The coracoacromial ligament: Morphology and study of acromial enthesopathy

The coracoacromial ligament (CAL), normally a superior restraint against humeral translation, is frequently involved in rotator cuff impingement pathology. However, surgical excision of the CAL is not always clinically successful. Little anatomic information exists about the morphology and function of this ligament. The CAL and glenohumeral joint in 56 cadaveric shoulders were examined in 31 cadavers. Nineteen dimensional parameters were obtained by direct measurement. In 16 shoulders, specific attention was directed at the anterior band of the CAL. Variation exists in the morphology of the CAL. The most common configuration of the CAL was two distinct ligamentous bands that could be classified anatomically as an anterolateral band (ALB) and posteromedial band (PMB). The ALB commonly extended to the posterolateral aspect of the acromion. Furthermore, it frequently extended anterolaterally to the acromion, ending in a coracoacromial falx. Spur formation had occurred in 10 of 16 shoulders evaluated and always appeared in the ALB. Spur formation in the ALB correlated with a focal CAL that was narrower, less divergent, shorter, and thicker than a diffuse CAL that did not have a spur. The mean angle of diversion between the ALB and PMB, when a spur was present, was 31° compared with 45° when no spur was present. CAL band thickness varied, with the ALB being thicker at the acromion than at the coracoid and the PMB being thicker at the coracoid than at the acromion. During arthroscopic subacromial decompression, failure to visualize the anterolateral corner of the acromion adequately may result in incomplete resection of the CAL, especially if the PMB is mistaken to be the entire ligament. Incomplete removal of the CAL may be a factor in clinical failures of arthroscopic subacromial decompression. The preferential location of spurs in the ALB suggests that it is a major load-bearing structure. Furthermore, the ALB is thicker at the acromion, suggesting increased strain. Our data suggest that a possible function of the CAL is to dampen stress on the acromion from muscle activity.