Coracohumeral & Glenohumeral Ligamentous Complex

The coracohumeral ligament (CHL) originates from the base of the coracoid process and spans across the rotator interval, enveloping the supraspinatus tendon margin. It acts in conjunction with the superior glenohumeral ligament (SGHL) to form a stabilizing pulley system for the long head of the biceps tendon within the bicipital groove.

Concavity-Compression Mechanism

Because the osseous socket is inherently flat, stability is maintained by pressing the convex humeral head into the concave glenoid socket bounded by the glenoid labrum. Dynamic co-contraction of the rotator cuff creates compressive forces preventing translation under load.

Physical Examination & Diagnostics

• Neer Sign: Positive pain response on passive forced forward flexion with arm internally rotated.
• Hawkins-Kennedy Test: Pain elicited by passive internal rotation at 90° forward flexion.
• Jobe (Empty Can) Test: Pain or weakness during resisted elevation in scapular plane with thumbs pointed down.

In-Office Subacromial Infiltration

Technique: Posterolateral approach. Needle inserted 1-2 cm inferior to posterolateral border of acromion, directed toward undersurface of acromion tip.

Injectate Mix: 5 mL 1% Lidocaine + 40 mg Methylprednisolone or Triamcinolone acetonide.

Arthroscopic Subacromial Decompression (SAD)

Under arthroscopic visualization from posterior portal, a lateral working portal is established. High-speed burr resects the anteroinferior acromial spur, converting a Type II/III acromion into a flat Type I arch alongside subacromial bursectomy.

Rehabilitation Protocol

• Phase I (Weeks 0-2): Sling for comfort, early PROM and active-assisted ROM.
• Phase II (Weeks 2-6): Full AROM, scapular stabilization, rotator cuff isometric strengthening.
• Phase III (Weeks 6+): Progressive resistance training and sports-specific functional conditioning.

Physical Examination & Imaging

• Drop Arm Sign: Inability to smoothly decelerate arm from 90° passive abduction.
• External Rotation Lag Sign: Inability to hold shoulder in full external rotation (infraspinatus).
• Belly-Press Test: Assesses subscapularis power.

In-Office Infiltration

Ultrasound-guided diagnostic subacromial injection: 4 mL 1% Lidocaine + 40 mg Depo-Medrol to differentiate pain-inhibited strength from true structural nerve disruption.

Arthroscopic Double-Row Suture Bridge Repair

Footprint at greater tubercle is debridened down to bleeding bone. Medial suture anchors placed at articular margin; suture tails passed through tendon footprint and secured laterally with sutureless anchors to restore anatomic footprint contact area.

Postoperative Rehabilitation

• Weeks 0-6: Abduction sling immobilization. PROM limited to 120° elevation and 30° external rotation.
• Weeks 6-12: Discontinue sling; initiate AAROM and active ROM.
• Weeks 12+: Progressive resistive strengthening; avoid full loading until 6 months.

Physical Exam & Diagnostics

• O'Brien Test: Deep joint pain with resisted elevation in 10° adduction/internal rotation, relieved by supination.
• Speed's Test: Pain in bicipital groove with resisted elevation and forearm supinated.
• Yergason's Test: Pain during resisted supination/external rotation with elbow flexed 90°.

In-Office Bicipital Groove Infiltration

High-frequency linear ultrasound guidance targeting the bicipital sheath inside the bicipital groove: 3 mL 1% Lidocaine + 20 mg Depo-Medrol.

Arthroscopic Biceps Tenodesis / Tenotomy

Tendon is released from superior glenoid anchor and fixed extra-articularly into the bicipital groove or subpectoral region using an interference screw or suture anchor to avoid post-op stiffness.

Rehabilitation Guidelines

• Weeks 0-4: Sling support; avoid active elbow flexion and forearm supination.
• Weeks 4-8: Active elbow flexion without load; gradual restoration of full ROM.
• Weeks 8+: Progressive biceps dynamic resistance strengthening.

Physical Examination & Imaging

• Step-Off Deformity: Palpable elevation of distal clavicle.
• Cross-Body Adduction Test: Pain over superior AC joint line during horizontal adduction.
• Paxinos Test: Thumb pressure on posterior acromion + index pressure on distal clavicle reproduces pain.

In-Office AC Joint Infiltration

Palpate superior notch between clavicle and acromion; 25-gauge needle inserted superior-to-inferior: 1.5 mL 1% Lidocaine + 20 mg Triamcinolone acetonide.

Surgical Reconstruction

Indicated for high-grade Rockwood IV/V/refractory III. Reconstruction uses cortical fixation button devices (e.g., TightRope) or tendon graft passed through clavicle and coracoid bone tunnels, alongside distal clavicle resection (Mumford procedure, 5-8 mm) if degenerate.

Rehabilitation Protocol

• Weeks 0-6: Sling support to reduce vertical clavicular shear forces.
• Weeks 6-12: Gentle ROM restoration below 90° elevation; progressive trapezius/deltoid activation.
• Weeks 12+: Return to full overhead function and sport activities.

Physical Exam & Diagnostics

• Guarding: Severe limitation of active and passive movements due to acute bursal pressure.
• Tenderness: Exquisite tenderness on direct palpation over anterior greater tubercle.

US-Guided Needle Barbotage & Infiltration

Under real-time ultrasound guidance, two 18-gauge needles penetrate the calcific deposit. Repeated saline lavage aspirates fluid calcium deposit. Subacromial bursa is then injected with 40 mg Methylprednisolone to manage secondary bursitis.

Arthroscopic Evacuation

Indicated for refractory chronic pain. Tendon is identified, probed, and incised parallel to fibers to evacuate calcific material. Cavity irrigated thoroughly; residual defects repaired with suture anchors if necessary.

Rehabilitation Protocol

• Days 1-7: Early passive-assisted pendulum exercises as tolerated.
• Weeks 2-4: Full active ROM and progressive resistance strengthening as inflammatory phase settles.

Physical Examination & Imaging

• Global Loss of ROM: Equal restriction of both active and passive range of motion, most notably external rotation with arm at side (< 15°).
• Scapular Hike: Early compensatory scapulothoracic elevation during abduction attempts.

Glenohumeral Hydrodilatation & Infiltration

Ultrasound-guided posterior glenohumeral injection: 40 mg Triamcinolone acetonide + 4 mL 1% Lidocaine + 15-20 mL normal saline to distend capsule and rupture adhesions.

Manipulation Under Anesthesia (MUA) & Release

If conservative therapy fails after 6 months. Controlled, sequential manipulation into flexion, abduction, and rotation, combined with arthroscopic 360° capsular release (releasing rotator interval, coracohumeral ligament, and inferior capsule).

Rehabilitation Guidelines

• Day 1 Post-Op: Immediate intensive physical therapy within 24 hours to preserve capsular volume.
• Weeks 1-6: Daily stretching routines targeting end-range external rotation and elevation.

Physical Examination & Diagnostics

• Apprehension Test: Anxiety and resistance when shoulder is brought to 90° abduction and full external rotation.
• Jobe Relocation Test: Reduction of apprehension when posterior force is applied to anterior proximal humerus.

In-Office Infiltration

Diagnostic intra-articular Lidocaine injection (5 mL 1%) utilized to differentiate true mechanical instability from painful rotator cuff weakness prior to rehabilitation.

Arthroscopic Bankart vs. Open Latarjet

If glenoid bone loss is < 15%, an Arthroscopic Bankart Repair is performed using suture anchors placed at anteroinferior rim (3 to 6 o'clock). If bone loss > 15-20%, an Open Latarjet procedure is performed (coracoid process transfer with short head of biceps to anterior glenoid rim).

Rehabilitation Protocol

• Weeks 0-4: Sling immobilization. Restrict external rotation beyond neutral (0°) to protect anterior repair.
• Weeks 4-8: Gradual increase in external rotation (up to 30°) and elevation.
• Months 3-6: Plyometrics and sports-specific functional training; return to contact play at 6 months.