Coracoacromial Ligament: A Comparative Arthroscopic

and Anatomic Study

Mario Gallino, M.D., Bruno Battiston, M.D., Giovanni Annaratone, M.D.,
and Flavio Terragnoli, M.D.

Summary: An anatomic study of the coracoacromial ligament was conducted.

The data collected from 20 anatomical preparations and the arthroscopic findings
in 40 cases were compared. The shape and the tension of the ligament were
evaluated, as well as the thickness. Anatomic tradition describes the ligament as
a fibrous triangular lamina inserted with its apex on the acromial tip and its base
on the lateral edge of the coracoid. It simply closes the coracoacromial arch and
has no mechanical role. However, our observations suggest that the ligament has
a trapezoidal shape and is situated below the acromion with a wide reflex portion.
Its thickness varies from 2 to 5.6 mm. Given that structure, the ligament appears
like a robust suspension structure of the coracoid, which contrasts the action of
the muscles that connect to it. From these observations, a pathogenic hypothesis
of the subacromial impingement proposes itself. Key Words: Shoulder-Anatomy-Coracoacromial ligament-Subacromial impingement.

he subacromial impingement syndrome derives

from an anomalous friction of the tendons of the
rotator cuff with the undersurface of the coracoacromial arch that overhangs them. Neer clearly described
it and defined its staging. Later Nee? and Apoil et a1.3
identified the two principal areas of conflict with the
areas of acromial and coracoid connections of the coracoacromial ligament. In the literature,4-6 the ligament
is described as a fibrous triangular lamina whose point
is connected to the apex of the acromion while its base
is connected to the whole lateral edge of the coracoid.
This would have meant the closure of the coracoacromial arch with no mechanical role.
The arthroscopic observations of Johnson7 and of
Ellmann allow us to hypothesize a differing configuration of the ligament that extends right under the acro-

From the Divisione di Ortopedia, Presidio Sanitaria Gradenigo,

Torino, Italy (M. G., G. A.); III Divisione Ortopedica, C.T.O., Torino, Italy (B. B.); and Clinica Ortopedica delllJniversit& Brescia,
Italy (F. T.).
Address correspondence and reprint requests to Mario Gallino,
M.D., Via Boves IO, 10099 San Mauro (Torino), Italy.
0 I995 by the Arthroscopy Association of North America
0749-8063/95/I 105-1126$3.00/O
564

Arthroscopy:

The Journal

of Arthroscopic

mion. Our arthroscopic observations confirmed this

view and encouraged the following arthroscopic and
anatomic study that aimed to better evaluate its structure and function.
MATERIALS

AND METHODS

We analyzed the arthroscopic findings of 40 patients, 27 women and 13 men, with an average age of
35 (30 to 52) years, affected by subacromial impingement who underwent arthroscopic surgery with subacromial debridement. Each patient had localized
shoulder pain and experienced increased pain during
the arc of forward elevation. The diagnosis of impingement was made following Neers criteria. We describe
that part of arthroscopic diagnosis that regards the anatomic description of the coracoacromial ligament. Under general anesthesia, the patient is positioned in lateral decubitus on the healthy side with the limb to be
examined abducted 30, flexed by 15 and under axial
traction of 3 to 4 kg.
The arthroscope is placed through a posterior portal
situated l- to 2-cm below and l-cm medial to the

and Related Surgery,

Vol II, No 5 (October),

1995: pp 564-567

ANATOMY

FIG 1. Anatomic
dissection
the deltoid muscle has been
and coracoacromial
ligament.
the projection
of the insertion

of left shoulder.
made to expose
The dotting on
of the ligament

OF CORACOACROMIAL

LIGAMENT

56.5

A distal overturn
of
acromion,
coracoid,
the acromion
shows
at its undersurface.

posterior apex of the acromion. An anterior portal is

defined under direct view by inserting a needle from
outside the joint into the triangle formed by the subscapularis, the glenoid, and the tendon of the long head
of the biceps. The procedure is divided into two parts:
the arthroscopy of the glenohumeral joint and that of
the subacromial space. No additional portal for irrigation was used. No local injection of epinephrine or
other vessel constrictors was carried out so as not to
alter the anatomic view of the structures. Nor was a
bursectomy performed before observation. The ligament was observed through the subacromial bursa, thus
visualizing it for the whole of its acromial insertion
and its anterior portion, as well as after a removal of
the bursa by shaving. Through the anterior portal, a

FIG 2. Anatomic
dissection
of left shoulder.
After vertical
omy of the acromion,
the whole extension
of the ligament,
wide insertion
on the acriomal
undersurface,
is visible.

osteotwith its

CA4

FIG 3. (A) Arthroscopic

view of the insertion
of the ligament
under the acromion
in the subacromial
space in a left shoulder.
(B)
Drawing
of the latter view. A, acromion;
SST, supraspinatus
tendon;
CAL, coracoacromial
ligament.

hook-shaped probe was inserted to verify its extent

and consistency. A transcutaneous needle was placed
to correspond to the anterior apex of the acromion to
arthroscopically verify where this projected out and
how great a portion of the ligament carried on under
the acromial arch. A 5-mm diameter cannula was introduced via the anterior portal along the supraspinatus
outlet to verify where a stenosis might be, which would
make it impossible for the cannula to proceed. We
chose this technique because it is simple, quick, and
reliable. We observed an easy progression of the cannula in patients with no impingement who underwent
arthroscopic surgery for other reasons (e.g., shoulder
instability).

566

M. GALLINO

An anatomic comparison with 20 autopsy preparations (from fresh bodies) was made.g The dissection
of the subacromial space was carried out with removal
of the acromial insertions of the deltoid muscle and its
distal overturn. Besides showing the morphological
and course characteristics of the coracoacromial ligament, measurements were also taken (length, width,
and thickness of the subacromial portion). Measurements were always taken by the same surgeon using
a precision caliper.

ET AL.

natus tendon from above, with the subdeltoid bursa

interposed. An arterial vessel is constantly available
on the posterior surface of the ligament, coming from
the coracoid and circulating upwards, a branch of the
suprascapular artery. In the arthroscopic observations,
the palpation through a probe revealed a constant tension of the ligament (Fig 4). The 5-mm cannula always
stopped at the level of the subacromial portion of the
ligament, confirming the site of the stenosis.
DISCUSSION

RESULTS
All observed cases, both arthroscopic and fresh anatomic specimens, showed a different structure of the
coracoacromial ligament from that described in the
classic literature. Its form appears to be a trapezoidal
ribbon with the greater base inserted at the undersurface of the acromion and posteriorly originated from
the dorsal edge of the acromion. The ligament is moderately twisted into a helix downwards and to the exterior as far as the insertion on the coracoid apophysis
(Figs l-3). In particular, the subacromial portion of
the ligament is variable in thickness; in the anatomic
preparations, it varies from 2 mm to a real curtain
of 5.6 mm (average, 3.9 mm). Nine cases out of 20
(45%) presented a subacromial portion above 4 mm
measured at the level of the anterior acromial edge.
The ligament has a close relationship with the rotator
cuff. In some cases, this is presented on a level almost
perpendicular to the anterior portion of the supraspi-

FIG 4. Palpation and traction with a probe

subacromial
arthroscopy
of a right shoulder.

of the ligament

during

Despite valid theses that describe a local area of

relative avascularity,l the mechanical pathogenesis of
impingement against the coracoacromial arch is generally accepted as determining the degenerative lesions
of the rotator cuff.
Anatomic variants of the acromion, defined as
curved and hooked, have been associated with
the impingement syndrome by Bigliani et al., as well
as Fu et al. Nonetheless, based on recent anthropometric studies by Edelson and Taitz,13 a true hook
appears to be quite rare in incidence representing an
unusual development of preacromial epiphysis being
the influence of the hook determined mainly by the
slope of the acromion to which it is attached.
In 1970, Pujadas14 emphasized how the conflict in
subacromial pathology was not so much between humerus and acromion, as between greater tuberosity and
the free edge of the coracoacromial ligament. He noted
that patients with impingement position their arm anteriorly and with internal rotation. Our findings that the
coracoacromial ligament inserts beyond the tip and
extends onto the undersurface of the acromion is of
clinical significance, and the surgeon has to consider
potential variations in origin and size (thickness) of
the ligament.
Two orders of consideration emerge from the present study. First of all, the constant presence of a wide
portion of the ligament below the acromion, variable
in size and thickness, makes a stenosis of the supraspinatus outlet possible, not only because of protruding
bones, (as in the case of spurs as well as in the anatomic
variants of the acromion already mentioned) but also,
and above all, because of the fibrous structures. The
variability of size of this ligament portion would offer
an explanation of the origin of primitive impingement
syndromes that have arisen in young patients, and that
are linked neither to bone alterations nor articular instability nor muscular imbalance.
Furthermore, some reflections can be made on the
biomechanical role of the ligament on the basis of the

ANATOMY

OF CORACOACROMIAL

pathogenesis of the impingement syndrome. According

to Tillmanns biomechanical studies,15 the acromion
and the coracoid are under opposite directional forces
exerted by the muscles attached to them. The coracoacromial ligament acts as a tension band within the
humeral fossa, and this reduces the bending movement
of the coracoid process and of the acromion, counteracting the action of the pectoralis minor and of the
coracobrachialis and the short head of the caput brevis
biceps. From this viewpoint, the coracoacromial ligament takes on the significant role of the transmitter of
forces from the pectoralis minor to the acromion, and
its more or less ample extension may be consistent
with more or less tension.
Should there be muscular imbalances with an increased tone of the pectoralis minor compared with
the external rotators of the upper arm, this would lead
to the behavior of anterior positioning and internal
rotation of the scapula as described by Pujadas,14 and
the ligament tension will also increase. An increase of
its thickness is possible, leading to a further increased
friction. The development of an anterior spur from the
acromial edge that takes place within the substance of
the coracoacromial ligament probably results from the
transmission of tensile forces through it and is a possible expression of the passage from a dysfunctional
syndrome to an organic stenosis.16
Acknowledgment:
The Authors thank Julian Hoskins,
Ph.D., English lecturer at the University of Turin, for
translating and reviewing the manuscript.

LIGAMENT

567

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