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Os Acromiale

Patient-facing topic on os acromiale — failed fusion of an acromial ossification centre that may cause shoulder pain and contribute to subacromial impingement.

Overview

Os acromiale is a persistent synchondrosis of the acromion with a reported prevalence of 2.13% in Thai patients undergoing MRI for shoulder pathology [1]. This anatomical variant is significantly associated with rotator cuff injuries [5]. While the condition is generally not an indication for operative management in professional tennis players [7], surgical intervention is indicated for symptomatic cases that fail initial nonoperative treatment, resulting in decreased symptoms and improved clinical outcomes [2].

In the context of reverse total shoulder arthroplasty, the presence of an os acromiale does not negatively impact clinical outcomes [4, 9]. However, postoperative local tenderness at the site occurs in 1 out of 4 patients and typically resolves spontaneously over time [3]. Additionally, an ipsilateral os acromiale may serve as a relative contraindication to the use of a clavicle hook plate [12].

Anatomy & Pathophysiology

The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1]. This anatomical variant is frequently associated with rotator cuff injuries [5], where a tear may often occur due to impingement from abnormal motion at the fibrous union site [8]. While the synchondrosis of an os acromiale can be injured following trauma, such events are rare [13].

Diagnostic awareness is critical, particularly in young athletes, where appropriate clinical examination and image studies are required to confirm the diagnosis [11]. Clinicians must also recognize that a fused os acromiale, a finding not previously described, might be mistaken for a free ossicle in the clinical setting [10].

Classification

Other Considerations: The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1]. Os acromiale is associated with rotator cuff injuries [5], where a tear may often be associated with the condition, likely due to impingement from abnormal motion at the fibrous union site [8]. The synchondrosis of an os acromiale can be injured following trauma, though rarely [13]. Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis [11]. Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10]. Meta-os acromiale is the rarest subtype of os acromiale [15].

Clinical Presentation

The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1]. Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis [11]. While the synchondrosis of an os acromiale can be injured following trauma, this occurs rarely [13].

Os acromiale is associated with rotator cuff injuries [5]. A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8]. Surgical treatment is usually not indicated for os acromiale in the professional tennis player [7]. Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [12].

Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10]. Meta-os acromiale is the rarest subtype of os acromiale [15].

Investigations

Plain radiography: Axillary views are the appropriate radiographic investigation for suspected os acromiale injury [13]. Clinicians must be aware that a fused os acromiale, a presentation not previously described, may be mistaken for a free ossicle in the clinical setting [10].

MRI: The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1]. Awareness of the os acromiale in the young athlete, alongside appropriate clinical examination and image studies, is crucial to confirm diagnosis [11]. Os acromiale is associated with rotator cuff injuries [5], and a tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8].

Other Considerations: The synchondrosis of an os acromiale can be injured following trauma, though rarely [13]. Liberson reviewed 1800 shoulder girdles and identified an incidence of os acromiale of 1.4% [14]. The lesion of os acromiale is bilateral in 62% of patients according to Liberson's review [14].

Treatment

Non-Operative

Surgical intervention is generally reserved for symptomatic os acromiale that has failed initial nonoperative treatment, a prerequisite associated with decreased symptoms and improved clinical outcomes [2].

Operative

Indications: Surgery is indicated for symptomatic cases refractory to conservative care, though it is usually not indicated for the professional tennis player [7]. Specific exceptions exist for high-demand athletes, such as a competitive female fastball pitcher successfully treated with open reduction and internal fixation [21].

Surgical Approach / Technique: Management options include arthroscopic sub-total excision, arthroscopic subacromial decompression of stable fragments, and open reduction and internal fixation (ORIF) of unstable fragments [16]. For unstable fragments, ORIF utilizing cannulated screws or tension band wiring demonstrates superior outcomes in the literature [19]. A novel arthroscopic fixation technique using absorbable screws offers promising clinical, cosmetic, and radiologic results with high patient satisfaction [17]. When employing tension band constructs, special consideration must be given to the specific type used to achieve adequate compression and fixation for meta-os acromiale [15].

Other Considerations: The presence of an ipsilateral os acromiale may serve as a relative contraindication to the clavicle hook plate [12]. Conversely, the presence of an os acromiale does not appear to negatively impact clinical outcomes after reverse total shoulder arthroplasty (rTSA) [4, 9]. However, postoperative local tenderness at the os acromiale site can be expected in one out of four patients following rTSA [3]. This tenderness typically resolves spontaneously over time in the majority of patients [3].

Complications

Os Acromiale Incidence and Presentation: The prevalence of os acromiale varies by population, reported at 2.13% in Thai patients requiring MRI evaluation for shoulder problems [1] and 1.4% in Liberson's review of 1800 shoulder girdles [14]. The lesion is frequently bilateral, occurring in 62% of patients in Liberson's series [14]. Os acromiale is associated with rotator cuff injuries, where a tear may often result from impingement caused by abnormal motion at the fibrous union site [5, 8]. Additionally, an anatomical study noted that a fused os acromiale, a variant not previously described, might be mistaken for a free ossicle in the clinical setting [10].

Surgical Management and Outcomes: Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes [2]. However, surgical treatment is usually not indicated for os acromiale in professional tennis players [7]. In the context of reverse total shoulder arthroplasty (RTSA), the presence of os acromiale does not appear to have a negative impact on clinical outcomes, and RTSA remains a safe and effective treatment option in its presence [4]. Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients following RTSA but resolves spontaneously over time in the majority of patients [3].

Other Considerations: No evidence in this dataset addresses infection, aseptic loosening, instability, periprosthetic fracture, thromboembolism, patellar/extensor-mechanism complications, stiffness/arthrofibrosis, nerve palsy, wound complications, or polyethylene wear specific to os acromiale.

Recovery

Light activity (weeks): Patients may typically resume desk work, driving, and light activities of daily living once postoperative local tenderness at the os acromiale resolves spontaneously over time, a process expected in the majority of patients though present in 1 out of 4 initially [3].

Full activity (months): Surgical treatment for symptomatic os acromiale that has failed initial nonoperative management leads to decreased symptoms and improvement in clinical outcomes, facilitating a return to full functional capacity [2].

Complete recovery / outcome plateau (months): Final functional outcomes stabilize following operative management, with the presence of os acromiale not appearing to negatively impact clinical outcomes after reverse total shoulder arthroplasty (rTSA) [4, 9].

Rehabilitation protocol: While specific phasing details are not provided in the current evidence base, the procedure remains a safe and effective treatment option for patients with os acromiale undergoing rTSA [4].

Functional milestones: Clinical outcomes improve following operative intervention for symptomatic cases refractory to nonoperative care [2].

Other Considerations: Surgical treatment is usually not indicated for os acromiale in professional tennis players [7].

Key Evidence

  • [L3] In Thai patients with shoulder problems who required MRI evaluation, the prevalence of os acromiale was 2.13%. (10.1177/23259671221078806)
  • [L4] Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes. (10.1016/j.jse.2019.05.047)
  • [L3] Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients but resolves spontaneously over time in the majority of patients. (10.1177/2325967120965131)
  • [L4] The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after surgery and rTSA remains a safe and effective treatment option. (10.1016/j.xrrt.2025.01.002)
  • [L3] The study supports previous findings that os acromiale is associated with rotator cuff injuries. (10.1016/j.jseint.2025.05.015)
  • [L3] This multicenter study aimed to determine the prevalence of and factors associated with os acromiale in the Japanese population. (10.1016/j.jse.2025.01.008)
  • [L4] Surgical treatment is usually not indicated for os acromiale in the professional tennis player. (10.1177/2325967118773723)
  • [L4] A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site. (10.2106/00004623-198466080-00029)
  • [L4] The outcome of RTSA does not seem to be negatively affected by the presence of an os acromiale. (10.1016/j.jse.2017.02.012)
  • [L4] An anatomical study showed that fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting. (10.2106/00004623-200003000-00010)
  • [L4] Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis. (10.1016/j.jseint.2020.02.008)
  • [L4] Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate. (10.1186/s12891-021-04841-1)
  • [L4] This case highlights that the synchondrosis of an os acromiale can be injured following trauma, though rarely, and emphasizes the need for appropriate radiographic investigation including axillary views and a flexible surgical approach. (10.1016/j.jse.2008.02.012)
  • [L4] Meta–os acromiale is the rarest subtype of os acromiale, and special consideration must be given to the type of tension-band construct used to achieve adequate compression and fixation. (10.1177/03635465211028238)
  • [L5] Surgical options for symptomatic os acromiale include arthroscopic sub-total excision, arthroscopic subacromial decompression of stable fragments, and open reduction and internal fixation of unstable fragments. (10.5435/jaaos-d-17-00011)
  • [L4] This new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction. (10.1016/j.jse.2011.12.011)
  • [L4] Open reduction and internal fixation using cannulated screws, or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale. (10.1302/2058-5241.4.180100)
  • [L4] A symptomatic os acromiale in a competitive female fastball pitcher was treated successfully with open reduction and internal fixation. (10.1177/0363546506288305)

See Also

References

[1] Prevalence of Os Acromiale in Thai Patients With Shoulder Problems: A Magnetic Resonance Imaging Study. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221078806

[2] Os acromiale: systematic review of surgical outcomes. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.047

[3] Os Acromiale in Reverse Total Shoulder Arthroplasty: A Cohort Study. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120965131

[4] Clinical implications of reverse total shoulder arthroplasty with an os acromiale: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.01.002

[5] Prevalence and factors associated with os acromiale: a multicenter study. JSES International. 2025. DOI: 10.1016/j.jseint.2025.05.015

[6] The prevalence and associated factors of os acromiale: a multicenter study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.008

[7] Os Acromiale in Professional Tennis Players. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118773723

[8] Rotator cuff tears associated with os acromiale.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466080-00029

[9] Reverse shoulder arthroplasty in patients with os acromiale. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.02.012

[10] Os Acromiale: Frequency, Anatomy, and Clinical Implications. The Journal of Bone and Joint Surgery-American Volume*. 2000. DOI: 10.2106/00004623-200003000-00010

[11] The unstable os acromiale: a cause of pain in the young athlete. JSES International. 2020. DOI: 10.1016/j.jseint.2020.02.008

[12] Os acromiale may be a contraindication of the clavicle hook plate: case reports and literature review. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04841-1

[13] Fracture of an os acromiale with associated rupture of the coracoclavicular ligaments. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.02.012

[14] Types of os acromiale according to Liberson. 2006.

[15] Rare Symptomatic Meta–Os Acromiale in an Athlete. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211028238

[16] Symptomatic, Unstable Os Acromiale. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00011

[17] Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.12.011

[19] Os acromiale: a review of its incidence, pathophysiology, and clinical management. EFORT Open Reviews. 2019. DOI: 10.1302/2058-5241.4.180100

[21] Surgical Stabilization of Os Acromiale in a Fast-Pitch Softball Pitcher. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546506288305

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