Subcoracoid Bursitis

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Other Names

• Subcoracoid Bursitis
• Anterior shoulder bursitis
• Coracoid impingement syndrome
• Subcoracoid bursal impingement syndrome

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Background

• This page refers to subcoracoid bursitis, an uncommon cause of shoulder pain characterized by inflammation of the subcoracoid bursa

History

• First case published by Demirhan et al in 2000

Epidemiology

• Rare disease, poorly described in the literature

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Introduction

Illustration of the subcoracoid bursa (blue) relative to the subscapularis muscle and conjoined tendons of coracobrachialis and biceps tendons. Note the subcoracoid recess is also labeled in blue (as SSR=subscapularis recess)

General

• Rare, infrequently seen and discussed and generally poorly understood cause of shoulder pain
• Caused by inflammation of the subcoracoid bursa, which lies between the coracobrachialis and subscapularis tendons
• Literature is essentially limited to case reports

Pathophysiology

• Commonly results from repetitive overhead activity.
• Often associated with rotator cuff injuries and subcoracoid impingement
• Inflammation of the subcoracoid bursa, which is deep to the coracoid process and anterior to the subscapularis tendon.
• Most commonly from repetitive or chronic mechanical impingement of the bursa between the coracoid process and the lesser tuberosity of the humerus, leading to microtrauma and synovial inflammation

Associated Conditions

• Rotator Cuff Tear

Anatomy of the Subcoracoid Bursa

• The subcoracoid bursa sits anterior to the subscapularis muscle and deep to the coracoid process
• It lies deep to the conjoined tendons of the coracobrachialis and short head of biceps brachii
• Does not communicate with the glenohumeral joint
• Seen in about 90% of anatomic specimens
• Communicates with the subacromial bursa in about 11% of anatomic specimens
• One of the Bursa of the Shoulder

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Risk Factors

• Rotator cuff tear (particularly seen in anterior tears involving the subscapularis tendon)
• Narrowed coracohumeral interval (congenital or acquired)
• Prior shoulder trauma
• Repetitive overhead or cross-body activities
• Degenerative changes in shoulder girdle that alter normal biomechanics

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Differential Diagnosis

Differential Diagnosis Shoulder Pain

• Fractures
  • Proximal Humerus Fracture
  • Humeral Shaft Fracture
  • Clavicle Fracture
  • Scapula Fracture
  • First Rib Fracture (traumatic or atraumatic)
  • Floating Shoulder
• Dislocations & Separations
  • Acromioclavicular Joint Separation
  • Glenohumeral Dislocation (Acute)
  • Sternoclavicular Joint Dislocation
  • Chronic Glenohumeral Dislocation
  • Glenohumeral Instability (Chronic)
• Arthropathies
  • Glenohumeral Arthritis
  • Acromioclavicular Joint Arthritis
  • Sternoclavicular Arthritis
• Muscle & Tendon Injuries
  • Pectoralis Major Injuries
  • Pectoralis Minor Injuries
  • Proximal Biceps Tendon Injuries
  • Scapular Dyskinesis
• Rotator Cuff
  • Rotator Cuff Tear
  • Rotator Cuff Tendonitis
  • Calcific Tendinitis of the Rotator Cuff
  • Subcoracoid Impingement Syndrome
• Bursopathies
  • Subacromial Bursitis
  • Scapulothoracic Bursitis
• Ligament Injuries
  • Glenoid Labral Tears
• Neuropathies
  • Suprascapular Nerve Injury
  • Parsonage-Turner Syndrome
  • Quadrilateral Space Syndrome
  • Winged Scapula
• Other
  • Adhesive Capsulitis
  • Paget-Schroetter Syndrome
  • Shoulder Injury Related To Vaccine Administration
  • Distal Clavicle Osteolysis
• Pediatrics
  • Coracoid Avulsion Fracture
  • Humeral Head Epiphysiolysis (Little League Shoulder)

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Clinical Features

Demonstration of Yocums Test

History

• Insidious onset of anterior shoulder pain near the coracoid process
• Pain is often aggravated by reaching across the body or overhead
• May have mechanical symptoms if associated with shoulder impingement

Physical Exam: Physical Exam Shoulder

• Focal tenderness over coracoid process or just medial and inferior to the coracoid
• Range of motion may be limited by pain
• Pain is worse with forward flexion, adduction and internal rotation
• Clicks can sometimes be palpated

Special Tests

• Subcoracoid impingement test: pain elicited with shoulder adduction, forward flexion and internal rotation
• Yocums Test: place hand on opposite shoulder, lift elbow up against resistance
• Gerbers Test: abduct shoulder to 90, internal and externally rotate shoulder

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Evaluation

The most lateral sagittal fat suppressed T1-weighted MR arthrogram image demonstrates contrast within the joint and subscapularis recess (asterisk), fluid within the subcoracoid bursa (arrowhead), and the subscapularis tendon (SSc).

Axial MRI image demonstrating subcoracoid bursitis, with fluid signal intensity noted between the coracobrachialis and subscapularis

Radiology

• Standard Radiographs Shoulder
  • Screening tool, typically normal

Ultrasound

• Can visualize bursal distension and impingement

MRI

• can distinguish subcoracoid bursal effusion from subscapularis recess fluid
• Useful for identifying associated rotator cuff tears or interval pathology
  • Subcoracoid bursal effusion is frequently assocaited with rotator cuff tears

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Classification

• Not applicable

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Management

Non-operative

• Typically treated conservatively with activity modification, physical therapy, and NSAIDs
• Subcoracoid Bursa Injection
  • US-guided corticosteroid injection into the subcoracoid bursa may be considered

Operative

• Indications
  • Unknown
  • Cases refractory to conservative management
• Technique
• Arthroscopic bursectomy or decompression

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Rehab and Return to Play

Rehabilitation

• Acute phase
  • Gentle passive and active-assissted range of motion to maintain shoulder mobility
• Initial stages of rehab program focuses:
  • Stretching,
  • Passive mobility exercises
  • Pendulums,
  • Doorway stretches to increase anterior shoulder flexibility
• Strengthening should focus on targeting the rotator cuff and scapular stabilizers

Return to Play/ Work

• Unknown
• Athlete should be relatively pain free and able to perform sport specific exercises

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Prognosis and Complications

Prognosis

• Generally good prognosis with conservative management

Complications

• Adhesive Capsulitis
  • Due to disuse or persistent inflammation
• May progress to communication of bursal effusion with adjacent bursae
• Surgical intervention carries risk of neurovascular injury

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See Also

• Shoulder Pain
• Shoulder Anatomy
• Physical Exam Shoulder

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