Coracoid Process Fracture Rehabilitation: Conjoint Tendon Protection and Recovery

Coracoid process fractures are rare skeletal injuries accounting for roughly 3% to 5% of all scapular fractures, commonly occurring in association with acromioclavicular (AC) joint dislocations, anterior shoulder dislocations, or direct anterior shoulder impacts. Classified by Ogawa into Type I (fractures proximal to the coracoclavicular ligament insertion, carrying inherent instability of the scapuloclavicular connection) and Type II (fractures distal to the CC ligaments, typically stable), these injuries disrupt the anatomical origin of the conjoint tendon (the short head of the biceps and coracobrachialis) and the pectoralis minor. While displaced Type I fractures frequently require open reduction and internal fixation (ORIF) with cannulated lag screws to restore superior shoulder suspensory complex integrity, Type II fractures heal reliably with conservative sling immobilisation. Physiotherapy must strictly protect the healing conjoint tendon against resisted elbow flexion and shoulder adduction while preventing adhesive capsulitis.

Domestic and Cultural Indian Realities

Managing a coracoid fracture in an Indian domestic setting requires adapting everyday upper limb pulling and lifting habits. Lifting heavy grocery bags (jhola), handling brass milk cans, or lifting domestic gas cylinders recruits the short head of the biceps and coracobrachialis, producing powerful distracting forces across the coracoid base; these tasks must be delegated for 8 to 12 weeks. Reaching across the chest to pin a traditional saree pallu or tucking garments forces horizontal adduction, stretching the pectoralis minor insertion; patients should wear loose, front-opening kurtas. Bathing with a heavy plastic bucket and mug (lota) involves resisted biceps flexion; patients should use lightweight cups or install a fixed shower. Commuting on crowded buses where passengers hold overhead handrails exposes the anterior shoulder to sudden traction jerks; patients must wear a supportive sling during all public transit.

Clinical Biomechanics and Anatomical Healing

The coracoid process resembles a crow beak projecting anterolaterally from the superior scapular neck, serving as the anterior anchor of the Superior Shoulder Suspensory Complex (SSSC). Three major muscles originate or insert upon it: the pectoralis minor, coracobrachialis, and short head of the biceps brachii, alongside the coracoacromial and coracoclavicular (trapezoid and conoid) ligaments. Active elbow flexion against resistance and resisted forearm supination activate the biceps brachii, creating an inferior tensile pull that displaces the coracoid fragment downward. Conservative management relies on keeping the elbow flexed at 90 degrees in a supportive sling, which relaxes the conjoint tendon and allows primary fibrous bridging to stabilize the bone.

Validated Special Tests and Differential Diagnosis

Clinical examination identifies pinpoint focal tenderness directly over the coracoid process in the deltopectoral groove, approximately 2.5 centimeters inferior to the clavicle. Pain is reproduced during resisted elbow flexion (Speeds test variation) and resisted horizontal shoulder adduction. Axillary and Stryker notch radiographs or 3D shoulder CT scans confirm fracture displacement and rule out associated acromioclavicular dislocation. Differential diagnosis distinguishes isolated coracoid fractures from distal clavicle fractures and superior labral anterior-to-posterior (SLAP) tears.

Stage-by-Stage Functional Recovery Protocol

Phase 1 (Weeks 0 to 4) immobilises the arm in a broad arm sling with the elbow bent at 90 degrees. Active wrist, hand, and gentle neck exercises are performed continuously. Codman pendulum swings are initiated within pain tolerance out of the sling, while all active elbow flexion is strictly avoided. Phase 2 (Weeks 4 to 8) weans the sling, introducing active-assisted forward elevation up to 90 degrees using a cane, accompanied by active unresisted elbow flexion-extension. Phase 3 (Weeks 8 to 12) advances to unrestricted overhead elevation, progressive biceps and rotator cuff resistance training, and functional lifting tasks once radiographic union is verified.

Red Flags and Urgent Surgical Indicators

Seek immediate orthopaedic assessment if you notice persistent anterior shoulder numbness or electric tingling radiating into the arm, which indicates musculocutaneous nerve traction (the nerve penetrates the coracobrachialis muscle just distal to the coracoid process). A visible high-riding clavicle accompanied by severe deformity indicates an associated complete acromioclavicular dislocation requiring surgical reconstruction. Severe spreading redness or purulent drainage along surgical incisions indicates infection.

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