Lymphedema, Post-Mastectomy

Presentation of a patient with lymphedema post-mastectomy

Like Comment

Scenario: Patient is a 52-year-old female diagnosed with right invasive breast cancer 2 years ago with a right modified radical mastectomy and axillary node dissection. Patient deferred reconstruction due to the need for chemotherapy and radiation to right axilla and chest wall. She reports healing well from surgery and completed radiation and chemotherapy with limited side effects and only mild radiation fibrosis.

Patient reports going on a canoe trip with her family and soon after, noticing her rings and bracelets becoming tight and some edema in her knuckles and hand that subsided with elevation. In the next week, the edema became worse, did not subside and she began to notice tingling and mild numbness in her fingertips that worsened in the evening and also when she first woke up in the morning. An ultrasound was negative for a deep vein thrombosis (DVT) in right upper extremity.

Patient now presents with limitations in available AROM in elbow flexion, wrist extension and flexion and finger flexion. Full AROM measured in shoulder flexion and abduction. Grip is 10 lbs less than non-dominant left hand and lateral pinch strength also is 5 lbs below left. Patient has limited muscle endurance in right shoulder due to weight of her arm and has begun using left arm for many tasks. There is a shiny appearance to the skin over the hand and forearm and pitting is noted. Stemmer’s sign is positive as well as a 15% greater limb volume noted with arm-volume measurement than unaffected left arm.

Question: What is a Stemmer’s sign test, and what does a positive sign mean?

Potential answers:

  1. Check for the radial pulse of the arm when rotating the head to the opposite side with arms outstretched; a loss of radial pulse is a positive test and lends to the diagnosis of thoracic outlet syndrome.
  2. A test for pinch grip on the involved upper extremity using a flat object such as paper; a positive test is an inability to maintain grip when the examiner attempts to pull the object away, and lends to the diagnosis of ulnar nerve palsy.
  3. A skin pinch to the dorsum of the hand or foot; an inability to pinch the skin would be a positive finding and it lends to a diagnosis of lymphedema.
  4. A flick of the middle fingernail on the involved upper extremity by the examiner, looking for flexion and adduction of the same side thumb; a positive test would be flexion and adduction of the same side thumb, which would lend to the diagnosis of hypertonia.

Answer with rationale: A skin pinch to the dorsum of the hand or foot; an inability to pinch the skin would be a positive finding and it lends to a diagnosis of lymphedema.

Adson’s sign is a test checking for the radial pulse of the arm when rotating the head to the opposite side with arms outstretched; a loss of radial pulse is a positive test and lends to the diagnosis of thoracic outlet syndrome.

Froment’s sign is a test for pinch grip on the involved upper extremity using a flat object such as paper; a positive test is an inability to maintain grip when the examiner attempts to pull the object away, and lends to the diagnosis of ulnar nerve palsy.

Hoffman’s sign is a flick of the middle fingernail on the involved upper extremity by the examiner, looking for flexion and adduction of the same side thumb; a positive test would be flexion and adduction of the same side thumb, which would lend to the diagnosis of hypertonia.

For more information see Chapter 66 in The Color Atlas of Physical Therapy

Eric Shamus, DPT, PhD

Professor, Chair of Department of Rehabilitation Sciences, Florida Gulf Coast University