A 52-year-old woman one entered my office with chief complaints of right shoulder, neck and lower back pain. She stated that the shoulder pain had been present for six months, while the neck and back pain had only been present for the previous few weeks.The patient initially had sought care from her family medical doctor for the shoulder pain, just after returning from a European vacation. The medical doctor diagnosed her condition as a mild strain due to carrying a heavy purse during the two-week trip. Rest and pain relievers were prescribed.
The patient returned to her medical doctor three months following the initial visit after the shoulder pain failed to resolve. The doctor's updated diagnosis was arthritis. It had "set in" after the strain. Additional medications were prescribed for pain and inflammation.
Finally, after six months without relief, the patient reluctantly presented for chiropractic care at the persistence of her co-workers. The patient considered the second diagnosis of arthritis given by her medical doctor to be accurate, and assumed the newer neck and back pain were the result of the arthritis spreading.
The patient stated that the pain relievers and anti-inflammatory medications helped some, but that the pain had persisted and spread. She was now desperate. Otherwise, she would not have sought chiropractic care.
When asked to describe the timing of her pain, the patient said she felt her work duties distracted her from the pain during the day. This was because the pain was much worse at night. In fact, she said it woke her frequently during the night. The resulting lack of sleep added to her desperation.
Cancer Causing Night Pain
The report of night pain struck a chord with me. I immediately referred back to the initial paperwork the patient had completed upon entering the office. Under past history, the patient listed a history of breast cancer with removal of the right breast seven years earlier.
I immediately asked her about post-surgical follow-up care. "Did you have chemo or radiation treatment? Did you have follow-up scans; MRI, CT and/or bone?" She told me she did not have chemo or radiation treatments. Her surgeon felt he had removed the entire tumor and that further treatment was not necessary. She did have follow-up scans at six months, one year and two years post-surgery. All follow-up testing was negative for the return or spread of the cancer.
The combination of night pain and previous cancer bothered me, so I questioned the patient further. Specifically, I wanted to know the answers to two questions:
- "Does the pain wake you when you move or does it wake you when you are lying perfectly still?"
- "Does the pain occur only when you lie on the painful shoulder or can it occur when lying on either shoulder?"
Her responses revealed that the pain woke her with or without movement and was present in her right shoulder regardless of the side she was lying on.
Physical examination of the shoulders, neck and lower back was unremarkable. Findings that were remarkable were minimal in comparison to the degree of pain reported. Cervical and lumbar radiographs were also unremarkable. However, radiographs of the right shoulder revealed lytic lesions in the humeral head, with gaps in the bony cortex at two locations. Multiple surgical staples from the breast surgery were also seen throughout the axillary area on the shoulder film.
The radiographic results prompted the ordering of a bone scan. The scan showed metastatic lesions in the right humerus, scapula and ribs. There were also lesions in the cervical and lumbar spine. The lesions in the shoulder were more advanced and had resulted in enough metabolic activity and bone destruction for them to appear on both the bone scan and the less-sensitive plain film. The lesions in the cervical and lumbar regions were less advanced and had caused only enough bone metabolic activity and bone destruction to be detected on the more-sensitive bone scan.
I contacted the patient's medical doctor to provide the imaging results and to make arrangements for the patient to see an oncologist. The patient died 15 months after the final diagnosis of metastatic breast cancer.
The combination of night pain and previous cancer was the key to arriving at an accurate diagnosis in this case. Night pain is often a symptom of ominous spinal conditions1-2 and cancer often recurs. Breast cancer can return more than five years after treatment,3 a point in time when cancer survivors are usually considered to be completely cured.
Other Causes of Night Pain
Night pain is also common in mechanical musculoskeletal conditions – especially with movement during sleep or when the patient's sleeping position places pressure on the affected joint(s).
Night pain not associated with movement or weight-bearing is different. Pain experienced while lying perfectly still in a comfortable position is frequently associated with disease processes.1-2 Diseases that are continuously active, such as neoplasms and infections, must always be considered when a patient reports night pain.
Thankfully, more benign causes of night pain are seen with higher frequencies in chiropractic practice. As stated, night pain from moving sore, painful musculoskeletal structures or bearing weight on them during sleep is common. The shoulders and hips are frequently affected by weight-bearing while a patient is sleeping in a side-lying position.
Radicular conditions can cause night pain. Radicular pain originating in the cervical spine often results in a patient being unable to sleep unless the affected arm is resting above the head. This is the mechanism of Bakody's sign for diagnosis of cervical radiculopathy.4 Radicular pain from the lumbosacral region also results in loss of sleep. In these cases, the patient can find relief by keeping the knees bent while lying on the back or side.
Pain from hip, knee and ankle injuries is routine with movement of the lower extremity during sleep. A specific irritation here results from bedding that is tucked in tightly at the foot of the bed. The foot can become wedged between the bedding and the mattress, preventing the lower extremity from turning with the rest of the body when the patient rolls to a different position. The torque on the lower extremity created in this situation can be painful and damaging.
Last, but not least in the discussion of night pain is mechanical spine pain agitated by poor sleeping postures, bad pillows and deficient mattresses.
Obviously there are several reasons chiropractic patients can present with night pain. Some are the result of the conditions we treat routinely and others are the result of conditions outside our scope of practice. The key is to always be alert to the report of night pain and be diligent in pursuing the cause of the pain.
- Reilly BM. Practical Strategies in Outpatient Medicine, 2nd Edition. Philadelphia: W. B Saunders Company, 1991.
- Greenhalgh S, Selfe J. Red Flags, A Guide to Identifying Serious Pathology of the Spine. Philadelphia: Churchill Livingstone, 2006.
- Yochum T, Rowe L. Essentials of Skeletal Radiology, 3rd Edition. Baltimore: Lippincott, Williams and Wilkins, 2005.
- Miller KJ. Orthopedic and Neurological Examination in a Flash. Philadelphia: Lippincott, Williams and Wilkins/Wolters Kluwer, 2008.
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