This topic contains 8 replies, has 5 voices, and was last updated by 
William Brady, DC May 24, 2019 at 8:34 am.
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Doc Nina
I have a question about what a data point means. If the location of symptoms were numb/tingly, I’d think this were a “pain arc” loading a disc pushing on a nerve root. The “warmth” makes me think this is a “TOS” type symptom occluding a blood vessel. But it’s weird to me that it looks like a “pain arc” and doesn’t get worse at top of range of motion. Any help on clarifying this would be helpful.
Shoulder
2 fingers bilat – 80%
No pain on left
Mild on right in the superior aspect of the shoulder –> supraspinatus insertion location, as well as anterior superior aspect –> infraspinatus insertion location.
Feel tingling and “warmth” radiate from shoulder down to the 3rd-5th digits in approximately 70-40 degrees of the ROM of shoulder abduction on the way DOWN specifically, not on the way up. This has been happening for years.
Seth Schultz, DC
Before we go into too much detail can you share the 7 1st order history data points? This will help guide the discussion.
Adam Holen D.C.
What’s the 7 first-order history? (age, sex, symptom: location, quality, intensity, along with palliative & provocative) This information will better help us understand this case.
There are several potential causes as it sounds like it could be rotator cuff tear or shoulder joint with the painful arc and symptoms at end range, but they could also have nerve entrapment or compression. Is the tingling and ‘warmth’ felt on both aspects of the hand or just one?
James Phipps
It’s helpful to have all the data points in order to answer a question about what a specific data point means.
7 first order history questions, relevant 2nd order.If shoulder abduction is the only motion or position that creates that symptom I would break down the shoulder abduction test more to see if it can give you more information.
-If she holds end range shoulder abduction for a minute or 2 does that cause tingling in the hand.
-Have her lay supine with her neck supported and see if the same thing happens.
-Double down on symptoms location, make sure its only in 3-5 fingers.
-Passive shoulder abduction while testing for the radial pulse will tell you if an arterial TOS is causing the symptoms..I could see how shoulder abduction would occlude the artery on the way up and then as she lowers down the blood perfusion causes the tingling/warmth ( I would expect that to cause symptoms in all of the fingers though)Thats where I would start, if that all checks out as normal, then moving to cervical exam (ID tests and max cervical compression test) and palpating nerve roots at scalenes would be my next move.
Doc Nina
35 y/o F known history of supraspinatus and infraspinatis pathology (MRI positive for supraspinatus partial thickness tear, MR and XR positive for calcific tendinitis supraspinitis and infraspinatus). Pain is located at the supraspinatis insertion, superior shoulder, and infraspinatis insertion anterior superior shoulder. Pain is a deep burning 3/10 most days, when there is a flair it is a deep burning and tearing sensation and a 9/10. Pain is provoked most by swimming laps (freestyle stroke, I am a US Master Swimmer), palliative.. don’t move my shoulder. Warmth and tingling on palmar(ventral) aspect of the 2-5th digits. If I hold end rand abduction I will feel the warmth but not tingling. Tingling only occurs with the warmth on the way back down out of abduction as described. I have ligament and joint laxity related to Acromegaly, shallow ulnar groove with ulnar nerve subluxation when performing elbow flexion/extension. Hopefully that is helpful! Thanks!
Adam Holen D.C.
Sounds like she has two separate problems. Her CC is explained via the imaging (SS & IS pathologies) and a painful arc should only increase symptoms throughout the motion (can still have different or less intense symptoms at end range). So in her case, the SS tendon is loaded the most during the arc of shoulder abduction, then other muscles aid in the movement. If you try passive supine shoulder abduction this should decrease the symptoms related to her known pathologies as the SS and IS tendons aren’t under much load. This can also cue you in on cervical involvement as active shoulder abduction will load the cervical spine, passive supine SA is unloaded other than tissue lengthening.
As for the warmth/tingling, if she still gets that with passive supine SA (and possibly limited range or moderate effort at end range) I would look to nerve entrapment in the neurovascular bundle. If not, I would consider the cervical spine and/or nerve roots at scalenes. Since there isn’t a single nerve distribution in 3-5th fingers, she may have multi-level nerve entrapments or compression via SOL – C7/C8 (or both). Which begs the question, does she ever have neck symptoms? Without any (significant) prior neck pain it’s difficult to put multi-level disc damage compressing/irritating nerves in a 35-year-old. Although an avid swimmer will have a lot of compressive forces (duration/frequency vs overall load) on both the shoulder and cervical spine.
And to take a stab at the symptoms during the “down” phase of shoulder abduction, my hypothesis would be that it’s more compressive forces on the neck/shoulder to decelerate the motion, especially with known joint laxity. Hopefully, this helps and can give you some guidance as for what to look for next. Others may have more insight, this is just where I would start.
William Brady, DC
Great case with great answers! Following the ID system and helping others is awesome. Adam and JJ covered the majority of the case. My additional thoughts:
Acromegaly causes increased bone growth. Likely the result of the ulnar subluxation with elbow flexion. As for the hand symptoms in fingers 2-5 palmar aspect- that makes me think vascular, the palmar arch from the ulnar artery (also it’s not a neuro distribution). The warmth makes me think hyperemia- this can be caused by rapid heart beat which can be common in cardiomyopathy related to acromegaly.
Given all of that, palpation for adhesion will be huge in this case. If there is some and you can treat it you will be providing an important service, but keep in mind it will not be all of the problem. There is a lot going on here.
Thanks for posting Nina and welcome to the ID community.
Doc Nina
Thank you for your input Dr. Brady! I appreciate you joining the conversation!
While it is true that Acromegaly causes bone overgrowth in a sense, its generally cortical expansion, thickening as opposed to length (unless patient has open growth plates). Acromegaly will also causes a predisposition to calcium deposition diseases like DISH, CPPD and HADD, and is also associated with a higher incidence of Gout.
One frequently overlooked issue in Acromegalic patients is that the soft tissues and muscles including tendons and ligaments hypertrophy, leading to weakness and dysfunction that leads to laxity. This weakness and laxity often affects the joint capsules leading to excessive motion and dysfunction.
In regard to the ulnar nerve at the cubital tunnel it passes beneath the arcuate ligament of Osbourne which in Acromegaly is subjected to the hypertrophy, weakness and laxity. This pathology should also be considered as the cause of ulnar nerve subluxation in these cases.
Regarding cardiomyopathy and hyperemia, that is a great thought, and in someone with Acromegaly it should make the list of potential pathologies. In my case specifically this is unlikely, only because my resting heart rate rarely goes above 60, and its a chore to get it over 120 doing cardio. My EKGs and Echos are perfect (YAY!) This is UNCOMMON in someone with Acromegaly for sure, and I owe the great condition of my heart to years of athletic conditioning as both a gymnast, and an endurance swimmer.
Going back to hypertrophy and ligament laxity, could it be that along with adhesion there is potentially also compression of the neurovascular bundle related to enlarged tissue that is not being biomechanically maintained?
Again thanks for taking the time to join the conversation!
William Brady, DC
There are a lot of details here that we could unpack, but… The forum is great for exchanging ideas and directing the thought process, while not ideal for being thorough. Many of the details you are looking for are towards the mastery level, and Acromegaly is very rare for presentation to a chiro. I would have you default to test, palpate, treat and watch the response to treatment.
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