Case Report – Utilization of the Transcapular Y-view radiograph in the diagnosis of shoulder impingement syndrome
By: Jordan Kovacs DC
The patient is a pleasant, 48-year-old male with insidious onset right shoulder pain worsening over the last 3 months. He reports that the pain is worst when lifting the arm over the head and while lying on the affected side, which affects his sleep. He denies any trauma to the region and is in otherwise good health. He takes Ibuprofen to alleviate the shoulder pain with some relief. He takes no other medication or supplements.
The patient’s superficial appearance indicated no obvious distress. The patient measures 5 feet 11 inches tall and weighs 195 pounds. BMI is calculated at 27.2. His heart rate is 74 BPM, blood pressure of 124/82 mm Hg, and blood oxygen of 98%. On examination, the patient was alert and oriented to person, place and time. Examination of the eyes, ears, and throat appeared normal.
The patient’s right shoulder range of motion was limited to 90 degrees in abduction and flexion by pain. All other ranges of motion were observed within normal limits. Muscle testing of the upper extremity revealed 5/5 using the Oxford scale throughout. Deep tendon reflexes were 2+ bilaterally, and Wartenberg pinwheel testing revealed no evidence of sensation changes. There were taught and tender fibers over the C5/C6 level on the right. Cervical range of motion was within normal limits but dysrhythmic motion in flexion and extension was noted.
Orthopedic testing of the cervical spine was unremarkable. Neer test was positive on the right with anterosuperior pain. Neer test is performed by the examiner stabilizing the scapula in a static position while the examiner passively raises the arm over the head. A positive sign is pain in the anterior or anterosuperior portion of the shoulder. Hawkins-Kennedy test was positive on the right. The Hawkins-Kennedy test is performed by elevating the arm to 90 degrees while maintaining the scapular plane, then internally rotating the arm. Pain in the shoulder is considered a positive sign.
Neer and Hawkins-Kennedy are both standard tests that indicate shoulder impingement, particularly sub-acromial impingement. There is some debate in the literature of their diagnostic value. Çalış et al reports high sensitivity[i] while Hegedus et al did not report high sensitivity or specificity.[ii] Given the confusion in the literature, one might jump to advanced imaging such as MRI to further advance the diagnostic picture. This is a particularly good case for the transcapular Y view, also called the lateral scapula Y view. This is a cost effective and useful image that can add pertinent clinical information to a shoulder impingement evaluation.
The transcapular Y-view is taken along the axis of the scapular body, perpendicular to the glenoid cavity. This particular view is excellent at visualizing the otherwise hidden areas of the subacromial/subclavicular space. It visualizes the space that the supraspinatus tendon traverses on its way to its insertion on the superior facet on greater tuberosity of humerus.
This is a “textbook normal” view. Notice how the view is perpendicular to the supraspinatus tendon showing the “roof” of the shoulder joint in the acromion and clavicle.
Image 1 - This image is the patients AP view of the right shoulder.
Image 2 – This is the same image but it is marked to show widening of the distal clavicle (in YELLOW) and some arthritic changes on the acromion (in RED). We are not sure if these changes are affecting the shoulder, and specifically the supraspinatus tendon from this image alone. Transcapular Y view will better enhance the diagnostic picture.
Image 3 – The patient’s transcapular Y view. There is a large, subacromial ostephyte that extends inferiorly into the supraspinatus tendon causing extrinsic impingement.
Image 4 – This is a magnified and marked image showing the outline of the subacromial osteophyte (in RED).
Management of this patient consisted of cervical adjustment and orthopedic referral for a second opinion on the subacromial osteophyte causing the impingement. Due to the dysrhythmic motion of the cervical spine, Arthrostim adjustment while the patient was performing resisted flexion and extension of the neck was utilized.
The orthopedist opinion of the shoulder was that we would initiate a month of conservative therapeutic exercises focusing on strengthening of the rotator cuff, though he was not optimistic that this condition would respond to physical therapy exercises and would likely need surgical intervention. The patient was compliant with their care plan, but the functional goals of being able to lift the arm overhead with a 25% reduction in pain was not met. Arthroscopic subacromial decompression was performed. The patient returned to the clinic 6 weeks post-op and reported a good outcome and was performing his usual activities of daily living without pain.
Rotator cuff tendinopathy and shoulder impingement is a common condition. This will become increasing problematic as we sit in poor posture increasingly more. “Text neck” is the media buzzword, but as chiropractors we often see the postural ramifications of sitting in forward cervical flexion for too long demonstrated by anterior head posture along with rounding of the shoulders. The shoulder is the most mobile joint in the body and relies heavily on the muscular balance and coordination of the accessory muscles to maintain a healthy joint. The shoulders/scapula being out of alignment causes additional wear and tear of the articular surfaces of the shoulder as well as the rotator cuff tendons. This thickening of the tendon more easily impinges when the arm is elevated resulting in pain.
Proper diagnosis of shoulder impingement begins with a good history. The pain is described as intermittent and experienced when reaching overhead and often when lying on the shoulder at night. Examination will provoke pain while lifting the arm beyond parallel to the ground as well as special rotator cuff tests such as Neer and Hawkins-Kennedy. The Transcapular Y View may be useful to look at the shape of the acromion and the condition of the rest of the joint. If those prove unremarkable, then special imaging with an MRI may become necessary.
In cases of extrinsic impingement, such as a space occupying subacromial osteophyte, there is evidence to suggest that this is more common in the dominant versus non-dominant side[iii]. The outcomes of surgical intervention appear to be better in those patients that tried and failed conservative measures prior to surgery, such as in this case[iv].
[i] Yamaguchi, Ken, et al. "The demographic and morphological features of rotator cuff disease: a comparison of asymptomatic and symptomatic shoulders." JBJS 88.8 (2006): 1699-1704.
[ii] Faber, Elske, et al. "Treatment of impingement syndrome: a systematic review of the effects on functional limitations and return to work." Journal of occupational rehabilitation 16.1 (2006): 6-24.
[iii] Çalış, Mustafa, et al. "Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome." Annals of the rheumatic diseases 59.1 (2000): 44-47.
[iv] Hegedus, Eric J., et al. "Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests." British journal of sports medicine 42.2 (2008): 80-92.