Research progress on pathological changes of glenohumeral capsule in patients with recurrent shoulder anterior dislocation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHEN Pai , LIANG Daqiang , WU Bing , LI Hao , LIU Haifeng , LONG Zeling , LIU Yuwei ,  LU Wei

Department of Sports Medicine, the Second People’s Hospital of Shenzhen, the First Affiliated Hospital of Shenzhen University, Shenzhen Guangdong, 518025, P. R. China;

Corresponding author：

LU Wei, Email: 4415147@qq.com

Keywords：

Recurrent shoulder anterior dislocation; glenohumeral capsule; anatomy; biomechanics; histology; molecular biology

DOI：

10.7507/1002-1892.202408090

Video：

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Objective To review the research progress of pathological changes of glenohumeral capsule in patients with recurrent shoulder anterior dislocation (RSAD). Methods The literature on shoulder capsules, both domestic and international, was reviewed. The anatomy, histology, and molecular biology characteristics of the glenohumeral capsule in RSAD patients were summarized. Results Anatomically, the glenohumeral capsule is composed of four distinct parts: the upper, lower, anterior, and posterior sections. The thickness of these sections is uneven, and the stability of the capsule is further enhanced by the presence of the glenohumeral and coracohumeral ligaments. Histologically, the capsule tissue undergoes adaptive changes following RSAD, which improve its ability to withstand stretching and deformation. In the realm of molecular biology, genes associated with the regulation of structure formation, function, and extracellular matrix homeostasis of the shoulder capsule’s collagen fibers exhibit varying degrees of expression changes. Specifically, the up-regulation of transforming growth factor β₁ (TGF-β₁), TGF-β receptor 1, lysyl oxidase, and procollagen-lysine, 2-oxoglutarate 5-dioxygenase 1 facilitates the repair of the joint capsule, thereby contributing to the maintenance of shoulder joint stability. Conversely, the up-regulation of collagen type Ⅰ alpha 1 (COL1A1), COL3A1, and COL5A1 is linked to the recurrence of shoulder anterior dislocation, as these changes reflect the joint capsule’s response to dislocation. Additionally, the expressions of tenascin C and fibronectin 1 may play a role in the pathological processes occurring during the early stages of RSAD. Conclusion Glenohumeral capsular laxity is both a consequence of RSAD and a significant factor contributing to its recurrence. While numerous studies have documented alterations in the shoulder capsule following RSAD, further research is necessary to confirm the specific pathological anatomy, histological, and molecular biological changes involved.

Citation： CHEN Pai, LIANG Daqiang, WU Bing, LI Hao, LIU Haifeng, LONG Zeling, LIU Yuwei, LU Wei. Research progress on pathological changes of glenohumeral capsule in patients with recurrent shoulder anterior dislocation. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(2): 243-249. doi: 10.7507/1002-1892.202408090 Copy

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2.	Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. Ann R Coll Surg Engl, 2009, 91(1): 2-7.
3.	Longo UG, Candela V, Berton A, et al. Epidemiology of shoulder instability in Italy: A 14-years nationwide registry study. Injury, 2021, 52(4): 862-868.
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5.	Calvo E, Valencia M, Foruria AM, et al. Recurrence of instability after Latarjet procedure: causes, results and treatment algorithm. EFORT Open Rev, 2022, 7(12): 800-807.
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8.	Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med, 1990, 18(1): 25-28.
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24.	Bey MJ, Hunter SA, Kilambi N, et al. Structural and mechanical properties of the glenohumeral joint posterior capsule. J Shoulder Elbow Surg, 2005, 14(2): 201-206.
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1. Zhao WG, Ma JT, Yan XL, et al. Epidemiological characteristics of major joints fracture-dislocations. Orthop Surg, 2021, 13(8): 2310-2317.
2. Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. Ann R Coll Surg Engl, 2009, 91(1): 2-7.
3. Longo UG, Candela V, Berton A, et al. Epidemiology of shoulder instability in Italy: A 14-years nationwide registry study. Injury, 2021, 52(4): 862-868.
4. 王惠芳, 王予彬, 崔芳, 等. 动力与静力性稳定结构对肩关节稳定作用的生物力学研究[C]//中国康复医学会运动疗法分会第十一届全国康复学术大会学术会议论文摘要汇编. 上海: 中国康复医学会运动疗法分会, 2011.
5. Calvo E, Valencia M, Foruria AM, et al. Recurrence of instability after Latarjet procedure: causes, results and treatment algorithm. EFORT Open Rev, 2022, 7(12): 800-807.
6. Wang VM, Flatow EL. Pathomechanics of acquired shoulder instability: a basic science perspective. J Shoulder Elbow Surg, 2005, 14(1 Suppl S): 2S-11S.
7. Burkart AC, Debski RE. Anatomy and function of the glenohumeral ligaments in anterior shoulder instability. Clin Orthop Relat Res, 2002(400): 32-39.
8. Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med, 1990, 18(1): 25-28.
9. Bigliani LU, Pollock RG, Soslowsky LJ, et al. Tensile properties of the inferior glenohumeral ligament. J Orthop Res, 1992, 10(2): 187-197.
10. Adams CR, DeMartino AM, Rego G, et al. The rotator cuff and the superior capsule: why we need both. Arthroscopy, 2016, 32(12): 2628-2637.
11. 李怀胜, 杨明宇, 李焱, 等. 肩关节上关节囊重建治疗肩袖损伤适应证和移植物处理方法研究进展. 中国修复重建外科杂志, 2021, 35(2): 252-257.
12. Kask K, Põldoja E, Lont T, et al. Anatomy of the superior glenohumeral ligament. J Shoulder Elbow Surg, 2010, 19(6): 908-916.
13. Dekker TJ, Aman ZS, Peebles LA, et al. Quantitative and qualitative analyses of the glenohumeral ligaments: an anatomic study. Am J Sports Med, 2020, 48(8): 1837-1845.
14. Bächler J, Bergman S, Lancigu R, et al. Arthroscopic anatomy of the middle glenohumeral ligament. A series of 300 cases. Morphologie, 2020, 104(346): 187-195.
15. O’Brien SJ, Neves MC, Arnoczky SP, et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med, 1990, 18(5): 449-456.
16. Pouliart N, Somers K, Eid S, et al. Variations in the superior capsuloligamentous complex and description of a new ligament. J Shoulder Elbow Surg, 2007, 16(6): 821-836.
17. Ciccone WJ, Hunt TJ, Lieber R, et al. Multiquadrant digital analysis of shoulder capsular thickness. Arthroscopy, 2000, 16(5): 457-461.
18. Ishihara Y, Mihata T, Tamboli M, et al. Role of the superior shoulder capsule in passive stability of the glenohumeral joint. J Shoulder Elbow Surg, 2014, 23(5): 642-648.
19. Wilson WR, Magnussen RA, Irribarra LA, et al. Variability of the capsular anatomy in the rotator interval region of the shoulder. J Shoulder Elbow Surg, 2013, 22(6): 856-861.
20. Lee JG, Peo H, Cho JH, et al. Dynamic ultrasonographic measurement of inferior joint capsule thickness in patients with unilateral frozen shoulder. Diagnostics (Basel), 2021, 11(5): 898. doi: 10.3390/diagnostics11050898.
21. Ferrari DA. Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule. Am J Sports Med, 1990, 18(1): 20-24.
22. Winkelmann MT, Achenbach L, Zeman F, et al. The throwing shoulder in youth elite handball: adaptions of inferior but not anterior capsule thickness differ between the two sexes. Res Sports Med, 2023, 31(2): 112-124.
23. Passanante GJ, Skalski MR, Patel DB, et al. Inferior glenohumeral ligament (IGHL) complex: anatomy, injuries, imaging features, and treatment options. Emerg Radiol, 2017, 24(1): 65-71.
24. Bey MJ, Hunter SA, Kilambi N, et al. Structural and mechanical properties of the glenohumeral joint posterior capsule. J Shoulder Elbow Surg, 2005, 14(2): 201-206.
25. Antonio GE, Griffith JF, Yu AB, et al. First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging, 2007, 26(4): 983-991.
26. Bankart AS. Recurrent or habitual dislocation of the shoulder-joint. Br Med J, 1923, 2(3285): 1132-1133.
27. Norlin R. Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study. Arthroscopy, 1993, 9(5): 546-549.
28. Rothberg DL, Burks RT. Capsular tear in line with the inferior glenohumeral ligament: a cause of anterior glenohumeral instability in 2 patients. Arthroscopy, 2009, 25(8): 934-936.
29. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. J Shoulder Elbow Surg, 1999, 8(1): 66-74.
30. Takenaga T, Yoshida M, Chan CK, et al. Direction of non-recoverable strain in the glenohumeral capsule following multiple anterior dislocations: Implications for anatomic Bankart repair. J Orthop Res, 2023, 41(3): 479-488.
31. Browe DP, Rainis CA, McMahon PJ, et al. Injury to the anteroinferior glenohumeral capsule during anterior dislocation. Clin Biomech (Bristol), 2013, 28(2): 140-145.
32. Browe DP, Voycheck CA, McMahon PJ, et al. Changes to the mechanical properties of the glenohumeral capsule during anterior dislocation. J Biomech, 2014, 47(2): 464-469.
33. Rainis CA, Brown AJ, McMahon PJ, et al. Effects of simulated injury on the anteroinferior glenohumeral capsule. Med Biol Eng Comput, 2012, 50(12): 1299-1307.
34. Yoshida M, Takenaga T, Chan CK, et al. Location and magnitude of capsular injuries varies following multiple anterior dislocations of the shoulder: Implications for surgical repair. J Orthop Res, 2021, 39(3): 648-656.
35. Yoshida M, Takenaga T, Chan CK, et al. Increased superior translation following multiple simulated anterior dislocations of the shoulder. Knee Surg Sports Traumatol Arthrosc, 2023, 31(5): 1963-1969.
36. Nolte AK, Jäger S, Seifert MM, et al. Capsule elongation occurs after first time shoulder dislocation A biomechanical in-vitro investigation on human cadaveric specimen. J Orthop, 2024, 51: 130-136.
37. Kubo H, Gatzlik E, Hufeland M, et al. Histologic examination of the shoulder capsule shows new layer of elastic fibres between synovial and fibrous membrane. J Orthop, 2020, 22: 251-255.
38. Haywood L, Walsh DA. Vasculature of the normal and arthritic synovial joint. Histol Histopathol, 2001, 16(1): 277-284.
39. Smith MD. The normal synovium. Open Rheumatol J, 2011, 5: 100-106.
40. Smith MD, Barg E, Weedon H, et al. Microarchitecture and protective mechanisms in synovial tissue from clinically and arthroscopically normal knee joints. Ann Rheum Dis, 2003, 62(4): 303-307.
41. Simkin PA. Physiology of normal and abnormal synovium. Semin Arthritis Rheum, 1991, 21(3): 179-183.
42. Kaltsas DS. Comparative study of the properties of the shoulder joint capsule with those of other joint capsules. Clin Orthop Relat Res, 1983(173): 20-26.
43. Cohen MS, Schimmel DR, Masuda K, et al. Structural and biochemical evaluation of the elbow capsule after trauma. J Shoulder Elbow Surg, 2007, 16(4): 484-490.
44. Lee CJ, Yeh ML, Chang CH, et al. The relationship of the anterior articular capsule to the adjacent subscapularis: An anatomic and histological study. Orthop Traumatol Surg Res, 2017, 103(8): 1265-1269.
45. McFarland EG, Kim TK, Banchasuek P, et al. Histologic evaluation of the shoulder capsule in normal shoulders, unstable shoulders, and after failed thermal capsulorrhaphy. Am J Sports Med, 2002, 30(5): 636-642.
46. Rodeo SA, Suzuki K, Yamauchi M, et al. Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability. Am J Sports Med, 1998, 26(5): 634-643.
47. Castagna A, Cesari E, Gigante A, et al. Age-related changes of elastic fibers in shoulder capsule of patients with glenohumeral instability: a pilot study. Biomed Res Int, 2018, 2018: 8961805. doi: 10.1155/2018/8961805.
48. Voycheck CA, Luu K, McMahon PJ, et al. Collagen fiber alignment and maximum principal strain in the glenohumeral capsule predict location of failure during uniaxial extension. Biomech Model Mechanobiol, 2014, 13(2): 379-385.
49. Debski RE, Moore SM, Mercer JL, et al. The collagen fibers of the anteroinferior capsulolabrum have multiaxial orientation to resist shoulder dislocation. J Shoulder Elbow Surg, 2003, 12(3): 247-252.
50. Birk DE, Mayne R. Localization of collagen types Ⅰ, Ⅲ and Ⅴ during tendon development. Changes in collagen types Ⅰ and Ⅲ are correlated with changes in fibril diameter. Eur J Cell Biol, 1997, 72(4): 352-361.
51. Romanic AM, Adachi E, Kadler KE, et al. Copolymerization of pNcollagen Ⅲ and collagen Ⅰ. pNcollagen Ⅲ decreases the rate of incorporation of collagen Ⅰ into fibrils, the amount of collagen Ⅰ incorporated, and the diameter of the fibrils formed. J Biol Chem, 1991, 266(19): 12703-12709.
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