DeQuervain’s? Cording? Or???

New Zealand Therapist Karen Law sent me an email after I posted about my client with DeQuervain’s Tenosynovitis. Like many people with lymphoedema her client has a complex presentation with other co-morbidities that must be considered both in the assessment of the condition and in the treatment plan.

Not Karen client but a good example of a large, hard axillary cord
Not Karen’s client – but a good example of a large, hard cord extending from the mastectomy scar into the axilla and the arm.

I have posed some discussion questions at the end. If you would like to reply, please use the comments function here rather than sending me an email. That way everyone can see and participate in the discussion.

From Karen

“I have a client who had a mastectomy in 2001 after grade 4a breast cancer followed by transflap surgery that collapsed. She had >17 axillary nodes removed and radiotherapy for 6 weeks then chemotherapy for 10 weeks. She had skin grafts after the transflap collapsed and now now has a lump of soft tummy tissue surrounded by hard, hard scar tissue (on her chest wall). Her entire shoulder is badly affected, the axilla and lateral breast area are rock hard. There is limited ROM in her shoulder, abduction being the worst. She can only get to a maximum of 110 degrees which is about 20 degrees more than when I first saw her.

Since 2006 she has taken many international flights to the States for work.​ ​Without a garment mostly but at times she wore a borrowed round knit sleeve that didn’t fit her. At present she is about 30kgs overweight, she also has a child, 3 years old.

I think she may have cording, but if so it is very old and like a steel rod. It extends from her scar tissue around her lateral breast area into the axilla and possible down her arm​. I think it goes down to her thumb, but as she is a rather large lady it’s not easy to palpate.

She had seen a hand therapist (prior to seeing me) who said her tendon was more enlarged than any they had ever seen. She was prescribed a splint which she used for 8 weeks and then had 2 cortisone injections (affected arm). It was after this that she first noticed her arm swelling.

She came to me about the lymphoedema so this is what I concentrated on first. But she hated the bandaging in our late summer and just wanted a garment in the end. Of course her thumb was always a problem. The bandages aggravated it, she was working and very busy, not very compliant, other aspects of life always came first.

Her thumb pain has improved somewhat now she is in a compression sleeve and she has a little more ROM.

I haven’t seen her for about 3 weeks as she is busy with work and travels to Auckland a lot.  So much to treat on this lady! I am thinking maybe the cording isn’t down to her thumb and it could be tenosynovitis as you described but her thumb hurts with extension not flexion.

I think a lot of her issues are coming form her shoulder and neck. She needs a lot of work as her shoulder is not functioning normally and her neck is painful too. Difficult to spend the time needed and it is all long standing stuff​.

I saw her again on the 15th June. She was getting symptoms of Carpal tunnel in her R Wrist. She had seen her Dr and a chiropractor and opted for a cortisone injection in this wrist. The chiropractor has told her they will only do light work so as not to disturb any metastases. This of course scared her as she doesn’t want to consider this. I am now seeing her weekly and doing myofascial & MLD work on her neck and shoulder to release some of her fascia as I feel this is blocking all her lymph flow.

Any comments as always really appreciated! Karen”

Some questions for readers.

  1. What do you think is the cause of the cording like symptoms?
  2. What treatment would you recommend?
  3. What do you think of the Myofascial/MLD combination?
  4. What protocol would you use for combining these two modalities?

De Quervain’s treatments continued…

Follow up on my client with this painful inflammation of the Abductor Pollicis Longus tendon.

Third treatment (weekly intervals) we arranged the appointment to better accommodate her baby being present which gave us more time than on the second occasion.

The client reported that after each of the previous treatments she felt significant relief for about 2 days. It is really important to ascertain this feedback as accurately as possible. In a best of all worlds scenario, the length of noticeable effect determines optimal timing of the next treatment. If I was able to treat this lovely young mum every 3 days I know our results would progress much faster. So often these decisions are driven by finances and other practicalities rather than optimal treatment regimes.

With more time I was able to treat both arms using the special techniques from the Therapy 1 course. I did use some shoulder specials but only to look for the spots that had been tender on the previous visits. They were considerably better so I was then able to move onto the more distal areas for the rest of the time. If these shoulder spots had still been tender I would have remained working on the proximal areas.

I cannot stress enough how important it is to address proximal issues first when doing lymphatic work. It’s so tempting to go straight to the problem area and spend all the time there – and sometimes difficult to get the client to understand why we are not doing that either. But my own experience and that of the many therapists that communicate their results to me is that it is always a mistake to skip over the proximal treatments. This applies just as much for the skeletal-muscular work we do as it does to lymphoedema.

As you can imagine the areas over the thumb tendon were the most painful and required the longest treatment time. Remember that our palpation is only to find the painful areas, not to keep pushing on them, so I only needed to touch these spots once to find them. Then with such and acute condition I was very careful to work pain free, checking routinely during treatment that the pressure is not reproducing any pain.

On the second treatment I had used lymph tape to support the tissue around the tendon after testing a small piece of tape on her inner elbow. The hand therapist had tried taping but the client had a bad reaction to the adhesive causing a rash over the affected area. The reddened area of skin persisted for about 2 weeks, not very conducive to reducing inflammation! If you are using a good quality lymph tape the adhesive will be hypoallergenic and can usually be tolerated by people who might react to other tapes. I use a product from the Netherlands called Cure Tape which is available in Australia from Haddenham Health.

My client reported that the previous taping had felt good, like it was supporting the thumb a little but that it hadn’t lasted very long. (Hands are washed so frequently its often hard to keep the tape on them). I spent a bit of time giving her instruction in taping both thumbs and let her put the tape on the second thumb herself. The trickiest thing about getting tape onto this condition is that in order to fully stretch the skin under the tape they need to abduct the thumb across the palm – the most painful movement for them to do!

The tape is applied along the line of the abductor tendon and muscle on the forearm and then divided either side of the tendon as it emerges from the retinaculum.

Thumb postiton  for applying posterior tape strip, wrist deviated radially, thumb flexed at both joints.
Thumb position for applying posterior tape strip, wrist deviated radially, thumb flexed at both joints.

The thumb must be flexed across the palm as much as possible for the posterior strip. Then both the wrist and the thumb are extended as much as possible for the anterior strip.

Thumb position for anterior tape strip application.
Thumb position for anterior tape strip application.

It is really important not to stretch the tape during application, so before rubbing it a little to activate the adhesive check that in the neutral postition there is good wrinkling of the tape and that you can’t see any catching of the skin underneath.

Make sure the tape is not stretched during application and that the skin is not caught in wrinkles underneath the tape.
Make sure the tape is not stretched during application and that the skin is not caught in wrinkles underneath the tape.

Since I was leaving the next day to come to Myanmar I was very focused on teaching my client to do self drainage and apply the tape herself while I am gone so I forgot to photograph the tape. These photos are me applying it to myself in my hotel room here and taking the pictures with my phone so sorry if they are not the best angles!

I wrote about this condition briefly in my last MLD newsletter and a couple of therapists replied telling me of the great successes they have had with treating DeQuervains. I’ve asked them for permission to use their cases in this blog so hopefully I will post a few more stories about this in the near future.

 

 

 

DeQuervain’s Tenosynovitis

A new client last week presented with this painful condition which is notoriously hard to treat. Onset was just after giving birth to a bouncing baby boy about three months ago. Successful recovery usually depends on completely resting the thumb – no lateral flexion, but imagine picking up a baby without using your thumb!

De Quervains 1
Images from Wesley Hand Centre

The Mayo Clinic describes DeQuervain’s as a painful condition affecting the tendons of the thumb side of the wrist. If you have it, it will probably hurt every time you turn your wrist, grasp anything or make a fist. It can be caused by any activity that relies on repetitive hand or wrist movement such as working in the garden, playing golf or racquet sports or lifting your baby…

Image from Wesley hand Centre
Image from Wesley hand Centre

My client has been going to a hand clinic for a few weeks and they fitted a thumb splint for her right hand (I’ve seen a few of these cases that have been fitted with a wrist splint which is useless!) but this meant using the left thumb more and eventually she was fitted with a splint for that hand as well. The standard medical treatment involves using the splint for 4 weeks with complete immobilisation and if that is unsuccessful surgery will often be performed.

She was getting pretty desperate and then she noticed that Lighten Up Wellness Hub were offering Lymphatic Drainage and thought it might help. A friend told her she couldn’t have MLD because she is still breast feeding and the toxins would go into the breast milk – the misinformation out there about MLD never ceases to amaze me!

Luckily she persisted and rang me to find out if it was OK and we had our first appointment last week, agreeing to have 3 weekly treatments and then assess if she feels it is helping. The first treatment I did very general drainage for the arms and shoulders and addressed shoulder tension with Shoulder Specials (Therapy 1 class). I barely did any work on her wrists as an MLD treatment plan is always to address proximal issues first.

She came back this week for her second session and reported that she had reduced pain and a lot more flexibility after the first treatment – the first relief she had felt in weeks. Unfortunately that morning she had banged her wrist on the door frame with excruciating results. Fortunately by the end of the treatment that extra pain had subsided. This second treatment I managed to do a lot of Elbow Specials and Wrist Specials on the right side.

I am confident that with a course of MLD we will be able to relieve the inflammation, allowing her enjoy handling her baby and more importantly avoid surgery.

I’ll report back after we have completed the course of treatment.