Pancoast tumor and its similarity to musculoskeletal conditions.

An osteopath must always be aware of medical conditions mimicking musculo-skeletal ones so as not to miss a problem requiring a referral to another discipline. Osteopaths regularly treat musculo-skeletal pain originating from the lower cervical or upper dorsal spine that radiates into the shoulder, scapula, arm and hand. This symptom picture could be the result of narrow zygo-apophyseal joints compressing the C7-C8 nerve roots. It could similarly be justified as thoracic outlet syndrome or a shoulder condition.

When a patient complains about these kind of symptoms the osteopath should consider the possibility of a Pancoast tumor. A Pancoast tumor is an extrathoracic tumor of the lung, plaque-like, located in the upper apex of either lung usually found in smokers. It is the location of the tumor and not the pathophysiological changes in the lung tissue that result in the symptom picture, and so one rarely sees respiratory symptoms with this condition. The symptoms that do present are the result of the tumor invading adjoining tissue in the confines of the thoracic inlet compressing intercostal nerves, the lower roots of the brachial plexus, the stellate ganglion and the sympathetic chain.

Patients with a Pancoast tumor will most likely complain to the osteopath about shoulder pain and pain radiating down the medial border of the scapula, not an uncommon complaint in any osteopathic clinic! The invasion of the tumor into the lower roots of the brachial plexus (C8) and upper thoracic trunk (T1, T2), may also result in pain radiating down the ulnar border of the arm from the elbow (T1) and ultimately to the ulnar surface of the forearm to the small and ring fingers of the hand (C8).

The osteopath should examine the patient's hand muscles checking for weakness and atrophy. Reflexes may show a reduced or absent triceps reflex on the affected side (C7). Since the tumor may also involve the cervical sympathetic ganglion and stellate ganglion, sympathetic involvement leads to ispilateral Horner's syndrome (hemianhydrosis, enophthalmos, ptosis and miosis) on the affected side of the face. If the tumor invades the recurrent laryngeal nerve there may be hoarsness and a bovine cough associated with the symptoms.

The patient is often in extreme pain with postural change creating little relief. The patient may tell the osteopath that supporting the elbow of the painful arm with the unaffected hand in order to take the tension off the painful area is the only position that brings relief. The patient will most likely be taking narcotics.

The overlap of symptoms between Pancoast tumor and musculo-skeletal symptoms should now be evident to the osteopath. However, unlike an ordinary neck-shoulder condition or nerve root compression the osteopath may discover on questioning that the patient also experiences malaise, fever, weight loss and fatigue emphasising the importance of a comprehensive osteopathic case history.

A Pancoast tumor is just one example of a life-threatening pathalogical condition that mimics a musculo-skeletal one. The osteopath needs to be fully aware of these conditions in order not to make the mistake of treating the condition and potentially delaying the appropriate treatment
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The shoulder complex through the eyes of an osteopath

A unique quality of being an osteopath is the approach to biomechanics and the shoulder is no exception. The function of the shoulder is to guide the arm through space and hence it requires a considerable range of movement, in fact the shoulder is the joint with the largest range of movement in the body. It achieves the range of movement in a number of ways. The main factor is the incongruity between the head of the humerus and the glenoid fossa which allows the joint a massive range of movement due to its reduced bony apposition. This does however make the joint vulnerable due to lack of support. The shoulder compensates for this with a complex network of muscles and secondary joints and most importantly a tightly bound capsule that keeps the head of the humerus in apposition with the glenoid fossa.

The secondary joints are the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic joint. The acromioclavicular joint keeps the scapula suspended away from the body and allows for changes in the position of the scapula and therefore the axis of movement of the glenohumeral joint. The scapulothoracic joint allows for a large degree of play by sweeping around the thorax and allowing the scapula a large degree of movement. The sternoclavicular joint attaches the scapula to the axial skeleton keep in the shoulder complex firmly attached to the body.

Finally the muscles involved in shoulder function can be divided in to three groups. The suspensory muscles, that is, the muscles from which the scapula and glenohumeral joint are suspended. The suspensory muscles are latisimus dorsi, trapezius, rhomdoid major and minor posteriorly and anteriorly, pectoralis major and minor. The extra-conal muscles or prime-movers of the shoulder joint are middle fibres of trapezius, deltoid, teres major, biceps and triceps whose job it is to move the shoulder in its anatomical directions. The final group is the periarticular muscles, the rotator cuff muscles, supraspinatus, infraspinatus, teres minor and subscapularis.

As osteopaths it is important that our examination and treatment incorporate the role of each of these areas to the patient's shoulder condition. Any alteration due to postural change or trauma can affect the different categories of muscle or joints listed above. As osteopaths it is our duty to view the all the structures and treat them accordingly. The osteopath needs to integrate his knowledge of biomechanics and apply them to the structure of the shoulder and of the body as a whole and treatment should be given accordingly.
For more information on osteopathy and the shoulder:
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