What is the diagnosis and treatment for enthesopathy of the right shoulder acromion in a patient with a history of heavy lifting?

What is Enthesopathy of Right Shoulder Acromion

Enthesopathy of the right shoulder acromion is a pathologic condition at the insertion sites of tendons and ligaments into the acromion bone, which can be inflammatory, degenerative, metabolic, or traumatic in nature, and in the context of heavy lifting, is most likely a chronic degenerative or traumatic process requiring conservative management with physical therapy, NSAIDs, and potentially corticosteroid injections. 1

Definition and Pathophysiology

Enthesopathy refers to disease processes occurring at entheses—the sites where tendons, ligaments, and joint capsules attach to bone. 1 At the acromion, the most commonly affected enthesis is the insertion of the acromioclavicular ligament, which can develop characteristic enthesophytes (bony outgrowths) that appear as a "bearded acromion" on radiographs. 2

The condition can arise from:

• Repetitive mechanical stress from heavy lifting or overhead activities 1
• Inflammatory processes associated with seronegative spondyloarthropathies 2
• Degenerative changes from chronic overuse 1
• Metabolic disorders including crystal deposition diseases 1

Diagnosis

Clinical Presentation

• Pain localized to the acromion that worsens with overhead activities or heavy lifting 1
• Tenderness on palpation of the acromial process and surrounding soft tissues 3
• Limited range of motion particularly with forward flexion and abduction 3
• Stiffness and reduced physical function that impacts quality of life 4

Physical Examination

• Palpate the acromion and acromioclavicular joint for focal tenderness 3
• Assess active and passive range of motion in all planes, including forward flexion (0-180°) and external rotation (0-90°) 3
• Perform impingement testing to differentiate from rotator cuff pathology 3
• Evaluate for muscle atrophy in the supraspinatus and infraspinatus fossae, which suggests chronic rotator cuff involvement 3

Imaging Approach

Initial imaging should be standard radiographs including anteroposterior views in internal and external rotation, plus an axillary or scapula-Y view. 3 Radiographic features of enthesopathy include:

• Bone erosion at the enthesis 1
• Hyperostosis and enthesophyte formation 1, 2
• Fragmentation of the insertion site 1
• The characteristic "bearded acromion" appearance from acromioclavicular ligament calcification 2

If radiographs are noncontributory but clinical suspicion remains high, MRI without contrast or ultrasound are equivalent first-line advanced imaging studies. 4, 3 MRI is superior for:

• Detecting tendinosis and tendinopathy (signal abnormality without focal disruption) 4
• Identifying associated rotator cuff pathology 4
• Visualizing bone marrow edema at the enthesis 4
• Assessing subacromial bursa inflammation 4

Treatment Strategy

Conservative Management (First-Line)

Physical therapy is the cornerstone of treatment with goals of pain relief, improved physical function, and reduced disability. 4 The program should include:

• Gentle stretching and mobilization focusing on external rotation and abduction 3
• Progressive strengthening of weak shoulder girdle muscles 3
• Activity modification to avoid aggravating movements 5
• Gradual return to functional activities including controlled heavy lifting 3

Pharmacologic management:

• NSAIDs (ibuprofen) as first-line for pain and inflammation if no contraindications exist 3
• Acetaminophen for pain control in patients who cannot tolerate NSAIDs 3

Corticosteroid injections should be considered for persistent subacromial pain related to enthesopathy or associated bursa inflammation. 3 These can provide significant short-term relief and facilitate participation in physical therapy.

Important Caveats

• Enthesopathies in adults do not respond well to conventional medical therapy and are generally not preventable with standard treatments. 4 This underscores the importance of realistic expectations and focus on functional improvement rather than cure.

• Rule out underlying systemic conditions: Enthesopathy at the acromion can be associated with seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis) or metabolic disorders. 2 Consider screening for these conditions if multiple enthesopathies are present or if there are systemic symptoms.

• Medication history is critical: Isotretinoin (Accutane) use can cause enthesopathy even after short courses. 5 Always inquire about past retinoid use in patients presenting with enthesopathy.

• Distinguish from impingement syndrome: While enthesopathy can coexist with subacromial impingement, they are distinct entities. 6, 7 Impingement involves compression of rotator cuff tendons between the humeral head and acromion, whereas enthesopathy is a primary bone-tendon junction disorder.

Surgical Considerations

Surgery is rarely indicated for isolated acromial enthesopathy. However, if there is coexisting subacromial impingement with a prominent anterior acromion causing persistent symptoms despite 6+ months of conservative therapy, modified acromioplasty may be considered. 7 This involves resection of the anteriorly projecting portion of the acromion beyond the clavicle, followed by anteroinferior acromioplasty. 7

Prognosis

Most patients with traumatic or degenerative enthesopathy from heavy lifting respond to conservative management over 3-6 months. 4 Focus on maintaining shoulder mobility, strengthening the rotator cuff and scapular stabilizers, and modifying lifting techniques to prevent recurrence. 3