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Updated: 6/3/2021

Subcoracoid Impingement

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  • summary
    • Subcoracoid impingement is the impingement of the subscapularis between the coracoid and lesser tuberosity which can lead to anterior shoulder pain and possibly tearing of the subscapularis.
    • Diagnosis can be made clinically with tenderness over the anterior coracoid which is made worse with shoulder flexion/internal rotation and supplemented with CT scan showing decreased coracohumeral interval.
    • Treatment is a course of conservative measures including NSAIDs, physical therapy and corticosteroid injections. Arthroscopic or open coracoplasty is indicated for patients with progressive symptoms having failed conservative measures.
  • Etiology
    • Pathoanatomy
      • mechanism
        • position of maximal impingement is arm adduction,flexion, and internal rotation
      • risk factors
        • patients with a long or excessively lateral coracoid process
        • prior surgery that caused posterior capsular tightening and loss of internal rotation
    • Associated conditions
      • combined subscapularis, supraspinatus, and infraspinatus tears
  • Anatomy
    • Glenohumeral joint anatomy and biomechanics
    • Coracoid
      • muscle attachments
        • coracobrachialis, pectoralis minor, and short head of the biceps attach to the coracoid
      • ligamentous attachments
        • coracohumeral ligament, coracoacromial ligament attach to coracoid
        • coracoclavicular ligament which is composed of the conoid and the trapezium
    • Subscapularis tendon
      • inserts onto lesser tuberosity
  • Presentation
    • Symptoms
      • pain in anterior shoulder worsened by various degrees of flexion, adduction, and rotation
    • Physical exam
      • tenderness over anterior coracoid
      • position of maximal pain is 120-130° of arm flexion and internal rotation
  • Imaging
    • Radiographs
      • recommended views
      • findings
        • may show a decreased coracohumeral distance
    • CT scan
      • views
        • obtained with the arms crossed on chest is helpful to make the diagnosis
      • findings
        • a coracohumeral distance of < 6 mm is considered abnormal
          • normal is 8.7 mm in the adducted arm 6.7 mm in the flexed arm
    • MRI
      • indications
        • used to evaluate degree of rotator cuff pathology
      • findings
        • increased signal in subscapularis
        • increased signal in lesser tuberosity
      • views
        • axial view also effective to look for a decreased coracohumeral distance
  • Studies
    • Diagnostic injection
      • local corticosteroid injections should eliminate symptoms and can be diagnostic
  • Treatment
    • Nonoperative
      • rest, ice, activity modification, NSAIDS, corticosteroid injections
        • indications
          • first line of treatment
        • techniques
          • local corticosteroid injections can be diagnostic and therapeutic
          • PT focuses on stretching
    • Operative
      • arthroscopic coracoplasty ± subscapularis repair
        • indications
          • symptoms refractory to conservative treatment
          • subscapularis tearing secondary to impingement
        • technique
          • resect posterolateral coracoid to create 7 mm clearance between coracoid and subscapularis
          • if significant subscapularis tendon tear then repair
      • open coracoplasty
        • indications
          • symptoms refractory to conservative treatment
          • subscapularis tearing secondary to impingement
        • technique
          • resect lateral aspect of coracoid process and reattach the conjoined tendon to the remaining coracoid
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