The coracoclavicular (CC) ligaments are strong, fibrous bands of connective tissue in the shoulder. They connect the clavicle (collarbone) to the coracoid process, a projection of the scapula (shoulder blade). Comprised of two parts, the conoid and trapezoid ligaments, they provide significant support. Though extrinsic to the acromioclavicular (AC) joint, they contribute substantially to its stability.
The primary function of the CC ligaments is to maintain the proper relationship between the clavicle and scapula. They prevent excessive upward movement of the clavicle relative to the acromion, the highest point of the shoulder blade. This vertical stability is crucial for shoulder girdle function, allowing a wide range of arm movements and bearing upper limb weight.
Understanding Coracoclavicular Ligament Injuries
Coracoclavicular ligament injuries frequently occur with acromioclavicular (AC) joint dislocations, often called shoulder separations. These injuries typically result from traumatic events, such as a direct fall onto the shoulder or a high-impact collision, forcing the acromion downward relative to the clavicle. Contact sports like football, hockey, or cycling commonly cause these injuries.
AC joint injury severity is categorized into six grades by the Rockwood classification, with higher grades indicating greater CC ligament damage. Grade I involves stretched or partially torn AC ligaments with no significant joint displacement. Grade II includes a complete AC ligament tear, possible CC ligament stretching, and partial dislocation.
In Grade III injuries, both AC and CC ligaments are completely torn, causing a noticeable shoulder deformity as the clavicle pushes upward. Grades IV through VI are increasingly severe dislocations with significant clavicle displacement, often posteriorly or inferiorly, indicating extensive soft tissue disruption, including the CC ligaments. Common symptoms across all grades include localized pain, swelling, tenderness around the AC joint, and restricted arm movement, ranging from minor discomfort to severe pain in higher-grade injuries.
When Reconstruction is Considered
Coracoclavicular ligament reconstruction is considered for higher-grade acromioclavicular (AC) joint dislocations, particularly Rockwood Type III, IV, V, and VI injuries, where significant instability or deformity exists. Type I and II injuries, and sometimes stable Type III injuries, are often managed conservatively with rest, ice, immobilization, and physical therapy. However, these approaches are insufficient for severe CC ligament tears, as conservative management for lower-grade injuries aims to reduce pain and swelling, allowing natural healing.
For high-grade AC joint injuries, especially Type IV through VI, surgical intervention is recommended due to extensive ligament disruption and instability. Even for Type III injuries, if initial conservative treatment fails, reconstruction may be considered for persistent pain, functional impairment, or significant scapular dysfunction. Factors influencing surgery include patient age, activity level, and chronic pain or instability interfering with daily activities or athletic participation.
Reconstruction is necessary in severe cases because CC ligaments cannot heal adequately, leading to chronic AC joint instability. Without surgical intervention, the shoulder may remain unstable, causing ongoing pain, weakness, and difficulty with overhead activities. The goal of reconstruction is to restore the AC joint’s anatomical relationship and stability, which conservative methods cannot achieve for higher-grade injuries.
The Reconstruction Procedure Explained
Coracoclavicular ligament reconstruction aims to restore AC joint stability by recreating the torn ligaments. This procedure establishes a new connection between the clavicle and the coracoid process. Surgeons use a graft, which can be an autograft (tissue from the patient’s body, like a hamstring tendon) or an allograft (donor tissue). Synthetic materials may also be used.
A common approach involves drilling tunnels through the clavicle and coracoid process. The graft is then passed through these tunnels to recreate the ligament pathways. It is secured using various fixation devices, including screws, buttons, or strong sutures. Some techniques use specific buttons and tapes with an allograft, or a combination of suture and allograft.
The procedure can be performed using open techniques (larger incision) or arthroscopically (minimally invasive, using small incisions and a camera). The chosen technique depends on the surgeon’s preference, injury severity, and whether the AC joint capsule requires repair or augmentation. Some procedures also reinforce horizontal stability in addition to vertical stability for optimal shoulder function.
Recovery and Rehabilitation Journey
Following coracoclavicular ligament reconstruction, recovery begins with pain management and immobilization. Patients are placed in an abduction pillow sling for approximately four to six weeks to protect healing ligaments and allow initial tissue repair. During this initial phase, active movement of the affected shoulder is avoided to prevent stretching or disruption of the reconstructed ligaments. However, patients are encouraged to perform gentle exercises for the hand, wrist, and elbow to maintain range of motion.
Physical therapy commences around two to four weeks post-surgery. Initial exercises may be limited to passive range of motion (PROM), where a therapist or the patient’s other hand moves the arm without active muscle engagement of the injured shoulder. The rehabilitation program progresses through several phases, gradually introducing more active movement and strengthening exercises. Phase II, starting around weeks 4-6, includes gentle submaximal isometric exercises and continued PROM, avoiding specific movements like horizontal adduction or scapular depression.
Phase III, around weeks 7-10, focuses on progressing active and passive range of motion, strengthening rotator cuff and scapular stabilizer muscles, and increasing overall arm strength. Resistance exercises using bands and light weights are gradually incorporated. The final phase, Phase IV, from weeks 11-16 and beyond, involves dynamic strengthening, plyometric exercises for athletes, and sport-specific rehabilitation for a gradual return to full activities. Full recovery, including complete restoration of strength and function, can take several months, ranging from four to six months or longer. Consistent adherence to the prescribed rehabilitation protocol is important for optimal long-term outcomes.