Working Diagnosis:
Acromial apophyseal avulsion.

Treatment:
The patient was given a sling and instructed to wear while active during the day. He was also given exercises for rotator cuff strengthening. He was instructed to not play sports for a total of 6 weeks.

Outcome:
Upon his return visit after 2 weeks of therapy, the patient stated that his symptoms improved but he still was having moderate pain.

Author's Comments:
Osteochondroses are very commonly seen in young skeletally immature patients at the traction apophyses of the knee. Clinicians are very familiar with the treatment and have good outcomes with conservative management. However, there is very limited literature regarding osteochondroses of the acromion. They are similar injuries but the mechanics and weight bearing of the shoulder and knee are completely different. One case study of an acromial apophyseal osteochrondroses reported resolution of symptoms in 10 weeks with conservative management, including limitation of activities and manipulation. More commonly, the literature mentions apophysitis of the acromion. Most case studies reported overhead motions and overuse as the common mechanism without a specific injury. It is important to identify this injury in patients because improper treatment can lead to worsening of the condition and possibly need surgery.

Editor's Comments:
Teaching points:
1. The case reports suggest that repetitive overhead movements such as baseball pitching like in this patient can cause repeated stress over the acromion, since parts of the deltoid originate from the acromion, and the deltoid repeatedly contracts during overhead throwing [2,3]
2. Specific physical findings can assist in diagnosis of acromion apophysitis:
a. Pain over acromion during and after overhead throwing and less pain/no pain at rest [3]
b. Acromion tenderness [3]
c. Mild warmth over acromion [3]
d. Pain with resisted shoulder abduction [3]
3. Characteristic radiographic findings of acromion apophysitis: bony irregularity, sclerosis, or fragmentation [2,3]

References:
1. Doyle, Monahan. Osteochondroses: a clinical review for the pediatrician. Curr Opin Pediatr. 2010 Feb;22(1):41-6.
2. Quinlan, Bogar. Acromial apophysitis in a 13-year-old adolescent boy: a common condition in an uncommon location. J Chiropr Med. 2012 Jun;11(2):104-8
3. Morisawa et al.Apophysitis of the acromion. J Shoulder Elbow Surg. 1996 Mar-Apr;5(2 Pt 1):153-6.

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