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Intense shoulder and arm pain
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Intense shoulder and arm pain - February 23, 2007 10:47:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
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I'm getting no where fast with this patient and would love any advice:
85 yo female with Dx of right shoulder pain / adhesive capsulitis of almost 3 months duration.
Insidious onset - she feels it may be related to her going off Remicade for her RA. She had breast CA with mastectomy of the opposite side in August 2006.
Pain is in the GH joint region, posterior aspect of the upper arm, elbow and into her wrist. It is not activity dependent although any AROM of the arm increases her pain. She is only able to sleep if she lays against a heating pad.
Pain is bad at night, but worse first thing in the morning.
On day one she had roughly 10 deg of shld motion, actively, in any direction. She did not tolerate ANY passive ROM or muscle testing.
She had severe tenderness to light palpation of virtually the entire shoulder girdle, pec area, triceps, biceps.
She had an MRI 3 days ago and I don't know the results.
Denies any numbness, tingling. Repeated cervial movements do not reproduce or increase symptoms.
She has tremors, presumabley due to pain, with light massage of the aforementioned areas.
I have tried MHP with e-stim for pain control, light massage (as much for evaluation as for treatment). In supine, she is unable to relax and c/o severe pain with attempts at even grade II-II mobs or passive ROM - even at the elbow.
I've seen a lot of adhesive capsulitis over the years and she is WAY more painful / apprehensive than even the worst cases I've treated.
Obviously, and hopefully, the MRI will rule out any serious pathology. If it does.... Any advice on trying to proceed with this unfortunate lady?
Thanks to all.
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Intense shoulder and arm pain - February 23, 2007 10:56:00 AM
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SJBird55
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From: Michigan
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Who referred the patient for physical therapy? What stage was her breast cancer in? When was the last time she saw her oncologist? When was the last time blood work was done in regard to her cancer numbers? The MRI might not rule out serious pathology, for some reason all the oncologists in this area and with my family members with metastasized cancer use a CT scan to track tumor changes or diagnose new tumors. Of course the PET scan is the best diagnostic tool in regard to detecting cancer cells.
If a primary care physician or even an orthopaedic surgeon ordered the MRI, when you speak to the person providing you with the diagnostic test results, don't hesitate to ask what the sensitivity or specificity of the MRI is in diagnosing metastasized cancer OR asking what the gold standard is for ruling out a metastasized tumor. In my experience there is a lot of himming and hawwing at the other end of the phone. I then politely ask if I should defer to the oncologist...
Night pain and a recent history of cancer are 2 red flags in my book. I'd be contacting her oncologist.
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Re: Intense shoulder and arm pain - February 23, 2007 11:11:00 AM
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Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
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I agree with SJ... I would defer. Any X-rays available of the shoulder/apical lung? Don't want it to be pancoast tumour mimicking something MSK. That much tenderness to palpation, with the previous Hx of Ca, the age, the night pain/pain at rest are all red flags.... Play it safe and refer as delayed Dx can severely affect prognosis.
Good luck,
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Intense shoulder and arm pain - February 23, 2007 11:39:00 AM
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nari
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From: Australia
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Pain at night and at rest is typical of a nonpathological condition called chronic pain - but I agree that along with the Hx of cancer, this should be looked into much more closely by the oncologist.
She may well have a highly sensitised nervous system which can be treated neurologically - but metastases must be ruled out.
Nari
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Re: Intense shoulder and arm pain - February 23, 2007 11:46:00 AM
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chiroortho
Posts: 655
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A nuc med bone scan would be very helpful here IMO. I'd expect a spinal met before a shoulder met but you never know with breast CA.
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Greg Priest, DC, DABCO
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Re: Intense shoulder and arm pain - February 23, 2007 11:51:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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Marc / SJ:
I agree with all you have stated and that remains my primary concern. She was referred by her rheumatologist. When she saw her internist for a check up, he ordered the MRI. The patient feels that the two docs communicated before hand as they are part of the same practice. And, I am also more familiar with CT and PET scans for CA DX as well. Perhaps they are trying to rule out MSK first. Kind of backwards if you ask me. I'd rule out the scary stuff first.
nari:
If it ends up being MSK in origin, any tips on how I can get this lady comfortable enough to treat?
Thanks everyone.
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Intense shoulder and arm pain - February 23, 2007 12:34:00 PM
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SJBird55
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From: Michigan
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Greg, my sister in-law had metastatic tumors from breast cancer at the edge of her implant (she had a bilateral mastectomy), hip, shoulder and ribs... then the spine... then the brain. She had hip pain approximately 6-8 months after the cancer diagnosis/mastectomy. She never said anything to me... until later. She had been going to PT and the PT just kept treating and treating with no results assuming it was musculoskeletal in nature/chronic pain crap. (Sorry, nari... anyone with a history of CA requires to have metastatic tumors ruled out especially with the red flags this lady has - I would never initially assume anything nonpathological.) My sister in-law lost some time secondary to lack of professionals considering the idea that cancer metastasized. The week after the reason for her pain was actually determined, she was started on a whole different concoction of chemotherapy. Granted, I'm definitely more aware of cancer and take a very strong, proactive stance and never wait if I even think cancer is a possibility. I pick up the phone... I talk to the oncologist or nurse and 100% of the time, the patient is having a CT scan and blood work done within 48 hours. I'm never afraid to make waves or question because the patient's life is at stake.
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Re: Intense shoulder and arm pain - February 23, 2007 12:39:00 PM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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Just left a message with her internist regarding all of these concerns.
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Eric Yarrington, PT, MPT, OCS
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Re: Intense shoulder and arm pain - February 23, 2007 6:59:00 PM
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Marc Bronson
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From: Toronto
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Nari,
Chronic pain, in itself, would be one of the better diagnoses, IMO, at this point. However, I don't think that technically 3 months qualifies as chronic. Besides that, clearly her nervous system is sensitized and the longer it is, the increased chance at central sensitization which is a whole new ball game.
If it is MSK-related, perhaps it would be wise to consider taping along the paths of peripheral nerves in the area --cutaneous and motor. This should theoretically provide enough continuous proprioceptive data that the brain literally begins to ignore the stimulus. Kinesiotaping would be good since it can stretch/bend along the course of the roots unlke other tapes. Decreasing her inflammatory pathways naturally --diet modification and OFA supplementation --if possible would be good complementary to/instead of any current and potential longterm NSAID use. Equally as important, IMO, is to create an environment that is welcoming and pleasant, so that your patient enjoys the clinical experience... Don't forget there's more to bioPSYCHOSOCIAL model of health care than just the bio part. The words and conversations we choose in clinic with our patient should not to be taken lightly; they can be equally as powerful as our manual work and quite complemetary in creating a desirable, meaningful clinical experience for them as we try to help them improve their quality of life.
Both are easy to do, low tech, easy to do and harmless for the patient and hey, you get to review your regional anatomy again ;) Anywho, I hope your patient gets a definite Dx that suggest NMSK issues and you can both learn from this case.
Cheers,
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Intense shoulder and arm pain - February 24, 2007 6:00:00 AM
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chiroortho
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As far as I'm concerned a patient with a relatively recent dx of breast CA, in combination with LBP is a met until proven otherwise. Straight to nuc med they go.
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Greg Priest, DC, DABCO
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Re: Intense shoulder and arm pain - February 24, 2007 6:41:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
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Greg:
No LBP, just shoulder, elbow, wrist pain. But this is unrelenting and much more irritable and severe than ANY frozen shoulder patient I've ever seen.
TENS seems to be effective in the short term. I will try Kinesiotaping as marc suggested. Fortunately, she and I have good rapport and I maintain the type of environment you speak of with all of my patients.
I'll keep you all posted. Again, thanks for the comments. Keep 'em coming.
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Intense shoulder and arm pain - February 24, 2007 8:41:00 AM
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nari
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From: Australia
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I would suggest precisely what Marc has stated - taping along the peripheral/cutaneous nerves.
SJ, I made it quite clear that metastases should be ruled out first. In the meantime, taping can do no harm and just might help while further investigations are done. Chronic pain is NOT crap-ask 70% of patients attending physiotherapy what they think. Three months is not too early to call something "chronic" - those researching consider that six weeks is not too early, if we have to have a strict dividing line between acute and chronic. Depends on the circumstances that are generating pain.
Eric - hope all goes well.
Nari
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Re: Intense shoulder and arm pain - February 24, 2007 9:11:00 AM
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SJBird55
Posts: 2438
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From: Michigan
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In my sister in-law's case, the assumption that all she had was chronic pain at her hip was crap... given her history it was ridiculous from my perspective that the little blinders would be on and the focus would be around her symptoms and the assumption she had chronic pain. It was crap. If in the States we are to be the supposed neuromusculoskeletal providers of choice, then there needs to be an aspect of our brain that immediately thinks of differential diagnosis.
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Re: Intense shoulder and arm pain - February 24, 2007 2:20:00 PM
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matotoms
Posts: 57
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From: nbn
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she has RA, she newly off her meds. She told you exactly what the problem is and everyone wants to diagnose a tumor.LOL..if she is in a flare up stage she will not be a happy camper. its a pharma problem if this is indeed the root of it. MH and mobs with basically acute/active inflammation is not going to help. it is basically palliative care until the inflammation is under control. find something she can tolerate, most likely gentle massage/MFR, relaxation techniques.......until the inflammation is under control by pharma.
RA is a biatch when its in a 'hot' stage.
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Re: Intense shoulder and arm pain - February 25, 2007 1:18:00 PM
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Karie
Posts: 107
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From: Wisconsin
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I definately agree metastatic CA needs to be ruled out but another thought to add to the mix. Since she had left breast cancer, that means the left axillary lymph nodes may be compromised and the body has redirected some or all of the lymph from this area to the right axillary region. (yes, it could direct to the right or left groin etc.) Since she has RA and recently off her meds and could be in a flare-up the inflammatory patterns normally seen could be very different with a lymphatic system functioning outside of normal. So just another thought to be aware of.
Karie
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Re: Intense shoulder and arm pain - February 25, 2007 1:27:00 PM
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mcap56
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From: New York, NY
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Agree with the previous posters, rule out cancer, particularly a pancoast tumor. Don't forget that with RA medications a withdrawl flare up is possible. But, you must also consider the possibility that the medications predispose her to cancer, particularly in light of her history.
Marc
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Re: Intense shoulder and arm pain - February 25, 2007 3:27:00 PM
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matotoms
Posts: 57
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From: nbn
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[QUOTE however I would look for other signs that would accompany the Dx, such as rheumatic nodules on the extensor surface of the arms/elbow, symmetrical edema, stiffness greater than 1-2 hours in the morning, etc.
[/QUOTE]
why? she was referred by a rheumo who obviously sees her for her RA. she has the RA dx made by a physician..
nodules, symmetrical edema, stiffness...? this lady has 10 degrees of shoulder mobility and intense pain. that is her PT issue, everything else is fluff for documentation, or for someone else to rule out.
Do the PT things we all do, if it helps keep doing it. if it doesnt, D/C. avoid anything contraindicated in the prsence of tumors like ultrasound..
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Re: Intense shoulder and arm pain - February 25, 2007 4:23:00 PM
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ginger
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From: Melbourne Victoria
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This poor old girl is a candidate for gentle Cervical mobs , AP/PA , sit her up, help her with your hands. Do the ground work with the oncologist first. Mets are entirely possible as SJ and others offer. It is possible that you are the only one that will ultimately be able to help this girl. Be wise. Don't let her slip into the too hard basket if by assering your skilled hands you can make a real difference . CM works best. Doesn't require lots of force and is soothing right from the beginning provided you know how. Do the right thing however, eliminate bony mets as cause. The rest is up to you.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Intense shoulder and arm pain - February 26, 2007 3:58:00 AM
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Shill
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From: Madison WI USA
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Let us know the MRI results when you get them. It is quite common to have little or no cuff integrity by the time one reaches 85. Lack of supporting structures can be chronically and constantly painful, as the arm is then suspended by non -contractile tissues.
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Steve Hill PT
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Re: Intense shoulder and arm pain - February 26, 2007 6:41:00 AM
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matotoms
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Joined: February 16, 2005
From: nbn
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her non contractile supporting structures have shrunk down to 1/4 their voloume. cuff integrity? she can only wish she had a use for a rotator cuff seeing as she has adhesive capsulitis with 10 degrees of motion in any plane.
her arm is not being suspended by non contractile tissue,...it is being immobilized.
this is a funny thread.
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