What is the next best step in managing a deep axillary ache in a patient with Carney Complex, exacerbated by stretching or weight-bearing activities?

Management of Deep Axillary Ache in a Patient with Carney Complex

The next best step in management for this 38-year-old female with Carney Complex presenting with deep axillary ache during stretching or weight-bearing adduction is to obtain an MRI of the axillary area without IV contrast to evaluate for potential thoracic outlet syndrome or musculoskeletal abnormalities.

Understanding the Clinical Presentation

• The patient presents with deep axillary ache that occurs only with specific movements (stretching or weight-bearing adduction), suggesting a positional or mechanical cause 1
• The presence of Carney Complex is a significant factor that must be considered in the diagnostic approach 2, 3
• The localized nature of the pain and its relationship to specific movements points toward a musculoskeletal or neurovascular etiology rather than a systemic manifestation of Carney Complex 1

Diagnostic Considerations for Axillary Pain in Carney Complex

Relevant Carney Complex Considerations

• Carney Complex is a rare autosomal dominant multiple neoplasia syndrome characterized by:

  • Cardiac myxomas (a leading cause of mortality) 3, 4
  • Primary pigmented nodular adrenocortical disease 5, 3
  • Pituitary tumors (often causing growth hormone excess) 2, 4
  • Psammomatous melanotic schwannomas (which can affect nerve sheaths) 2, 3

• Nerve sheath tumors associated with Carney Complex can present with pain and radiculopathy, with 28% affecting spinal nerve sheaths 2

Differential Diagnosis for Axillary Pain

• Thoracic outlet syndrome (TOS) - compression of neurovascular structures 1
• Musculoskeletal issues - tendinopathy, adhesive capsulitis, rotator cuff injury 1
• Axillary web syndrome ("cording") - common after breast surgery but can occur spontaneously 1
• Nerve sheath tumor - particularly relevant given the Carney Complex diagnosis 2

Recommended Diagnostic Approach

Imaging Selection

• MRI without IV contrast is the preferred initial imaging study because:

  • It provides excellent visualization of soft tissues, brachial plexus, and potential nerve compression 1
  • It can identify both musculoskeletal and neurovascular causes of axillary pain 1
  • It has high sensitivity for detecting nerve sheath tumors that may be associated with Carney Complex 2
  • It can evaluate for thoracic outlet syndrome, which commonly presents with positional symptoms 1

• Plain radiographs would be insufficient as they cannot adequately visualize soft tissue structures or neural elements 1

• CT would provide less detailed evaluation of soft tissues and neural structures compared to MRI 1

• Ultrasound has limited utility in this case as it cannot fully evaluate deeper structures in the axilla 1

Management Considerations After Diagnosis

If Musculoskeletal Cause Identified:

• Physical therapy focusing on stretching and strengthening exercises 1
• Activity modification to avoid pain-provoking movements temporarily 1
• Analgesics such as acetaminophen or NSAIDs for pain relief 1, 6
• Consider acupuncture for pain management 1

If Neurogenic Thoracic Outlet Syndrome Identified:

• Physical therapy with specific exercises to improve posture and strengthen supporting muscles 1
• Activity modification to avoid positions that compress neurovascular structures 1
• Surgical decompression may be considered if conservative measures fail 1

If Nerve Sheath Tumor Identified:

• Surgical consultation would be warranted given the association with Carney Complex 2
• These tumors may be malignant in 10% of cases and require appropriate management 2

Important Considerations and Pitfalls

• Patients with Carney Complex require multidisciplinary care and regular follow-up for various manifestations of their condition 3
• Do not attribute all symptoms to Carney Complex without appropriate evaluation, as common musculoskeletal conditions can coexist 1
• Avoid prolonged use of NSAIDs without monitoring, especially in patients with complex medical conditions 6
• Consider that positional symptoms may indicate a dynamic compression that requires evaluation in both neutral and provocative positions 1