Physiotherapy & Breast Cancer Rehabilitation for Shoulder Pain
Breast cancer is the most commonly occurring cancer among women in Singapore (1). In lieu of World Cancer Day, we’d like to showcase how physiotherapists have a part to play in helping a patient recover from breast cancer. In particular, this article will focus on the most common musculoskeletal complaint after breast cancer, shoulder pain and how physiotherapy can help with breast cancer rehab. We also cover a real case study of a patient who came to us with limited shoulder mobility after mastectomy – find out how we were able to help her.
Shoulder pain after breast cancer
A large proportion of breast cancer survivors who have had surgery, chemotherapy and radiation report shoulder pain especially when lifting their arm overhead. Shoulder pain can often be associated with decreased shoulder range of motion, decreased strength, and lymphoedema (3). Shoulder pain in breast cancer survivors is a common complaint that should not be ignored. Early detection and treatment are important in preventing long-term complications.
Why am I having shoulder pain? What should I do?
It is always important to inform your oncologist of any new pain symptoms. However, shoulder discomfort after breast surgery is very common and is unlikely to be a sign that your cancer has spread or returned. After a mastectomy, the 3 most common causes of shoulder pain are:
1) Axillary web syndrome (aka: cording)
Cording is a common side effect after breast cancer surgery caused by hardened lymph vessels. It can feel like a tight cord that can run from your armpit down to your inner arm. Sometimes, cording may even extend to the palm of your hand. This can restrict shoulder range of motion and be painful to touch.
2) Rotator cuff tendinitis
Compression of one or more of the rotator cuff tendons can cause tendinitis. Breast cancer patients are prone to get this due to muscle tightness that can occur after surgery or other treatments, especially radiation. In addition, poor posture can contribute to tendinitis. Studies have shown that alterations in women’s posture after breast surgery can lead to tendinitis of the shoulder.
3) Frozen Shoulder
This condition involves a very stiff shoulder which may or may not be painful. Reduced usage and movement of the shoulder after breast cancer treatment is a common cause. In addition, radiation can add to this stiffness.
If I have shoulder pain after breast cancer, how can physiotherapy help?
A trained physiotherapist can help you by:
- Performing a thorough assessment to determine the cause of your shoulder pain and contributing factors
- Hands on treatment to restore shoulder range of motion (ROM), which may include soft tissue massage, scar tissue massage, lymphatic massage, or joint mobilisations.
- Customising a home exercise programme for mobility and strengthening
A case study of how physiotherapy can help with shoulder pain related to breast cancer complications
Jennifer (mid 30s) was diagnosed with breast cancer in 2020. At the end of 2020, she underwent a right mastectomy with level 3 lymph node clearance with temporary reconstruction. She underwent radiation therapy for 1 year. In Apr 2022, she did an implant reconstruction surgery.
A few months after her mastectomy, she began to notice some tightness in her right shoulder but dismissed it thinking it was not a serious issue and would resolve on its own. At the time, she was busy undergoing radiation therapy and had a lot of other concerns on her mind. However, over time this stiffness did not go away but increased. One month after her implant reconstruction surgery, the stiffness in her right shoulder had gotten so bad that it was limiting her daily activities such as getting dressed and reaching overhead. While she had not been particularly active before, she now wanted to start living an active lifestyle, as advised by her oncologist that regular exercise can reduce the risk of her cancer returning.
Jennifer’s physiotherapy journey
After doing some online research, she decided it was time to visit a physiotherapist to address her shoulder mobility issues. This led her to our team at Core Concepts. On her first visit, her physiotherapist did a thorough history-taking to find out more about her medical history. On assessment, it was found that she had a reduced range of motion in her right shoulder, thick scarring over the surgical site and reduced strength in her right upper body. Her physiotherapist took time to understand her lifestyle, goals, and discussed a plan of how physiotherapy could help her work towards them.
After completing 6 months of physiotherapy, Jennifer is about to be discharged. Here is how her recovery journey went: In the first month, she underwent intensive physiotherapy twice a week to address her mobility issues. In the first phase of her rehabilitation, the goal was to help her regain mobility. Treatments focussed on scar tissue massage and joint mobilisations. She was given a home exercise programme focussed on improving mobility. The sessions were painful and not the most comfortable, but she was able to see gradual improvements in mobility over time. She was able to more easily dress herself and complete her daily activities with no problem.
Moving into the second phase of her rehab with the goal of strengthening her upper body, she completed 10 sessions with our team to help her build back strength in her right arm. Over the course of time, her physiotherapist helped her design a modified exercise regime that she was able to carry out on her own at home.
The Results of Shoulder Pain Physiotherapy After Breast Cancer
6 months into physiotherapy, her mobility is at about 90%. While her right shoulder still feels slightly stiffer than her left side, this doesn’t bother her much during her daily activities. Her strength has also improved significantly. Notably, she knows how to safely exercise without aggravating her condition. She is very grateful that she decided to visit a physiotherapist and is happy with the outcome. She only wishes that she had known about what to do for her shoulder stiffness and started physiotherapy earlier!
Seek Physiotherapy Help for Shoulder Pain
Shoulder stiffness or pain are common complaints after mastectomy, and physiotherapy can help to address mobility and strength issues. However, prevention is always better than cure. If you notice shoulder mobility restrictions, speak to your oncologist about physiotherapy treatment options.
Apart from managing shoulder pain, physiotherapists play a role in guiding cancer survivors back to full physical function. Physiotherapists also help to design safe exercise programmes that are suitable for post surgery rehab. There are many benefits of general exercise: cardiovascular health, bone health, quality of life and reducing risk of cancer recurrence. Your doctor will be able to advise you on when it is appropriate for you to begin physiotherapy.
- Breast cancer (no date) Singapore Cancer Society. Available at: https://www.singaporecancersociety.org.sg/learn-about-cancer/types-of-cancer/breast-cancer.html#support-groups (Accessed: January 31, 2023).
- Home – National Cancer Centre Singapore (no date). Available at: https://www.nccs.com.sg/ (Accessed: January 30, 2023).
- McNeely, M.L. et al. (2010) “Exercise interventions for upper-limb dysfunction due to breast cancer treatment,” Cochrane Database of Systematic Reviews [Preprint]. Available at: https://doi.org/10.1002/14651858.cd005211.pub2.