What is the initial management for a patient with Type 3 acromion and associated bursitis?

Initial Management of Type 3 Acromion with Bursitis

Begin with conservative management including NSAIDs, physical therapy, and activity modification, as Type 3 acromion morphology alone does not mandate surgical intervention and should be treated based on the underlying bursitis pathology rather than acromial shape. 1, 2

Conservative Treatment Approach

First-Line Pharmacological Management

• Start with NSAIDs for symptomatic relief of bursitis, such as naproxen 500 mg twice daily or 250 mg every 6-8 hours, with initial doses not exceeding 1250 mg/day 3
• Consider acetaminophen or tramadol as alternatives in patients with cardiovascular risk factors or contraindications to NSAIDs 4
• Avoid routine corticosteroid injections initially, as the American Academy of Orthopaedic Surgeons notes conflicting evidence regarding efficacy of subacromial corticosteroid injections 1

Non-Pharmacological Interventions

• Implement physical therapy focusing on scapular strengthening, postural reeducation, and core strength endurance 5
• Apply local modalities including ice, rest, and activity modification 5, 6
• Consider nasal saline irrigation analogy applies here as local measures for symptom control 3

Role of Corticosteroid Injection

If conservative measures fail after 6-8 weeks, consider subacromial corticosteroid injection with triamcinolone acetonide 40-80 mg (for larger joints/spaces), though evidence shows this is more effective than alternatives but has conflicting support for routine use 1, 7, 8

• Triamcinolone acetonide demonstrates superior efficacy compared to newer biologics like rilonacept for subacromial bursitis 8
• Injection should be performed using strict aseptic technique with the suspension shaken before use to ensure uniformity 7

Imaging Considerations

• Obtain standard shoulder radiographs including AP views and suprascapular outlet or Rockwood view to confirm Type 3 acromion morphology 1, 2
• Do not obtain advanced imaging unless conservative treatment fails or complications are suspected 4, 2
• MRI without contrast or ultrasound may be appropriate for evaluating soft tissue pathology if radiographs are noncontributory and symptoms persist 1, 2

Critical Decision Point: Surgery is NOT Indicated Initially

The presence of Type 3 acromion does not justify acromioplasty, as Level II randomized studies demonstrate no significant difference in outcomes between rotator cuff repair with versus without acromioplasty 1, 2

• Studies of 47-80 patients show no differences in ASES, Constant-Murley, or DASH scores regardless of acromioplasty 1
• Adequate conservative treatment trial (minimum 6-8 weeks) should precede any surgical consideration 1

Treatment Timeline and Reassessment

• Continue conservative management for 6-8 weeks minimum before considering escalation 4, 5
• If symptoms improve, continue initial treatments until complete resolution 4
• If no improvement occurs, reassess for alternative diagnoses or complications before proceeding to injection or surgical consultation 5

Common Pitfalls to Avoid

• Do not perform routine acromioplasty based solely on Type 3 morphology - this represents outdated practice not supported by current evidence 1, 2
• Avoid premature corticosteroid injection without adequate trial of NSAIDs and physical therapy 1
• Do not obtain MRI or advanced imaging as initial diagnostic step - radiographs are sufficient initially 4, 2
• Ensure proper injection technique if corticosteroids are used, as improper administration can cause subcutaneous fat atrophy 7