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