52 Fig. 1 Anterior view of shoulder joint demonstrating coracoid process and surrounding structures [4] Table 1 Causes of coracoid impingement syndrome [8–10] Idiopathic Traumatic Iatrogenic Malpositioned coracoid tip Calciﬁcation of the coracoid tip, subscapularis tendon Humeral head and neck fracture Malunion of previous coracoid or glenoid fracture Displaced fractures of scapular neck Posterior sternoclavicular dislocation Previous anterior shoulder surgery (Bristow/Trillat procedure) Posterior glenoid osteotomy Acromionectomy also an important entity to be aware of as it is a cause of persistent postoperative shoulder pain after rotator cuff repair [12]. Physical examination follows the orthopaedic edict of ‘Look, Feel, and Move’. It is important to look for previous scars and any obvious deformity in the shoulder area. Palpation often elicits tenderness of the soft tissues around the coracoid process and between the coracoid process and the lesser tuberosity [8]. The coracoid impingement test is performed in a manner similar to that used to perform the Kennedy–Hawkins impingement sign, except that the patient’s shoulder is placed in a position of cross arm adduction, forward elevation, and internal rotation to bring the lesser tuberosity in contact with the coracoid [13]. Pain is elicited more consistently in the midrange of forward elevation than in the full elevation that is used to detect subacromial impingement [10]. The coracoid impingement test is passive on the part of the patient, and this is used to differentiate it from the superior labrum test [14] which requires the patient to resist downward pressure on the arm. Curr Rev Musculoskelet Med (2009) 2:51–55 Another method that is used to evaluate whether a patient has coracoid impingement is to inject lignocaine into the subcoracoid region [13]. Although it has been suggested that relief of pain with this injection can help to establish the diagnosis, this test has not been studied to determine either its validity or its accuracy [15]. The proximity of multiple structures in the subcoracoid region, including the joint itself, makes the accuracy of these injections questionable. Radiological investigations include ‘X-rays’ of the shoulder, in particular an AP view and an axillary view perpendicular to the plane of the scapula (Fig. 2). These can detect anatomical aberrations that may be contributing Fig. 2 Plain X-Rays demonstrating a laterally projecting coracoid causing impingement Fig. 3 MRI Scan demonstrating coracohumeral interval in the same patient as in Fig. 2: the distance between the coracoid tip and the closest portion of the proximal part of the humerus