What is the recommended treatment for a patient with a Type 2 acromion?

Management of Type 2 Acromion

For patients with a Type 2 acromion, routine acromioplasty is not recommended as it has little to no effect on clinical outcomes compared to rotator cuff repair alone. 1

Understanding Type 2 Acromion

• Type 2 acromion (curved shape) is the most common acromial morphology associated with shoulder impingement syndrome 2
• The Bigliani classification categorizes acromion morphology into three types:
  • Type 1: Flat
  • Type 2: Curved
  • Type 3: Hooked
• Type 2 acromion has been theoretically linked to increased risk of subacromial impingement, but treatment should focus on underlying pathology rather than acromial morphology alone 1

Initial Non-Surgical Management

• First-line treatment should consist of conservative measures:

  • Exercise therapy focusing on rotator cuff and scapular muscle strengthening 3, 4
  • NSAIDs for pain management 5, 1
  • Activity modification to avoid painful movements 5

• Physical therapy protocol should include:

  • Progressive strengthening exercises for rotator cuff muscles 4
  • Manual therapy targeting thoracic spine and glenohumeral joint 4
  • Stretching exercises for posterior shoulder structures 4

• Subacromial corticosteroid injections may be considered, though evidence is inconclusive:

  • Can provide short-term pain relief in some patients 2
  • The American Academy of Orthopaedic Surgeons (AAOS) notes conflicting evidence regarding efficacy 1

Surgical Management

• Surgery should be considered only after failure of appropriate conservative treatment 1

• If rotator cuff repair is indicated:

  • Routine acromioplasty is not required for Type 2 acromion 1
  • Level II randomized studies show no significant difference in outcomes between rotator cuff repair with acromioplasty versus repair alone 1
  • One study of 47 patients with Type 2 acromion showed no difference in ASES scores between those who had repair with acromioplasty versus repair alone 1
  • Another study of 80 patients with Type 2 or 3 acromion showed no significant differences in Constant-Murley or DASH scores between repair with or without acromioplasty 1

• For irreparable rotator cuff tears:

  • Partial repair, debridement, or muscle transfers may be considered 1
  • These procedures have shown improvement in pain and function in level IV studies 1

Prognostic Considerations

• Type 2 acromion has a less favorable prognosis with non-operative treatment compared to Type 1:

  • Studies show 68% success rate with non-operative treatment for Type 2 acromion versus 91% for Type 1 3
  • However, this doesn't necessarily indicate that surgical modification of the acromion is beneficial 1

• Patient age affects treatment outcomes:

  • Patients aged 20 or younger and 41-60 years respond better to conservative treatment than those aged 21-40 or over 60 3

Imaging Recommendations

• Initial radiographic evaluation should include:

  • Standard shoulder radiographs including AP and lateral views 1
  • Suprascapular outlet view or Rockwood view (30° angled caudad) to evaluate acromial morphology 1

• For further evaluation when radiographs are noncontributory:

  • MRI without contrast or ultrasound (if expertise available) are appropriate for evaluating associated soft tissue pathology 1
  • MR arthrography may be considered if labral pathology is suspected 1

Key Clinical Pitfalls

• Avoid assuming that the presence of a Type 2 acromion alone necessitates surgical intervention 1
• Don't overlook the importance of adequate conservative treatment before considering surgery 3, 4
• Be aware that simply adding more strengthening exercises to standard care may not improve outcomes 6
• Remember that approximately half of patients may still have unacceptable symptoms after 4 months of non-operative care 6