Massage Today
February, 2013, Vol. 13, Issue 02

Following a Road Less Traveled

Finding the cause of chronic shoulder pain where you least expect it.

By Debbie Roberts, LMT

What do you think a shoulder injury, breast augmentation, lymphatic system, mammograms and orthopedic assessments have in common? A road less traveled would be the answer.

I never dreamed when I added another tool to my tool box of Manual Lymphatic Drainage that it would lead me down a path to help thousands of women and, specifically, my very best friend. The information I am about to relay to you will not only help you be aware in your every day practice, but will hopefully bring about a global warming effect to the importance we can play in a women's life.

The Shoulder Injury

My dear friend is a personal trainer, yoga instructor, egoscue practioner, and a gyrotonics trainer. She is also one of the healthiest people I know, but she was suffering from a should injury that just would not heal. The injury was caused by slipping off of a stability ball while performing a tricep dip. Being a trainer, she immediately iced, took arnica and rested. She went to see her chiropractor and naturopath for additional help and examination. After doing three to four months of exercises for shoulder rehabilitation, she still lacked complete range of motion and there was an ongoing dull, nagging pain.

road less traveled She began thinking there must be a myofascial component to the injury, so she made an appointment to come see me. I performed ROM and manual muscle testing to the shoulder joint. I found loss of flexion by 10 degrees, loss of external ROM by 20 degrees, a positive impingement sign and some weakness to supraspinatus and infraspinatus (indication of a possible partial tear). Based on these assessments, I suggested making an appointment with an orthopedist, to hopefully get a MRI done so the rehabilitation process has a complete picture and nobody is guessing. This wasn't the route she wanted to take. She wanted to try some soft tissue work first and continue the shoulder rehabilitation exercises. I explained that in four visits or less we would know if massage therapy, combined with her doing her own physical therapy, would help. In two weeks, there was improvement happening with the range of motion, but there was still this dull pain.

Anytime I see a patient, in the back of my mind is always Hilton's Law. Hilton's Law as espoused by John Hilton in a series of medical lectures given in 1860-1862, is the observation that the study of anatomy often finds that a nerve that innervates a joint also tends to innervate the muscles that move the joint and the skin that covers the distal attachments of those muscles. Not ready for the traditional medical route, she sought more chiropractors care. He adjusted the shoulder and rib cage which made her pain increase, reduced her range of motion, and now she had a burning in the sternum. Be sure to read on because it wasn't his technique that was the problem. She was in so much pain from the adjustment that she came back to see me to try to calm down the symptoms and now there was a palpable place along her sternum that was mobile and felt like a piece of calcium. I performed again the orthopedic assessments to determine where we were from the last time I saw her, and this time in addition to loss of external range of motion, there was an audible clicking sound (possible labrum tear). I begged her to go seek out an orthopedist's opinion and possible MRI. She ignored me yet again and another couple of months went by with her still in the same place.

Breast Augmentation

Here is where the breast augmentation comes in. Another symptom appeared in her opposite breast from the shoulder problem. The right breast had begun to sag and take on an odd appearance. This finally forced her into seeking out medical care in the form of a plastic surgeon. He did an ultrasound and found that both breast implants had ruptured and had been leaking for what appeared to be a very a long time. This contributed to the underlying cause of why she could not heal. The surgeon found tremendous calcification in the chest wall underneath her breast, which had to be scrapped in order to add a new implant. If a woman's silicone gel implant ruptures, it might feel less full or flatter, and may bulge where the rupture is. This can be accompanied with pain or tenderness, swelling, numbness, burning or tingling. Her implants had been in for more than 23 years.

Lymphatic Load

He put new implants back in and sent her home to rest. The right breast did fine, but the left breast stayed swollen. After one MLD session, the breast immediately became softer. Her surgeon was impressed and told her to continue the MLD. In the meantime, she went back to work and when I saw her on the next visit, her breast was back to square one swollen and uncomfortable. Red Flag! She also didn't feel well and was experiencing flu-like symptoms and her axillary lymph nodes were swollen and tender to touch. Another Red Flag! Lymphatic overload. Another trip back to the doctor and he had to remove the implant because the underlying tissue was just not healing. She will get the implant eventually, but not until the chest wall has time to heal. I can report finally that without the implant, she is back to her usual good state of health.

What a lymph node does is filter the lymph and fight infection and in which lymphocytes, monocytes and plasma cells are formed. Most lymphatic nodes are clustered in areas such as the mouth, the neck, the lower arm, the axilla and the groin. The lymphatic network and nodes of the breast are especially crucial in the diagnosis and treatment of breast cancer.

The suspected mechanisms of breast-implant rupture are:

Damage during implantation.
Damage during (other) surgical procedures.
Chemical degration of the breast implant shell.
Trauma (blunt trauma, penetrating trauma, blast trauma).
Mechanical pressure of traditional mammographic breast examination.

What to watch out for and how you can contribute to patient education:

Do orthopedic testing.
Always keep Hilton's law in the back of your mind.
Remember, pain is only a symptom, it is not the cause.
Any pain that doesn't go away should be ruled out by a medical professional.
Make sure your history form includes asking if they have had a breast implant.
Ask how old the implant is because the older the implant the more likely a rupture.
Encourage your patients to speak up about their implants when having a mammogram. There are now special protocols in place for implants.
The FDA recommends that women with implants have an MRI every three years to help with early detection of rupture or leakage.
Keep studying!

And finally, remember Benjamin Franklin's great quote: "By failing to prepare, you are preparing to fail."

Sources:

Symptoms of a Silicone Gel Breast Implant Rupture, www.ehow.com/facts_5001446_silicone-gel-breast-implant-rupture.html#ixzz2EZi8ctlH.
Brown SL, Middleton MS, Berg WA, Soo MS, Pennello G (2000). "Prevalence of Rupture of Silicone gel Breast Implants Revealed on MR Imaging in a Population of Women in Birmingham, Alabama". American Journal of Roentgenology 175 (4): 1057-1064. PMID 11000165.
Walker PS et al. (2009). "Natrelle Saline-filled Breast Implants: a Prospective 10-year Study". Aesthetic Surgery Journal 29 (1): 19-25. doi:10.1016/j.asj.2008.10.001. PMID 19233001.
FDA Breast Implant Consumer Handbook - 2004. 2004-06-08. www.fda.gov/cdrh/breastimplants/handbook2004/localcomplications.html.

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