Coracoidopathy Diagnosis Confirmed in New Study

This paper just came out in June this year confirming what I call coracoidopathy (tendinopathy of the short head of the biceps and coracobrachialis muscles where they attach at the coracoid process). They called it “coracoid syndrome,” which I might as well, if they had named it before I did, however I do feel like “coracoid syndrome” sounds a lot like “coracoid impingement syndrome” which isn’t at all the same thing.

For what might be easier reading my write up on how I diagnose and treat coracoidopathy, how it relates to the bench press exercise, and how it differs from coracoid impingement syndrome is available. Since I think the condition is very common, more common than even these researchers describe, I am glad to see it get more attention. Like Karim 2005, I think these guys nail the condition and they reference a number of the same studies I found. Also, like Karim, they treated it with a cortisone injection which was for the most part successful. However, since I think cortisone is generally fools gold for tendinopathy, I’m against it’s use, and I think the one failure they had was illustrative as to why. So I thought it would be good to quote some comments from the paper and comment how similar or different my experiences have been with the condition.

Coracoid syndrome: a neglected cause of anterior shoulder pain. Gigante A, Bottegoni C, Barbadoro P. Joints. 2016 Jun 13;4(1):31-8. [FREE FULL TEXT]

“Conclusions: the present study documents the existence, and characteristics, of a “coracoid syndrome” characterized by anterior shoulder pain and tenderness to palpation over the apex of the coracoid process and showed that the pain is usually amenable to steroid treatment. This syndrome should be clearly distinguished from anterior shoulder pain due to other causes, in order to avoid inappropriate conservative or surgical treatment.”

I think this is exactly right and appreciating the diagnosis I think would go a long way towards presenting plenty of unnecessary acromioplasties.

“Bench-presser’s shoulder is an overuse insertional tendinopathy of the pectoralis minor muscle usually affecting weightlifters and bodybuilders. On examination, medial juxta-coracoid tenderness is present and the active-contraction test and bench-press maneuver are positive (7).”

Here I would differ with their conclusion. They are citing Bhatia 2007 and taking him at face value. However, as I explained in my Bench Press Shoulder Pain blog I expect that what Bhatia is calling “bench-presser’s shoulder” is really slightly misdiagnosed coracoidopathy. I don’t think the active contraction test or the bench-press maneuver are able to isolate the pectoralis minor from that of the short head of the biceps or coracobrachialis and that if an isometric Speed’s test were performed on his patients, I speculate it would have been positive as well.

“In the course of the senior Author’s long experience with shoulder problems, a large number of patients have presented with anterior shoulder pain but no clinical signs of subacromial or subcoracoid impingement, rotator cuff or pectoralis minor tendinopathy, subscapularis or LHBt disorders, or symptoms and signs of instability.”

I wholeheartedly agree with that.

“The exclusion criteria were: pain symptoms elicited by digital pressure applied on an area of tenderness medial to the coracoid along the inferior-medial orientation of the muscle fibers, the anterolateral subacromial area and the apex of the contralateral coracoid process; symptoms, clinical signs (e.g. painful active contraction test and bench-press maneuver), X-ray, or MRi findings suggesting other shoulder girdle disorders, including tendon tears, adhesive capsulitis or coracoid impingement; previous or multiple shoulder problems; neck pain symptoms or clinical features indicating neck pathology; ipsilateral upper limb problems; suspected nerve compression; clinical signs or laboratory test findings of rheumatic disease, including fibromyalgia (19); and obesity, as this condition hampers digital palpation of the coracoid process.”

I’m of the opinion that the authors exclusion criteria are too restrictive, such that a fair amount of patients with coracoidopathy/coracoid impingement were excluded. When I did the demographics on my patients with shoulder pain, I found that 88% of my patients with coracoidopathy also had something else, most frequently rotator cuff tendinopathy or adhesive capsulitis. I think for the purpose of Gigante’s study, the bulk of these exclusions were useful in that if they are going to treat the condition with a focused cortisone injection and see if it works, you want to do it on someone with an isolated condition. However, I think the exclusions based on obesity, previous shoulder problems, and particularly the “bench-press maneuver” lessen the true incidence of even isolated coracoidopathy which they describe as 5.28% compared to my 10.2%.

I’m particularly concerned about their use of the “bench-press maneuver” (which is a simulated bench press motion against manual resistance) as an exclusion test because I think it will be positive in a fair number of patients with coracoidopathy who don’t bench press. Also, because all the patients I have had as of recent with anterior shoulder pain, and a tender coracoid process had coracoidopathy. While I am unaware of anyone doing an EMG test to confirm, it is widely thought that both the short head of the biceps and coracobrachialis both work in shoulder flexion and horizontal adduction (the combination thereof is what the upper arm does when bench pressing) and thus should be positive (painful with resistance in the bench press motion). In fact the authors report:

“Eleven patients (73.33%) remembered performing abrupt, repetitive flexion and adduction movements of the shoulder against resistance with the elbow in extension (as when lifting a person from a bed) prior to symptom onset; the other 4 reported that their job involved movements of this kind.”

The above is a pretty big clue that the “bench-press maneuver” should not be used to exclude someone from the diagnosis of coracoidopathy.

Treatment, which as with Karim and Bhatia, was with a corticosteroid injection to the coracoid process, which seems to have been largely successful. In my main coracoidopathy paper, I go into detail with citations as to why I’m against the use of cortisone injections to damaged tendons, with the reason being that while smaller short term studies find cortisone injections beneficial, larger longer term studies find a high incidence of recurrence and increased risk of tendon rupture such that those who have corticosteroid injections are, on average, worse off than those who have had no treatment whatsoever. The patients in this paper were followed for two years and this does not seem to have been much of an issue, however they were largely sedentary patients and the ones who failed treatment I think is illustrative.

“The last patient (6.66%) had residual pain (EQ-VAs: 22) and unsatisfactory shoulder function (sst: 66.67), and received a third infiltration. At 60 days this patient still complained of anterior shoulder pain and his scores were the same as at the previous visit, but he admitted that he had never stopped lifting heavy weights.”

“A possible explanation for this case is that his coracoid syndrome, combined with an initially undiagnosed supraspinatus tendinitis, worsened with shoulder overuse and finally led to tendon inflammation, which does not respond to steroid treatment.”

Here’s another possible explanation. In the active patient who continued to workout, the corticosteroid injection being catabolic (meaning it weakens the tissue where it’s injected) had reduced capacity to heal, which was worsened with each subsequent injection, only being offset by the anabolic (strengthening) action of their weight training. This would explain corticosteroid injections increase the risk of rupture (with more injections being worse) in collagenous type tissues and why in other types of tendinopathy corticosteroid injections have been shown to slow long term rates of healing in comparison to measured and progressive resistance training and also in comparison to no treatment whatsoever. As such I think the treatment that’s in the long term best interest in all patients to include both the active ones and sedentary ones. Given that resting tendons with tendinopathy isn’t particularly evidence based, and that tendinopathy generally isn’t inflammatory, I don’t find the authors’ explanation particularly compelling. Rather I think if they had added supinated front raises (as described with video in both my Coracoidopathy the Missing Link in Shoulder Pain and my Bench Press Shoulder Pain blogs) to an otherwise balanced exercise program, perhaps with some some internal and external rotation rotator cuff exercises, they might have had a complete resolution of symptoms.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask.

Chad Reilly, Physical Therapist

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