Shoulder Pain after Breast Cancer treatment

Shoulder problems are very common after treatments for breast cancer; such problems are normally not a sign that your cancer has returned or spread. Up to 68% of patients with breast cancer experience shoulder pain and/or restricted motion of the shoulder during or after treatment.

According to the present literature, shoulder pain after breast cancer surgery is a fairly common problem:

  • 85% of women have mild or moderate shoulder problems six months after surgery.
  • 50% of women reported moderate to severe shoulder problems six months after surgery
  • Lymphedema, or swelling of the lymph nodes, was not the best indicator of shoulder problems, as 44% of women who did not have lymphedema still had shoulder problems six months after surgery.

Lets take a look at the reasons for the shoulder pain. Currently there are 3 main modes of treatment :

Surgery : There are several types of surgery, which range from removing just a lump to the entire breast. During any of these procedures, the tissues and nerves are manipulated and can be damaged. As healing progresses, you can develop visible scar tissue. Internally, there may be changes in connective tissue that can feel like a tightness when you move. It may also feel like a thickening or cordlike structure in the armpit, upper arm, or upper torso. All of these are normal and can contribute to shoulder pain.

Radiation: Many people will have radiation therapy within weeks of surgery. Radiation will affect both cancer cells and normal cells.Your chest muscles may be repaired with tissue that’s more fibrous, and therefore less able to expand and contract like normal muscle tissue.This type of interior scar tissue is called radiation-induced fibrosis and can lead to frozen shoulder if not treated appropriately.

Chemotherapy : Chemotherapy like radiation damages both the cancer and normal cells.Oral antihormone drugs, such as aromatase inhibitors, can cause joint pain and reduce bone density. This can put you at risk for developing osteoporosis and fractures.Other chemotherapy agents, especially taxanes, can damage peripheral nerves in your hands and feet.

The above mentioned reasons can lead to either of the following conditions:

Rotator cuff tendinitis : The rotator cuff is a group of muscles and tendons that connects your shoulder blade to your arm bone. It keeps the head of your arm bone in the socket of your shoulder. Because it is a network of muscle and tendons, it is closely connected to the tissues of the breast, including the lymph nodes. Rotator cuff tendinitis can usually be diagnosed on the basis of clinical symptoms such as shoulder pain, limited range of motion, shoulder weakness, and reduced arm function. Associated pain may be anterior or anterolateral, possibly with radiation to the elbow. Pain may occur when patients reach overhead or behind or sleep on the affected side. Most patients respond well to conservative treatments such as physical therapy and analgesics. Physical therapy, focuses on improving the shoulder’s range of motion, strengthening shoulder muscles, and restoring anatomic alignment. Physical therapists may use such techniques as myofascial release, transcutaneous electrical nerve stimulation and muscle strengthening exercises. Lymphedema should be managed as well—lymphedema in the chest wall can limit shoulder motion. NSAIDs may be helpful in reducing mild to moderate pain during therapy. For patients with severe pain, subacromial corticosteroid injection may be necessary.

Frozen shoulder ( Adhesive capsulitis ): Breast cancer survivors frequently have restricted range of motion in the arm on the side of the surgery. The loss of both active and passive glenohumeral motion is known as adhesive capsulitis, or “frozen shoulder.” In breast cancer survivors, adhesive capsulitis often results from a cycle of morbidity in which the patient’s response to the adverse effects of various treatments exacerbates those effects. Postsurgical pain from scarring and damage to skin, muscle, fascia, and soft tissues is compounded by radiation fibrosis, as well as by fear of complications and pain, which causes patients to limit shoulder movement, further reducing function and increasing inflammation. Treatment of adhesive capsulitis focuses on physical therapy geared toward improving soft tissue dysfunction. Physical therapy strategies are similar to those used for rotator cuff tendinitis, NSAIDs may benefit those who have pain during therapy. Corticosteroid injections are helpful in improving symptoms.

Axillary web syndrome (AWS): Also referred to as cording, it is characterized by palpable, cordlike subcutaneous tissue extending from the axilla into the arm. It is visible and painful when the shoulder is in abduction. AWS occurs on the side of the axillary surgery, and generally develops within eight weeks of surgery, but may emerge more than three months later. The precise etiology, typical course, and most effective treatment for AWS have not yet been defined, but lymphovenous damage, hypercoagulation, superficial venous stasis, lymphatic stasis, and tissue injury secondary to lymphatic disruption during surgery are believed to contribute to its development. Although AWS almost always resolves spontaneously without treatment, treatment is important to prevent reduced shoulder flexion and myofascial pain syndrome. It is possible that early postoperative movement restriction, functional deficits, pain, and edema may be associated with development of AWS.

What can you do about it ?

It is not likely, but pain can be a potential sign of cancer spreading. Because cancer can form on the head of the humerus, it can interfere with movement and make it painful. Therefore, your first course of action should be to see your doctor to rule out any spreading of cancerous tumors. However the chances of it being cancer is very low.
Once your doctor confirms that you are not dealing with any cancerous issues in your rotator cuff area, you can concentrate on healing.

After surgery, it is important to begin moving as soon as you can. Under a doctor’s guidance, you should be able to take anti-inflammatories to reduce inflammation and pain. Once you are pain-free, you can start some gentle stretching and range of motion exercises. Start working on muscle strengthening, stretching, and postural training. Also learn more about ergonomics and how to pick things up.