Partial tear of the subscapularis with coracoid impingement as a possible contributing factor.
The patient was treated initially with a prednisone taper while the MRI was obtained. Oral steroids rather than steroid injection were used because it was not clear exactly what the mass was. The patient was markedly improved on day 5 of the taper and the inflammatory mass was decreasing in size. Weakness of the subscapularis was noted on exam and physical therapy was started.
The patient continued to improve with physical therapy. He regained full, pain free range of motion of the shoulder and strength of the left subscapularis was 95% that of the right. He was returned to full activity with follow-up as needed.
The puzzling thing about this case was the lack of a history of trauma or overuse. It was presumed that he had possible impingement of the subscapularis on the coracoid process. Since the patient was improving with conservative management, the orthopedic consultant recommended continued conservative management.
Coracoid impingement appears to be much less common (or at least less recognized) then acromial impingement of the supraspinatus tendon. The initial treatment is to avoid aggravating activities and reduce inflammation. Surgical decompression is an option in cases that fail to respond to conservative measures.
Okoro T., et al. Coracoid impingement syndrome: a literature review. Curr Rev Musculoskeletal Med. 2009 March;2(1); 51-55.
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