Working Diagnosis:
Based on his history, physical and radiographic examination, pain was predominantly due to subacromial impingement syndrome caused by narrowing of the coracohumeral interval, resulting in subscapular tendinosis, as well as, subcoracoid and superior subscapular bursitis. This disorder is due to impingement of the lesser tuberosity of the humerus against the coracoid process. To a lesser degree, he was also noted to have subacromial impingement syndrome.

Treatment:
Management options were discussed, including activity modification, non-steroidal anti-inflammatory medications, physical therapy, ultrasound guided aspiration and steroid injection, as well as surgical consultation. Physical therapy was initiated, working on range of motion, particularly stretching the pectoralis minor; and strengthening activities, focusing on scapular stabilizing and rotator cuff muscles. He deferred aspiration or injection until follow up.

Upon follow up at two months, he noted some improvement in pain, now 5/10 in severity. On ultrasound, distention of the subcoracoid and subacromial bursae were again noted. Subcoracoid and subacromial aspiration and injection was recommended, but the patient decided to only pursue the subacromial injection at that time.

Outcome:
The patient noted significant initial reduction in pain after the subacromial injection, with resolution of the lateral shoulder pain and improvement in anterior shoulder pain to about 3/10. At nine months, even with continued home exercise program, he reported return of anterior shoulder pain over a period of several months, now about 7/10 in severity.

Author's Comments:
Subcoracoid impingement syndrome should be considered in the differential diagnosis of anterior shoulder pain. Treatment should focus on alleviating the underlying cause of impingement. In this case, treatment resulted in improvements in performing activities of daily living; although, he has been unable to resume his prior frequency and intensity of recreational weight lifting. Management was limited by infrequent follow up; however, if symptoms do not improve with conservative treatment, surgical consultation will be obtained for possible coracoplasty and subscapularis repair.

Editor's Comments:
Subcoracoid impingement is characterized by anterior shoulder pain aggravated by anterior shoulder flexion, adduction and internal rotation. Activities such as driving or overhead activities such as a tennis serve may aggravate symptoms. In this case it would be interesting to know more which inciting activities increased his pain and if they were modified to decrease symptomatology.
Palpation of the coracoid may not be helpful as it can be tender in unaffected patients. A modified hawkins test with the shoulder in 90 deg of forward flexion, adduction, and internal rotation typically reproduces symptoms of subcoracoid impingement. Subscapularis and biceps testing often is positive. Measurement of the coracohumeral interval on MRI may be supportive, but has poor predictive value in establishing the diagnosis, but may also show subscapularis or biceps tendinopathy suggestive of the diagnosis. Avoiding aggravating activities, periscapular strengthening, rotator cuff strengthening and pectoralis major stretching are important components of treatment. Subcoracoid injection may be considered for pain relief if conservative measures do not relieve symptoms. If conservative measures do not improve symptoms over 3-6 months, surgical referral may be considered.

Buss D, Freehill M, Marra G. Typical and Atypical Shoulder Impingement Syndrome: DIagnosis, Treatment, and Pitfalls. AAOS Instructional Course Lectures 2009;58,447-457.

Giaroli EL, Major NM, Lemly DE, Lee J. Coracohumeral Interval Imaging in Subcoracoid Impingement Syndrome on MRI. Americal Journal of Roentgenology 2006; 186,242-246.

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