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Introduction
  • Subcoracoid impingement is defined as impingement of the subscapularis between the coracoid and lesser tuberosity
  • 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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