Diagnosis and Management of Subcoracoid Impingement

Michael J. McKernan, MD; Mark S. Schickendantz, MD; Salvatore J. Frangiamore, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(3):100-107. 

In This Article

Abstract and Introduction

Abstract

Impingement of the subcoracoid space is a poorly understood pathologic cause of anterior shoulder pain. Because of its relative rarity in isolation and nonspecific presentation, diagnosis and management are often challenging for orthopaedic surgeons and their patients. Stenosis of the subcoracoid space between the lesser tuberosity and the coracoid process <6 mm can lead to anterior shoulder pain and associated rotator cuff and biceps pathology. Multiple imaging modalities are available to assess narrowing of the coracohumeral interval, each with its strengths and limitations. If the patient can be accurately diagnosed with subcoracoid impingement, both conservative and surgical management options are available. Despite earlier case series demonstrating promising results with arthroscopic treatment, comparative studies have yet to support these initial claims.

Introduction

Shoulder pain due to coracoid impingement can be challenging for both orthopaedic surgeons and patients regarding diagnosis and management because of its variable and often vague clinical presentation. Classically it is thought that forward flexion, adduction, and internal rotation of the shoulder can cause entrapment of subscapularis or biceps tendon, leading to pain and restriction of daily activities. From its initial description by Goldthwait,[1] and later comprehensively described by Gerber,[2] multiple studies have analyzed the etiology of subcoracoid impingement and its effects on the structures within the subcoracoid space. The subscapularis acts as an internal rotator and stabilizer of the shoulder joint anteriorly, thus making it necessary for normal glenohumeral biomechanics.[3–6] Knowledge of anatomic variations, morphology of structures of the subcoracoid canal, and effective diagnostic tools can aid in clinical decision-making. This review will assess in further detail the anatomic and morphologic variations of the structures within the subacromial canal and the implications that such variations have on functional outcomes. We will also discuss what screening and diagnostic testing are currently being studied in the literature. Finally, we will review the current treatment options to address this clinically challenging pathology and whether a change exists in the clinical outcome with treatment.

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