Populations and Risk Factors
- Equal incidence in men and women
- Typical diagnosis at ages 40-50 (delayed 7-10 years after symptom onset)
- Pituitary adenoma (> 95% of cases)
- Rare causes: ectopic GHRH from carcinoid or pancreatic tumors
- Family history of MEN-1 (multiple endocrine neoplasia type 1)
Causes and Pathophysiology
- GH-secreting pituitary adenoma produces unregulated GH, stimulating the liver to produce excess IGF-1
- Periosteal bone growth: In adults (after growth plate closure), excess GH/IGF-1 causes periosteal new bone formation — enlarged hands, feet, jaw (mandibular prognathism), brow ridge. Bone cannot grow longer but grows wider
- Soft tissue hypertrophy: Thickened skin, enlarged tongue (macroglossia), enlarged organs (cardiomegaly — enlarged heart, hepatomegaly — enlarged liver, splenomegaly — enlarged spleen)
- Cartilage proliferation: Joint space widening followed by secondary osteoarthritis as the hypertrophied cartilage degenerates
- Nerve compression: Carpal tunnel syndrome is common (soft tissue hypertrophy narrows the carpal tunnel)
- Cardiovascular: Cardiomyopathy (leading cause of death), hypertension, left ventricular hypertrophy
- Metabolic: Insulin resistance leading to diabetes mellitus (30% of patients), sleep apnea from macroglossia and soft tissue thickening
- Mass effect: Pituitary adenoma may compress the optic chiasm, causing bitemporal hemianopsia
Signs and Symptoms
- Gradual enlargement of hands (rings no longer fit), feet (shoe size increases), and facial features
- Mandibular prognathism (jutting jaw), widely spaced teeth, frontal bossing
- Thickened, oily skin. Excessive sweating (hyperhidrosis)
- Macroglossia contributing to sleep apnea and snoring
- Joint pain and stiffness (degenerative arthropathy)
- Carpal tunnel syndrome
- Headaches (from pituitary tumor mass effect)
- Visual field defects (bitemporal hemianopsia)
- Deepened voice (laryngeal cartilage growth)
- Red flags: Sudden severe headache or visual field loss suggests pituitary apoplexy (hemorrhage into the adenoma) — emergency referral
CMTO Exam Relevance
- Category A7 Systemic Conditions — Endocrine
- Acromegaly causes secondary MSK conditions (carpal tunnel, OA, myopathy) that MTs may encounter first
- Recognize the constellation: enlarged hands/feet + coarsened features + joint pain + carpal tunnel
- If GH excess occurs before growth plate closure = gigantism (in children)
- Cardiomyopathy is the leading cause of death — cardiovascular awareness essential
Massage Therapy Considerations
- Indications: Massage is indicated for managing musculoskeletal symptoms — joint pain, myalgia, carpal tunnel syndrome. Relaxation massage addresses fatigue and stress
- Cardiovascular caution: Avoid deep pressure over the chest (cardiomegaly is common). Monitor blood pressure (hypertension is common)
- Arthritic joints: Require gentle mobilization — cartilage hypertrophy makes joints vulnerable to excessive force
- Carpal tunnel protocols: Apply standard CTS treatment approaches (wrist flexor stretching, carpal tunnel decompression techniques)
- Sleep apnea positioning: Avoid fully supine if the client has obstructive sleep apnea from macroglossia. Use elevated head positioning
- Diabetic protocols: Follow diabetes-specific considerations for the 30% with insulin resistance
- Skin changes: Skin may be thickened and oily — adjust lubricant use accordingly
Key Takeaways
- Acromegaly is caused by excess GH from a pituitary adenoma, causing progressive bone and soft tissue enlargement in adults
- Enlarging hands, feet, and coarsened facial features are the hallmark — diagnosis is often delayed by years
- Cardiomyopathy is the leading cause of death. Cardiovascular monitoring is essential
- Carpal tunnel syndrome and arthropathy are common secondary conditions addressable by massage
- Visual field loss suggests optic chiasm compression — urgent referral. Sudden severe headache suggests pituitary apoplexy — emergency referral