Surgical Treatment of Bilateral Coracoid Impingement by Coracoid Osteotomy-Case Report Volume 5 - Issue 3

Miklós Tátrai¹* and Attila Pavlik^1,2

• ¹Kastélypark Clinic, Department of Orthopedic Surgery, Tata, Hungary
• ²Semmelweis University, Faculty of Sport Medicine, Budapest, Hungary

Received:August 16, 2021   Published:October 29, 2021

Corresponding author: Miklós Tátrai, MD, Kastélypark Clinic, Hajdú Street 17., Tata, H-2890, Hungary

DOI: 10.32474/OSMOAJ.2021.05.000215

Abstract PDF

The subcoracoid impingement is a rare, painful condition and its diagnosis can be challenging and prolonged. In case of unsuccessful conservative treatment, surgical treatment is recommended which can be an arthroscopic coracoplasty or a coracoid osteotomy. In this case report we present a young, active patient with bilateral subcoracoid impingement, who was unable to work and play sport because of his anterior shoulder pain, and who has subsequently been treated by coracoid osteotomy with excellent results. The patients receiving this treatment could go back to physical work and sport without any complaint. The coracoid osteotomy can be an alternative surgical method in the treatment of subcoracoid impingement syndrome, especially for younger patients.

Keywords: Coracoid Impingement; Coracoplasty; Coracoid Osteotomy; Anterior Shoulder Pain

The subcoracoid impingement is a rare condition causing anterior shoulder pain and discomfort, especially in adducted and internally rotated position of the arm [1]. Lately, some studies advocated that its occurrence is higher than it was previously supposed. The most common mechanism of this condition is an amplified and repetitive activity of the patients or the athletes with forward flexion, adduction and internal rotation, because this position reduces coracohumeral distance, causing impingement of the subcoracoid soft tissues. The length and the shape of the coracoid process can be also a predisposing factor in the decreased coracohumeral distance. The main cause of the symptoms is inflammation and degeneration of the subscapular tendon and bursa due to the irritation of these soft tissues caused by the narrowed distance between the coracoid process and the lesser tuberosity of the humerus [2]. The coracohumeral distance can be constricted by an anatomic variation of the coracoid if it is too long and projected laterally, by a protuberance of the lesser tuberosity or by an irregularity of coracohumeral angle [3].
The primary treatment of the subcoracoid impingement is conservative including activity modification to avoid the predisposing movements of the arm, physical therapy to strengthen the rotator cuff, and other anti-inflammatory alternatives [1]. In case of unsuccessful conservative treatment surgery can be recommended, such as arthroscopic or open coracoplasty, combination of coracoacromial ligament resection and acromioplasty or coracoid osteotomy [1, 4, 5]. The purpose of this study is to present our patient with bilateral subcoracoid impingement who was successfully treated by coracoid osteotomy in both sides.

19 year old physical worker and handball player was suffering severe right and moderate left anterior shoulder pain during physical activity for 2 years. He had not had any significant injury. He was examined and treated conservatively unsuccessfully and referred to our institute. At that time he could not play handball and he could not even work because of his intensifying anterior shoulder pain. His shoulder range of motion was decreased and painful, especially in adduction and internal rotation; and the external rotation in 90 degrees of abduction was also restricted and painful. The patient’s ASES score (26 points on the right and 43 points on the left side) and Constant score (46 points on the right and 53 points on the left side) were very low in both sides. The VAS was 8 on the right and 6 on the left side. Native x-ray, CT and MR imaging also showed narrowing space between the humerus and the coracoid process without subscapular tendon tear The diagnosis was confirmed when a subcoracoid Lidocaine injection resulted in significant pain relief. Surgical treatment was indicated.
In general anaesthesia we performed coracoid osteotomy first on the right and 6 months later on the left side. During surgery we cut off a 20 degrees medially wedged bone slice from the medial side of the coracoid. The osteotomy was fixed by a partially threated AO screw. The patient had a sling for 4 weeks then range of motion exercises were begun under supervision of a physiotherapist followed by rotator cuff strengthening program. After 3 months unrestricted shoulder motion was allowed. On the follow up examination the patient’s shoulder range of motion was normal on both sides, the VAS decreased to 1 on the right and to 0 on the left side. The ASES and the Constant scores were significantly increased (91, 91, 86, 88 points) on both sides. The postoperative x-ray showed healed osteotomy and increased coracohumeral distance in both sides. The patient could go back to work and return to sport without pain after 4 months postoperatively.

Our patient with coracoid impingement syndrome was successfully treated by coracoid osteotomy after 2 years of unsuccessful conservative treatment and he could go back to physical work and sport on his previous level.
The coracoid impingement is noted to be a rare condition with strong anterior shoulder pain and dysfunction caused by a mechanical impingement of the subscapular tendon between the coracoid process and the lesser tuberosity of the humerus due to the narrowed space between them [1]. It can lead to a tear in the subscapular tendon with significant impairment of the shoulder function [2]. The diagnosis of the coracoid impingement is not obvious for the majority of the orthopaedic surgeons so the adequate treatment does not occur instantly in most of the cases as we also experienced in our case [2, 3].
Some studies recommended arthroscopic coracoplasty for the surgical treatment of this condition with good postoperative results [4]. However, in these studies the majority of the patients had not only coracoid but subacromial impingement and rotator cuff pathology as well, so their treatment was necessarily a combined surgery to address both conditions in the same session [3, 4]. Our young patient only had subcoracoid pathology without subacromial symptoms and the shape of his coracoid process was proved to be the origin of his condition. For this reason we chose correction osteotomy of the coracoid process to gain more space for the subscapular tendon rather than coracoplasty. The correction osteotomy can be a good surgical alternative method in the treatment of subcoracoid impingement syndrome in young patients.

1. Gerber C, Terrier F, Ganz R (1985) The role of the coracoid process in the chronic impingement syndrome. J Bone Joint Surg Br 67: 703-708.
2. Maria J Leite, Márcia C Sá, Miguel J Lopes , Rui M Matos , António N Sousa, et al. (2019) Coracohumeral distance and coracoid overlap as predictors of subscapularis and long head of the biceps injuries. J Shoulder Elbow Surg 28: 1723-1727.
3. Garofalo R, Conti M, Massazza G, Eugenio Cesari, Enzo Vinci, et al. (2011) A Subcoracoid impingement syndrome: a painful shoulder condition related to different pathologic factors. Musculoskelet Surg 95: S25-29.
4. Karnaugh RD, Sperling JW, Warren RF (2001) Arthroscopic treatment of coracoid impingement. Arthroscopy 17: 784-787.
5. Reddy VR, Okoro T, Rennie W, et al. (2010) Coracoid impingement treated with corrective osteotomy. A case report. Shoulder and Elbow 2: 103-106.