarding its scapular insertions. In 56% of cases (n\u0026thinsp;=\u0026thinsp;22), an unambiguous SGHL was identified, inserted in the area immediately anterior to the supraglenoid tubercle, and its anterior aspect showed bony insertions. In 12.8% of cases (n\u0026thinsp;=\u0026thinsp;5), the SGHL showed exclusively labral insertions. In 10,2% of cases (n\u0026thinsp;=\u0026thinsp;4), a two-layered SGHL was identified with both superficial bony insertions and deep labral insertions. All cases but one showed a ligament with glenoid insertions covering the area around 3 o'clock and coinciding with the more anterior projection of the articular angle; therefore, all cases but one were deemed to have a MGHL. Osseous insertions of the MGHL were present in 38.4% of cases (n\u0026thinsp;=\u0026thinsp;15), always in the articular angle and the border of the glenoid surface and extending anteriorly. Almost all cases (n\u0026thinsp;=\u0026thinsp;37) were inserted in the labrum, meaning that the MGHL was a somewhat deeper structure than most of the GHLs. In 30.7% of cases, the MGHL was a double-layered structure with both bony and labral insertions encompassing almost its entire cephalocaudal length. In 7.69% of cases (n\u0026thinsp;=\u0026thinsp;3, see D1, D14L, D16 in Supplementary Table\u0026nbsp;1), an almost purely labral MGHL was reinforced with a very thin cephalic fascicle of around 0.1 cm and inserted around 1 o`clock, probably corresponding with an amalgamated SGHL. Around 46% of cases (n\u0026thinsp;=\u0026thinsp;18) showed, clearly in the anterior aspect of the shoulder joint, an AIGHL that was inserted in the osseous border of the anterior and inferior region of the glenoid, around the lateral edge of the glenoid neck or in the immediately underlying labral cartilage (n\u0026thinsp;=\u0026thinsp;15, 38.4%, ). In 7.69% (n\u0026thinsp;=\u0026thinsp;3) cases, there was a close apposition between superficial bony-inserted fascicles and deeper labral ones, forming a two-layered structure (see above), and no cases with a purely osseous insertion were identified, while 9 (23.07% overall) cases showed purely labral insertions. All results are recorded in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eRegarding the pattern, 30.8% of cases (n\u0026thinsp;=\u0026thinsp;12) presented three ligaments (pattern 1, the \u0026lsquo;canonical\u0026rsquo; one, Figs.\u0026nbsp;1A, 2A, 2B, 3), 38.8% of cases (n\u0026thinsp;=\u0026thinsp;15) presented all GHLs amalgamated into one single ligamentous band (pattern 2, Figs.\u0026nbsp;1B, 2B, 4 and 5), and 30.8% (n\u0026thinsp;=\u0026thinsp;12) presented two ligaments (pattern 3; Fig.\u0026nbsp;1C, 2C and 6). Although the protocol followed to record cases considered any ligament including the range from 2 to 4 o`clock as an MGHL, ligamentous fascicles cephalic to 2 o'clock were identified (either a true SGHL or a SGHL-like structure included in an MGHL) in 38 cases. The morphometrical analysis of the SGHL rendered a range of bony insertions between 0.28 and 1.58 cm (x̄=0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31) and of labral insertions of 0.41 to 1.06 cm (x̄=0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25). The MGHL showed bony insertions between 0.1 cm and 2.09 cm (x̄=1.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72) and, almost invariably, labral insertions that range from 0.47 and 3.60 cm (x̄=1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73). The AIGHL showed bony insertions between 0.45 and 2.05 cm (x̄=0.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52) and labral insertions between 0.5 and 2.05 cm (x̄=1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51).\u003c/p\u003e\u003cp\u003eHowever, measures (see Supplementary Table\u0026nbsp;1) are dependent on the pattern of in-sertion. In pattern 1, where the three ligaments are identifiable from a frontal view of the shoulder, 83% of SGHLs showed bony insertions (range 0.28\u0026ndash;1.58 cm; x̄=0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38) and 25% of cases showed labral insertions (range 0.41\u0026ndash;0.98 cm; x̄=0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29). In pattern 1, almost all (91.6%) of the MGHL showed pure labral insertions (range 0.56\u0026ndash;2.4 cm; x̄=1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58), and bony insertions represented slightly smaller fascicles that were mostly discrete reinforcements of the main body of the ligament, present in 3 cases (25%; range 0.55\u0026ndash;1.49 cm; x̄=1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47). In AIGHLs, osseous insertions were present in 33.3% of cases (range 0.45\u0026ndash;1.05 cm; x̄=0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26), and 75% of cases showed labral insertions (range 0.5\u0026ndash;1.88 cm; x̄=1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49). In pattern two, all ligaments coalesced in a single band, which is universally inserted in the labrum (range 1.57\u0026ndash;3.6 cm; x̄=2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59); this band has osseous reinforcements in its upper border in up to half of the cases (53.3%) that probably represent remnants of a putative SGHL. These reinforcements range from thin connective bridges to true ligaments (range 0.1\u0026ndash;2.09 cm; x̄=1.056\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87). Pat-tern 3 is assigned when only two ligaments are identifiable from an anterior view of a dissected shoulder joint. From all the shoulders classified as pattern 3, 75% showed a combination of a MGHL with a putative SGHL (see Fig.\u0026nbsp;1C) (range 0.4\u0026ndash;2.5 cm for bony insertions and 0.42\u0026ndash;2.5; for labral insertions) and the other 25% a combination of a MGHL\u0026thinsp;+\u0026thinsp;AIGHL or AIGHL\u0026thinsp;+\u0026thinsp;SGHL (range 0.47\u0026ndash;2.05 cm for bony insertions and 0.58\u0026ndash;2.05 for labral insertions, see also Fig.\u0026nbsp;1C). Based on its \u0026lsquo;clockface-defined\u0026rsquo; insertions, no shoulder showed an absolute absence of MGHL except case D38. A Stu-dent t-test was performed to check whether the presence of a canonical (1) or non-canonical (2,3) pattern influenced the linear measurement of the insertion, which was the case for the labral insertion of the MGHL (t=-3.01, p\u0026thinsp;=\u0026thinsp;0.06). Related to this result, the patterning also influences the perimeter of ligamentous insertion as seen from the anterior surface of the joint (t\u0026thinsp;=\u0026thinsp;1.95, p\u0026thinsp;=\u0026thinsp;0.068). Sex and laterality were unrelated to the patterning (χ\u0026sup2;=1.17; sig.=0.55 and χ\u0026sup2;=0.75; sig\u0026thinsp;=\u0026thinsp;0.68, respectively). Sex and laterality did not show any statistically relevant relationship to the linear length of any set insertions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is a descriptive study in soft-embalmed cadavers that provides morphometrical data for the scapular insertions of the glenohumeral ligaments, except the posterior ligaments; GHLs are essential for shoulder stability and are frequently subject to traumatic injuries. Quantitative studies on the glenohumeral ligaments are rare [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], typically based on few cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] or focused on only one ligament [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Also, a few studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] describe regional variability in a systematized way, although this description is usually performed from an intra-articular point of view. However, arthroscopic patterns largely coincide with gross anatomical ones [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To our knowledge, this is both the first quantitative study of the glenohumeral ligaments in Thiel-embalmed cadavers (see also [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] for other studies using soft-embalming methods) and the first one considering the anatomical variability of the glenohumeral ligaments.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTechnical issues, nomenclature and embryological basis of the anatomical variability.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe main shortcomings of this study are those inherent to cadaveric-based studies. The fixation method, although allowing a good separation between structures in the connective tissue [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], hampers the histological assessment of the ligaments described and, therefore, a more precise identification. Additionally, complete information about subtle clinical details that may indicate shoulder pathology is not readily accessible to researchers. In any case, our samples still belong to a real-world population, although probably age biased. The dissection protocol offers the advantage of having previously separated the upper limb from the trunk, which frees up joint movements and eases the identification of the GHLs. This task is unfeasible when the limb hangs in a neutral position [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eComparability to other studies\u003c/h3\u003e\n\u003cp\u003eThe main findings of this study are the morphometrical data for the scapular insertions of the glenohumeral ligaments, related to their pattern of insertion. Despite the high prevalence and cost of shoulder pathology, these kinds of quantitative studies are scarce and remain relatively inconspicuous [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Our morphometrical data largely match the more recent ones [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], although measures in this work are linear ones that do not consider the curvature/perimeter of the glenoid rim or the labrum. Also, we have not measured the footprint of the ligamentous insertion. However, the data presented here remain in a comparable range and consider patterns diverging from the canonical one, which were not recorded in the aforementioned study, probably due to its reduced sample size. Regarding the SGHL, our findings point in the same direction as other studies that try to reconcile long-standing discrepancies regarding the origins of this fascicle [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], which has been described to be inserted both in the supraglenoid tubercle and the superior labrum at the 1 o\u0026rsquo;clock position. This difference is likely related to the double-layered nature of the glenohumeral ligaments (see Results and Fig.\u0026nbsp;7) and the fact that arthroscopic and gross anatomical studies describe different layers of the same structure [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. According to the work of Kask and colleagues [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], oblique fibres of the superior glenohumeral ligament arise from the supraglenoid tubercle, and the direct fibres arise from the labral insertions. Results presented here reinforce the idea of two distinct fascicles of the SGHL and provide quantitative data for them. This can also be applied to the remaining GHLs, particularly to the MGHL, which is very frequently double-layered, showing almost invariably a deep, labral fascicle (Fig.\u0026nbsp;7). Based on its insertions (see Material and methods), we have very few cases of agenesia of the MGHL (2,5%), contrasting to recent series [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and classical ones [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which found a much larger percentage (see also [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]). Again, this discrepancy may be rooted in the chosen method of nomenclating the ligaments. Remarkably, we have also not found any case of Buford complex [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Likely, the leaf-like MGHL reported in many studies corresponds to our pattern 2, and the cord-like MGHL corresponds to the canonical pattern 1 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], at least in our sample. More complicated are the findings related to the insertions of the AIGHL. First, we are limiting our description to the ligaments that are identifiable on the anterior surface of the shoulder joint and not considering the PIGHL, which is probably functionally intermingled with the AIGHL. Second, our data regarding its range of insertion provide a much more caudal position than many studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], although other studies, including some recent ones, challenge these descriptions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Again, discrepancies may be rooted in the method employed for defining the ligaments.\u003c/p\u003e\u003cp\u003e\u003cem\u003eClinical considerations.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFrom a clinical and radiological perspective, measures of insertions and the double-layered structure (osseous\u0026thinsp;+\u0026thinsp;labral) of many of them are useful in the field of radiological assessment. Ligaments in the anterior aspect of the shoulder joint are frequently affected after trauma [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], producing a characteristic Bankart lesion, a consequence of the detachment of the anterior and inferior labrum and glenohumeral capsule, frequently involving the anteroinferior glenohumeral ligament. The direct repair of glenohumeral insertions is the main solution for many cases of post-traumatic shoulder instability [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, our results point to the need to assess separately each glenohumeral ligament, as the set of insertions may be variable. Also, an anterior or even inferior instability may be a consequence of lesions of ligaments other than the AIGHL when patterns distinct than the canonical pattern 1 are present [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The presence of osseous insertions that do not necessarily match the set of labral insertions point to the need of careful radiological guidance before surgery and to the development of techniques based on a mixed intraarticular and extraarticular approaches. Conversely, the potential presence of duplicated labral-osseous insertions of all three anterior glenohumeral ligaments explains why lesions like the glenolabral articular disruption that imply tears and ruptures to the labrum may course without shoulder instability, if bony insertions are respected [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Also in this sense, the conjoined work of labral and osseous insertions may explain the rarity of scapular avulsions of the GHLs compared to humeral avulsions [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], and a possibly subtle clinical presentation of these lesions, like in the case of anterior ligamentous periosteal avulsions [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], leading to infradiagnosis. Conversely, insufficient repair (not repairing a putative MGHL along the AIGHL or not repairing the whole set of insertions) may lead to the recurrent occurrence of anterior shoulder stability following one single traumatic event [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Regarding the biomechanical consequences of lesions in patients with glenohumeral patterns distinct from the canonical one, more studies are needed.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere are three different patterns of glenohumeral ligaments in the anterior aspect of the shoulder joint, being the canonical pattern of a \u0026lsquo;superior\u0026rsquo; plus \u0026lsquo;middle\u0026rsquo; and \u0026lsquo;inferior\u0026rsquo; ligaments represented in less than half of the cases.\u003c/p\u003e\u003cp\u003eAll glenohumeral ligaments show distinct, and not necessarily overlapping, sets of labral and bony insertions, with a length and relative position that depends on the pattern.\u003c/p\u003e\u003cp\u003eFailing to recognize anatomical variability of the ligaments in the anterior aspect of the shoulder joint makes both descriptive studies and clinical classifications less consistent.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eThe following abbreviations are used in this manuscript:\u003c/p\u003e\n\u003cp\u003eGHL/GHLs, glenohumeral ligament/s; \u0026nbsp;AIGHL, anteroinferior inferior glenohumeral ligament MGHL, middle glenohumeral ligament; SGHL, superior glenohumeral ligament; PGHL: posterior glenohumeral ligament; CHL: coracohumeral ligament; cgl: coracoglenoid ligament; LHBB: long head of the biceps brachii\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e: Conceptualization EGA and MFP.; methodology, EGA.; investigation, EGA, IPS, EBB, AGP, CMC, LRY, MFP, data curation, EGA; writing, original draft preparation, EGA, EBB (illustration) writing, review and editing. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This work is self-funded by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement\u003c/strong\u003e: All procedures described here were carried according to the Spanish law and the Helsinki Declaration and in the context of a body donation program approved by the respective boards of the University of La Laguna and the Autonomous University of Madrid, as well as part of a broader project that received approval by the local ethics committee (reg. CHUC_2023_11, 2023-02-23).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e: Written informed consent has been obtained from the patient(s) to conduct research involving donated cadaveric material.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e: All data, including detailed photographical record of the dissections, are fully available on request to EGA or IPS. Most of the cadaveric material is still stored, although not completely preserved as further work has been developed in the same specimens.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: Authors are thankful to Francisco Clascá Cabré, from the Autonomous University of Madrid, for his invaluable work setting up and maintaining the Applied Anatomy Laboratory in its present form. Camino Braojos Rodríguez and Carolina Morallón-Chinchilla, from the same laboratory, made a significant contribution to tissue conservation. We are also grateful to Lorena Jiménez-Sánchez, now an independent researcher based in Edinburgh (Scotland, UK), for her contributions in the early steps of this project, in the form of illustrations and photographical records. The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase mankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e: Artimes García-Parra was self-employed by MundoFisio, a private cabinet in El Hierro (Canary Islands) dedicate to physical therapy. 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Skeletal Radiol 43:35\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00256-013-1744-y\u003c/span\u003e\u003cspan address=\"10.1007/s00256-013-1744-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"rotator cuff, shoulder, glenohumeral, anatomy, ligament","lastPublishedDoi":"10.21203/rs.3.rs-7783752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7783752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe glenohumeral ligaments are key stabilizers of the glenohumeral joint. Three distinct fascicles are usually described from the anterior surface of the shoulder joint: a superior glenohumeral ligament (SGHL); a middle glenohumeral ligament (MGHL) and an anteroinferior glenohumeral ligament (AIGHL). A remarkable interindividual variation has been reported, and there is a lack of consensus regarding terminology and quantitative measures of ligament attachments. A recent study provided a much-needed insight into the quantitative details of the glenohumeral ligament insertions. However, there is a lack of studies describing linear measurements (closer to real-life surgical anatomy) of glenohumeral ligamentous insertions according to their pattern. Hereby, we present a Thiel-based anatomical study describing proximal (glenoid) insertions of glenohumeral ligaments in 39 specimens. Only 43,5% of cases showed a canonical pattern of SGHL, MGHL, and AIGHL, with scapular insertions ranging from 0,28 to 1,58 cm for SGHL, 0,1\u0026ndash;3,6 cm for MGHL, and 0,45\u0026thinsp;\u0026minus;\u0026thinsp;2,05 cm for AIGHL, frequently mixed between the labrum and the bony edge of the glenoid surface. Most cases show a single glenohumeral ligament inserted, usually in the labrum. A wide range of patterns regarding the number of insertions and their labral or bony nature is present in our sample. Overall, there are three different patterns of glenohumeral ligaments in the anterior aspect of the shoulder joint, with the canonical pattern (three ligaments) represented in less than half of the cases. The morphometric study of the glenohumeral ligaments should consider their pattern of distribution. Also, insertions vary between the labrum and the scapular bony articular surface..\u003c/p\u003e","manuscriptTitle":"The glenohumeral ligaments of the anterior aspect of the shoulder: anatomical patterning and morphometry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-25 14:24:04","doi":"10.21203/rs.3.rs-7783752/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7106a37-67a2-40d3-82ca-938197f00ac6","owner":[],"postedDate":"October 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-28T08:17:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-25 14:24:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7783752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7783752","identity":"rs-7783752","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}