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