Ultrasonography of Subcoracoid Bursal Impingement Syndrome

The morphology of the subacromial and related shoulder bursae. An anatomical and histological study

Shoulder bursae are essential for normal movement and are also implicated in the pathogenesis of shoulder pain and dysfunction. The subacromial bursa (SAB), within the subacromial space, is considered a primary source of shoulder pain. Several other bursae related to the subcoracoid space, including the coracobrachial (CBB), subcoracoid (SCB) and subtendinous bursa of subscapularis (SSB), are also clinically relevant. The detailed morphology and histological characteristics of these bursae are not well described. Sixteen embalmed cadaveric shoulders from eight individuals (five females, three males; mean age 78.6 ± 7.9 years) were investigated using macro-dissection and histological techniques to describe the locations, dimensions and attachments of the bursae, their relationship to surrounding structures and neurovascular supply. Bursal sections were stained with haematoxylin and eosin to examine the synovium and with antibodies against von Willebrand factor and neurofilament to identify blood vessels and neural structures respectively. Four separate bursae were related to the subacromial and subcoracoid spaces. The SAB was large, with a confluent subdeltoid portion in all except one specimen, which displayed a distinct subdeltoid bursa. The SAB roof attached to the lateral edge and deep surface of the acromion and coracoacromial ligament, and the subdeltoid fascia; its floor fused with the supraspinatus tendon and greater tubercle. The CBB (15/16 specimens) was deep to the conjoint tendon of coracobrachialis and short head of biceps brachii and the tip of the coracoid process, while the inconstant SCB (5/16 specimens) was deep to the coracoid process. Located deep to the subscapularis tendon, the SSB was a constant entity that commonly displayed a superior extension. Synovial tissue was predominantly areolar (SAB and SSB) or fibrous (CBB and SCB), with a higher proportion of areolar synovium in the bursal roofs compared to their floors. Blood vessels were consistently present in the subintima with a median density of 3% of the tissue surface area, being greatest in the SSB and SAB roofs (4.9% and 3.4% respectively) and least in the SAB floor (1.8%) and CBB roof and floor (both 1.6%). Nerve bundles and free nerve endings were identified in the subintima in approximately one-third of the samples, while encapsulated nerve endings were present in deeper tissue layers. The extensive expanse and attachments of the SAB support adoption of the term subacromial-subdeltoid bursa. Morphologically, the strong attachments of the bursal roofs and floors along with their free edges manifest as fixed and mobile portions, which enable movement in relation to surrounding structures. The presence of neurovascular structures demonstrates that these bursae potentially contribute blood supply to surrounding structures and are involved in mechanoreception. The anatomical details presented in this study clarify the morphology of the shoulder bursae, including histological findings that offer further insight into their potential function.

Subcoracoid Impingement – A Global View

Modifications in joint anatomy on both soft and bony tissue level play a key role in subcoracoid impingement syndrome. The diagnostic is primarily clinical and is based on patient history and functional tests. Imaging tests support, but do not establish the diagnostic. Approach can take the form of targeted exercises with progressive load, or that of invasive surgery.

Shoulder pain has a diverse etiology which derives from the complex local anatomy which includes the clavicle, acromion, coracoid process and humeral head, the soft tissues surrounding this area, in particular the rotator cuff, but can also be unrelated to all of the above and be a reflection of a pathology located in the neck, arm or trunk, or adjacent visceral organs. More often, it is the manifestation of a traumatic episode or an anatomical anomaly, or it can be secondary to inflammation, tumors, or surgery.

It is the third most common musculoskeletal complaint presenting to physiotherapy, and largely impacts both an individual’s quality of life and the public health system.

Coracoid impingement syndrome can present itself as a cause of rotator cuff disease, but its role is not fully established yet. It is less prevalent than subacromial impingement, can coexist with it, and therefore should be considered into the differential diagnosis of anterior shoulder pain when a patient presents themselves with activity related anterior shoulder pain.

[CME Sonography 95: Sonographic Differential Diagnosis of Anterior Shoulder Pain]

CME Sonography 95: Sonographic Differential Diagnosis of Anterior Shoulder Pain Abstract. Anterior shoulder pain is common, and, compared to high-resolution dynamic sonography, the clinical examination is usually not precise enough for the exact classification of the cause of the pain. In this review we discuss possible causes of anterior shoulder pain with special emphasis on the ultrasound diagnosis of causes of subcoracoidal impingement and of anterior snapping syndrome. We use high-resolution ultrasound images to illustrate various possible underlying pathologies in anterior shoulder pain.

Can subcoracoid cyst formation be a sign of anterosuperior rotator cuff tears and biceps pulley lesions? A prospective radiologic and arthroscopic correlation study

BACKGROUND

The aim of this study was to investigate the pathologies associated with subcoracoid cysts (ScCs) in patients with rotator cuff (RC) tears and the postoperative appearance of ScCs after arthroscopic repair.

METHODS

A total of 114 patients who underwent arthroscopic RC repair were prospectively evaluated. The inclusion criteria were as follows: patients with or without ScCs, patients with Patte class 1 or 2 tears, and patients who were 40-65 years of age. Forty-four patients with ScCs (group 1) were evaluated during the 12-month study period. Fifty-two patients who had no ScCs (group 2) were evaluated as a control group. Preoperative and postoperative cyst volumes were measured on magnetic resonance imaging (MRI), and arthroscopic findings were noted.

RESULTS

Thirty-one patients (70%) in group 1 had a subscapularis tear vs. 10 patients (19%) in group 2 (P < .001). Biceps lesions were encountered in 32 patients (72%) in group 1, whereas 12 patients (23%) had a biceps lesion in group 2 (P < .001). Cyst volume was significantly higher in the following situations: (1) patients who had a subscapularis tear compared with patients without a subscapularis tear, (2) patients who had biceps pulley lesions compared with patients without pulley lesions, and (3) patients who had both pathologies (P = .047, P = .01, and P = .002, respectively). Cyst volumes significantly decreased following RC repair in group 1 (P < .001).

CONCLUSION

Among patients with small- to medium-sized, full-thickness supraspinatus tears, the prevalence of biceps pulley lesions and/or subscapularis tears is higher in patients with ScCs.

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.

Anatomic Study of Subcoracoid Morphology in 418 Shoulders: Potential Implications for Subcoracoid Impingement

Background:

Subcoracoid impingement has been implicated as a cause of anterior shoulder pain and subscapularis tendon tears.

Purpose/Hypothesis:

The purpose of this study was to evaluate the bony anatomy of the coracoid process and the subcoracoid space. We hypothesized that age-related changes that may contribute to subcoracoid impingement occur in the subcoracoid space.

Study Design:

Descriptive laboratory study.

Methods:

In total, 418 skeletal shoulder specimens were included in this study. We utilized 214 shoulders from a young cohort (25-35 years of age) and 204 shoulders from an older cohort (>55 years of age) for comparison. We evaluated several morphological characteristics of the coracoid process and the subcoracoid space: coracoid width, coracoid shape, coracoid thickness, and subcoracoid distance. Each coracoid was observed for the presence of spurring or other morphological changes.

Results:

The mean anteroposterior (AP) thickness of the coracoid tip was 7.9 and 9.4 mm in our young female and male cohorts, respectively, while the mean AP thickness was 8.1 and 9.7 mm in our older female and male cohorts, respectively. The coracoid tip was hooked in 31 of 108 young female shoulders compared with 55 of 102 older female shoulders, and the coracoid tip was hooked in 25 of 106 young male shoulders compared with 45 of 102 older male shoulders. The mean subcoracoid distance in neutral rotation was 14.8 and 12.5 mm in young and older female shoulders, respectively, while the mean subcoracoid distance in internal rotation in these same cohorts was 8.7 and 7.0 mm, respectively. The mean subcoracoid distance in neutral rotation was 14.8 and 13.3 mm in young and older male shoulders, respectively, while the mean subcoracoid distance in internal rotation was 8.6 and 8.1 mm in young and older male shoulders, respectively.

Conclusion:

The principal findings of our study demonstrate that anatomic changes implicated in subcoracoid impingement may be developmental and worsen with age. The subcoracoid space was narrower in our older cohort of shoulders. Additionally, these older shoulders also had a greater AP width and a more hooked coracoid compared with young shoulders.

Clinical Relevance:

Narrowing of the subcoracoid space has been shown to be implicated as a cause of anterior shoulder pain and subscapularis tendon tears. This is the first study to show that the morphological changes implicated in subcoracoid impingement become more prevalent with age. This may help to explain the increasing prevalence of subscapularis tendon tears in older patients. Furthermore, subcoracoid decompression may be seen as an option for older patients with anterior shoulder pain and subscapularis tendon tears.

Dynamic ultrasonography of the shoulder

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of shoulder pain. Its low cost, excellent diagnostic accuracy, and capability for dynamic evaluation are also advantages. To assess all possible causes of shoulder pain, it is better to follow a standardized protocol and to perform a comprehensive evaluation of the shoulder than to conduct a focused examination. Moreover, a proper dynamic study can enhance the diagnostic quality of US, especially when the pathology is not revealed by a static evaluation. The purpose of this article is to review the common indications for dynamic US of the shoulder, and to present the basic techniques and characteristic US findings.

Redefining anterior shoulder impingement: a literature review

Many different types of impingements have been described in the shoulder. Inasmuch as the term 'shoulder impingement' usually refers to subacromial impingement, anterior impingement usually refers to subcoracoid impingement. However, there are many different subtypes of anterior impingements in the shoulder, and awareness of their existence is critical as they vary in their nature and treatment. Recent advances in biomechanical research and arthroscopic exploration of the anterior structures of the shoulder have brought new insights on the various potential impingements, warranting a revision and update of the current definitions of anterior shoulder impingement. The purpose of this article is to propose a comprehensive review and classification of all different subtypes of anterior impingement in the shoulder, including newly described entities.

Sonography of the Coracoid Process Region

Sonography is widely known as an accurate imaging tool for assessment of the rotator cuff of the shoulder, the long head of the biceps tendon, and joint disorders, but it is rarely performed to evaluate the coracoid process and the adjacent soft tissues. Nevertheless, sonography can show anatomic details of this region and be used to assess several pathologic conditions. The aims of this pictorial essay are to briefly review the anatomy of the coracoid process region, describe examination technique and normal sonographic appearances, and present the sonographic findings of the main disorders affecting this region.

Ultrasonographic Evaluation and Feasibility of Posterosuperior Internal Impingement Syndrome: A Case Series

Posterosuperior impingement (PSI) is an underdiagnosed cause of posterior shoulder pain and should be differentiated from classic and external impingement. PSI involves the internal impingement of soft tissues, including the undersurface of the rotator cuff against the posterosuperior labrum when the arm is brought into abduction and external rotation (ABER). Ultrasonography (US) can be useful in the assessment of PSI because of its high resolution and ability to perform during dynamic maneuvers in ABER. This series of 3 cases illustrates the feasibility of US in the evaluation of PSI when the history and physical examination implicate this condition.

LEVEL OF EVIDENCE

V.

Sonographic Findings in Subcoracoid Impingement Syndrome: A Case Report and Literature Review

Subcoracoid impingement syndrome is a rare and underrecognized cause of anterior shoulder pain. Currently, subcoracoid impingement syndrome is understood to involve impingement of anatomic structures such as the subcoracoid bursa and subscapularis tendon within the coracohumeral space, and there are no reports of sonographic findings in subcoracoid impingement syndrome other than the impingement of thickened subscapularis bursa. Here we report a case of subcoracoid impingement syndrome, including a novel sonographic finding, arthroscopic findings, and a proposed pathophysiology.

LEVEL OF EVIDENCE

V.