Top 3 Musculoskeletal Side Effects of Breast Cancer Treatment
By: Lindsay Davey, MScPT, MSc, CDTAugust 1, 2017
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT
Complaints of upper body pain and dysfunction are common in patients who have had breast cancer treatment. Pain that occurs in the early period following surgery, radiation or chemotherapy is to be expected; but many women are surprised to learn that longer-term disorders can also arise as a side effect of breast cancer treatment, and these disorders are more common than you might think.
As many as 7 in 8 women treated for breast cancer experience one or more upper body pain or dysfunction disorders because of their treatment (ref 1).
In fact, it’s not surprising that so many women experience long-term complications from breast cancer treatment. As impressive as current oncological treatment tools are, surgery, radiation and chemotherapy create significant collateral damage to surrounding cells and tissues. The more extensive the tumour or stage of disease, the more extensive the treatment, and the greater the risk of collateral damage. This collateral damage is responsible for the varied and numerous side effects of breast cancer treatment.
The long-term side effects of breast cancer treatment can be grouped into three broad categories: (1) musculoskeletal disorders, (2) nerve disorders, and (3) edema (swelling) disorders. I’ll be covering the most common musculoskeletal disorders below.
For more side effects of breast cancer treatment, please see: Top 4 Nerve Disorder Side Effects of Breast Cancer Treatment
Musculoskeletal disorders include any pain or dysfunction related to muscles, joints or the skeletal system. Broadly speaking, breast cancer treatment can cause musculoskeletal disorders by damaging normal cells and tissues which in turn can disrupt the complex interplay between muscles, tendons, nerves, fascia (connective tissue), and joints. The result can be acute or chronic pain, weakness, reduced range of motion, and altered movement patterns.
Here I discuss the top 3 musculoskeletal side effects of breast cancer treatment including their cause, symptoms, and treatment.
Rotator Cuff Tendonitis
The rotator cuff is a collection of four muscles and their associated tendons that act to keep the shoulder joint stabile and functioning normally. In other words, they act together to keep the head of the ‘humerus’ (upper arm bone) positioned inside the joint grove of the ‘scapula’ (the shoulder blade) as the arm moves. When these muscles and tendons fail to work together properly due to injury, weakness, or altered motor patterning, the result can be pain, inflammation, increased risk of tendon degeneration/tearing, decreased range of motion, and reduced shoulder function.
Rotator cuff tendonitis is very common in the general population, a result of the high demands we place on this impressively mobile and complex joint. It is also one of the most common musculoskeletal side effects of breast cancer treatment.
Description and Causes
Rotator cuff tendonitis is an inflammation of one or more rotator cuff tendons in the shoulder. This inflammation causes pain with movement, muscle weakness, and can contribute to the risk of tearing a tendon. Tendon tears further intensify pain and diminish shoulder function.
The predominance of rotator cuff tendonitis in breast cancer patients likely arises due to multiple factors, but rubbing or impingement of the rotator cuff tendons between the shoulder joint’s bony surfaces (the head of the humerus and the shoulder blade’s ‘acromion’) is usually part of the underlying cause.
Why would breast cancer treatment cause shoulder tendonitis?
- Scarring. Breast cancer treatment typically involves surgery (either lumpectomy or mastectomy), which creates scar tissue in the breast or on the chest itself. An additional incision closer to the armpit is commonly necessary to retrieve lymph nodes, which introduces further scarring. Both surgical scar sites, and the necessary restrictions placed on overhead range of motion in the early post-operative phase, can contribute to altered mechanics at the shoulder joint. This, in turn, can cause the rotator cuff tendons to become impinged while performing certain arm movements. It can also mean that the muscles of the rotator cuff have to work harder to overcome this chest/armpit tightness, which further contributes to strain and inflammation.
- Radiation. Radiation also causes tissue changes within the chest/breast, armpit, neck, and back areas, depending on the treatment field. These tissue changes can include not only a burning to the skin, but also a tightening of muscles and tissues underneath. These changes create further restrictive forces on the shoulder joint’s normal movement pattern and range, causing further irritation and inflammation of the rotator cuff tendons.
- Posture. Another often overlooked contributing factor is altered upper body posture following cancer treatment. Postural changes are extremely common in patients after treatment and these often promote faulty biomechanics at the shoulder joint, leading to tendonitis.
- Weakness. Altered use or disuse of the arm (at first, due to post-operative restrictions, but later, due to pain, tightness, fear, or out of habit) can lead to further weakness of the rotator cuff muscles, putting patients at even higher risk of tendonitis. Weakness of the muscles of the rotator cuff, shoulder blade, or other stabilizing muscles will decrease the dynamic stability of the shoulder joint. This can decrease how well the humerus is held in an optimal position in the joint during movement. Even a subtle shift in the position of the humerus bone can cause impingement of the rotator cuff, which, if this becomes a persisting pattern, can lead to tendonitis.
Symptoms
The primary symptom of rotator cuff tendinitis is pain in the shoulder with movement. Actions such as reaching behind the back, reaching overhead, or picking up something with an outstretched arm, are common aggravating movements.
Diagnosis
The diagnosis of rotator cuff tendonitis is typically made through a physical assessment of shoulder movement pattern, strength testing of the specific muscles involved, impingement tests, an assessment of postural contributing factors, and an examination of any tenderness on palpation of the tendons or other actions that are associated with pain. Ultrasound imaging or Magnetic Resonance Imaging (MRI) are usually not necessary, but could offer definitive diagnosis. The presence of additional shoulder issues such as adhesive capsulitis (‘frozen shoulder’) can make the diagnosis of tendonitis more difficult.
Treatment and Prevention
The standard treatment for rotator cuff tendonitis is physiotherapy and over-the-counter non-steroidal anti-inflammatory drugs. Physiotherapy techniques including exercise therapy can be used to strengthen weak muscles at the shoulder, mid and upper back, and decrease inflammation. Improved biomechanics and motor patterning is essential to alleviate the tendonitis, and releasing the tight and/or scarred tissue (be it from surgery or radiation or both) is also often necessary. In severe cases that do not respond well to conservative treatment, steroid injections may be beneficial to provide further anti-inflammatory pain relief.
How to prevent impingement of the rotator cuff tendons
- Regularly perform rotator cuff strengthening exercises. In the photos below I demonstrate a particularly safe and effective rotator cuff exercise that does not require special equipment or detailed instruction. There are a variety of additional exercises that can be used to improve the function of the rotator cuff, although many are difficult to perform correctly without additional equipment and close instruction provided by a physiotherapist or other knowledgeable professional.
- Avoid or modify physical activity that can predispose you to impingement. If you regularly lift weights, there are certain exercises that you should either modify or avoid entirely. You can learn more here: ‘Weight Training and Shoulder Pain: Subacromial Impingement Syndrome’.
- Seek out the help of a physiotherapist or massage therapist who is familiar with breast cancer treatment-related tissue changes, to address any persisting tightness across the chest/armpit from surgery and/or radiation. At the same time, a physiotherapist can also provide you with a shoulder strengthening routine that you can perform at home.
A simple yet effective rotator cuff exercise to help maintain rotator cuff strength following breast cancer treatment. Hold a light weight in the hand, and lie on your side. The starting position is with your elbow resting against you at a 90 degree bend, holding a light weight in your hand. Keeping your wrist flat, rotate the arm so that the hand lifts toward the ceiling, keeping your elbow against your side. A good starting point is 3 sets of 8 – 10 repetitions, performed 3 – 4 times/week. DO NOT do this exercise if an appropriate weight cannot be found to perform it pain-free.
Adhesive Capsulitis (‘Frozen Shoulder’)
Adhesive Capsulitis, commonly called ‘frozen shoulder’, is another of the frequent side effects of breast cancer treatment. It is also relatively common in the general population where it can affect as many as 3%-5% of people, and 10%-20% of individuals with diabetes (ref 2).
Description and Causes
A frozen shoulder is both painful and restricts the shoulder’s range of motion. Although the underlying pathogenesis is unclear, it often occurs following a shoulder injury or other traumatic event. Shoulder inactivity, even if only temporary such as following an injury, is a strong contributing factor. Inactivity or disuse appears to promote inflammation of the connective tissue called the ‘synovial membrane’ which lines the shoulder joint. If persistent, this inflammation will ultimately result in fibrosis (scarring). This fibrosis thickens the connective tissue around the shoulder joint, and along with inflammation, tightens the joint capsule and restricts mobility.
Why would breast cancer treatment predispose women to frozen shoulder syndrome?
Because inactivity predisposes patients to developing frozen shoulder, and inactivity is common in breast cancer patients:
- Patients are recommended to limit use of the arm following surgery. After breast cancer surgery patients are typically given the instruction to limit both the use and range of motion of the arm on the same side, for a period of days/weeks to allow the surgical site to heal.
- Patient arm movement is often limited by pain or fear of pain. Pain from surgery (breast, lymph node or reconstruction), radiation, rotator cuff tendonitis, nerve damage, cording, or other side effects of breast cancer treatment including lymphedema can lead to shoulder underuse, either consciously or subconsciously.
Symptoms
The symptoms of a frozen shoulder change as the condition progresses and then resolves. They can be broken down in to three phases:
Symptom onset (‘freezing’)
The initial stage of frozen shoulder onset is dominated by inflammation, and so it can be very painful to move. Pain tends to limit shoulder use, and this in turn can encourage further progression of the condition.
Classic frozen shoulder (‘frozen’)
After what a period of weeks or months of persistent inflammation, the condition progresses to a classic ‘frozen’ shoulder presentation. Sufficient fibrosis and inflammation has now accumulated to significantly restrict both active range of motion (how much your arm can move on its own) and passive range of motion (how much I could move your arm when you are relaxed). Pain at rest tends to be less than during the initial stage of onset, however pain can still be significant when the arm reaches its limits of range of motion.
Resolution (‘thawing’)
As a frozen shoulder begins to heal, pain typically reduces further and range of motion begins to improve.
Diagnosis
Diagnosis is usually made based on a description of symptoms in combination with a physical assessment of the pattern of loss of range of motion at the shoulder joint.
Treatment and Prevention
Frozen shoulders arising as a side effect of breast cancer are usually self-limited, which means that they will normally resolve on their own. Unfortunately, this process can take upwards of 1-3 years, and without therapy including specific strengthening exercises, function and/or range of motion of the shoulder may not be fully restored. As with other musculoskeletal side effects of breast cancer treatment, conservative treatment options are available, and have been shown to offer benefit.
Patients can benefit from conservative treatments that can help speed-up and maximize recovery.
Conservative “first-line” treatments for frozen shoulder are nearly always recommended. These include: physiotherapy, anti-inflammatory medication, and occasionally, injections (steroid or hyaluronate). Unfortunately, there are not yet enough high-quality clinical studies to help us understand the relative benefits of these treatments either alone or in combination. Physiotherapy stretching and strengthening exercises may help to prevent further loss of range of motion, and when the shoulder is ready, help increase the range of motion.
A smaller number of patients may require more aggressive “second-line” treatment including: blocking the suprascapular nerve with an injection of anesthesia and steriod which can reduce pain signals and when added to physiotherapy may help improve functional recovery (ref 3); arthrographic distension (injecting fluid to break up fibrosis) may provide short-term benefits (ref 4), and manually stretching the shoulder joint under general anaesthetic may also be effective (ref 4). A small number of patients who develop severe cases may be candidates for surgical release (arthroscopic capsular release).
Breast cancer patients with frozen shoulder resulting from surgery, and who have no other underlying shoulder conditions, typically respond well to conservative treatment and recover completely. Whereas patients with other side effects of breast cancer treatment that underlie the frozen shoulder, such as nerve impingement/irritation or rotator cuff tendinopathy, may require more aggressive avenues of treatment (ref 5).
How to prevent frozen shoulder
- Maintain good shoulder health by following the prescribed exercises following your breast cancer surgery. This can help maintain basic muscle strength and shoulder/shoulder blade range of motion. Incorporating exercise into your recovery can help reduce the risk of this and other side effects of breast cancer treatment.
- Be careful not to be overly protective of your shoulder during and following breast cancer treatment. Resuming normal activities (and exercise) as soon as possible is beneficial. However, pain should be your guide. Activities that cause pain at your shoulder should generally be avoided to prevent inflammation, further pain, and further activity avoidance.
- If you do experience pain in your shoulder, seek out professional advice early. Your physiotherapist can assess your shoulder joint, rotator cuff, and muscle patterning/function, and provide you with a specific list of do’s and don’ts, exercises, and hands-on manual therapy as needed. This can help ease your recovery from the breast cancer treatment, and potentially prevent progression to more significant shoulder complications.
Trapezius Myalgia Syndrome
Trapezius myalgia syndrome, often experienced as neck-shoulder tension, is another of the commonly observed side effects of breast cancer treatment.
Description and Causes
Trapezius myalgia (myalgia meaning muscle pain) refers to dysfunction and pain arising in the large trapezius muscle that joins the back of the head/neck, to the shoulder blade and spine. Its function is to stabilize the shoulder blade and rotate it upward as the arm elevates. There are several risk factors shown to contribute to the development of trapezius myalgia, including but not limited to: holding prolonged positions at work, repetitive tasks, weakness in the upper body, and a past history of neck dysfunction. This syndrome is most commonly found in women in the general population.
Why would breast cancer treatment predispose woman to pain in the neck-shoulder region?
Tightness across the chest (from surgery or radiation or both), restricted range of motion in the upper extremity (due to physical limitations, post-surgery recommendations, and/or pain avoidance), postural changes during treatment, and stress are all common after breast cancer treatment. As we saw above, changes in the normal use of the arm and shoulder can encourage the development of long term side effects of breast cancer treatment. Likewise, they can spell trouble for the trapezius muscle too, contributing to overuse of the muscle and excess ‘tone’, which can initiate development of this syndrome.
Symptoms
Myalgia in the upper trapezius muscle can cause considerable muscle tension, soreness, and deep ache, and the muscle itself is usually very tender between the neck and shoulder when pressure is applied. There may be the feeling of ‘spasm’ of the muscle, and a limited range of motion in the neck is common. Trapezius myalgia can also cause headache, in particular at the back of the head.
Diagnosis
This syndrome is diagnosed based on clinical findings, signs and symptoms. For example, the presence of painful trigger points in the muscle that when pressed cause a referral of pain, often to the back of the neck, shoulder, temple, or can feel like a headache behind the eye. In the absence of any other concerning ‘red flags’, no further testing or imaging is required to diagnose trapezius myalgia.
Treatment and Prevention
Since this condition is multifactorial, it responds best to a multifaceted approach to treatment. Naturally, addressing the factors of stress, overuse, and reducing the amount of time spent in aggravating postures, can all bring meaningful improvement.
Treatments for trapezius myalgia
- Being as active as possible, particularly if your occupation involves a lot of sitting/desk work, as studies show that the more sedentary the individual, the higher the frequency of neck and shoulder dysfunction of this nature.
- Exercise Therapy. Studies show that specifically tailored strength training (for example 3x per week for 20 mins) results in more long-term benefits in pain reduction than general fitness training (ref 9). Valuable exercises include: one-arm-rows, reverse fly’s, shoulder shrugs, and lateral raises.
- Manual therapy. This includes ischemic compression, also known as trigger point release, stretching of the upper trapezius muscle, and transverse friction massage are all manual techniques that provide immediate pain relief.
- Dry Needling. Intramuscular stimulation (a type of acupuncture) has a positive impact on pain intensity and range of motion, in both the short and medium term (ref 10).
- Other modalities. There is some evidence to support the use of TENS, laser, and ultrasound for temporary pain relief in patients with trapezius myalgia (refs), so these might be considered.
How to prevent trapezius myalgia
- Maintain good shoulder and back strength through regular exercise, which has the added benefit of promoting good posture and shoulder biomechanics that have also been shown to be beneficial.
- Be careful not to be overly protective of your shoulder following breast cancer treatment, and seek treatment for any residual tightness or restriction across the chest, trunk, or armpit regions that you feel limit your full range of motion of the arm. This tightness can lead to overuse of the upper trapezius and neck muscles, and predispose you to trapezius myalgia.
- If you begin to experience pain in the neck or shoulder region, you may benefit from physiotherapy which should include manual therapy to address any trigger points that may be present, and to design an exercise program that will help you prevent further worsening of symptoms.
Other Upper Body Musculoskeletal Side Effects of Breast Cancer Treatment
There are several other upper body musculoskeletal disorders that are frequently observed side effects of breast cancer treatment. However, these disorders are a bit less common, or arise primarily in special populations or under specific circumstances. Some of the more common examples include:
Other forms of tendonitis in the arm
In addition to rotator cuff tendonitis discussed above, additional forms of arm tendonitis can arise as side effects of breast cancer treatment. These include tendonitis of the tendons of the elbow (Lateral Epicondylitis, or ‘tennis elbow’), thumb (De Quervain’s tenosynovitis) and biceps muscle (bicipital tendonitis), and they are typically caused by abnormal use or function of the shoulder.
Bone fractures
The side effects of breast cancer treatment can include bone loss and the related increased risk of bone fracture in women treated with anti-tumor drugs that are estrogen modulators.
Use of aromatase inhibitors to treat estrogen responsive breast cancer in postmenopausal women results in a precipitous drop in estrogen levels. Since estrogen has a protective effect on maintaining bone density, aromatase inhibitors can lead to a loss of bone density and resulting bone frailty. In fact, breast cancer patients treated with aromatase inhibitors have been shown to exhibit significantly greater bone loss and increased bone fractures compared to similar (‘matched’) breast cancer patients who were not treated with aromatase inhibitors (ref 8). In a similar manner, tamoxifen treatment in premenopausal women reduces estrogen activity and thus decreases bone density and predisposes otherwise healthy women to fractures and osteoporosis. Interestingly, the opposite is true post-menopause where Tamoxifen can have bone-protective effects.
Patients treated with aromatase inhibitors or tamoxifen can help improve bone density through weight-bearing and balance exercises. This also offers the added benefit of decreasing risk of falls in the first place.
For more side effects of breast cancer treatment, please see: Top 4 Nerve Disorder Side Effects of Breast Cancer Treatment
References
- McCredie M.R., Dite G.S., et al. Prevalence of self-reported arm morbidity following treatment for breast cancer in the Australian Breast Cancer Family Study. Breast 2001;10:515-522. https://doi.org/10.1054/brst.2000.0291
- Manske R.C., Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med. 2008;1:180–189. http://doi.org/10.1007/s12178-008-9031-6
- Klc Z., Filiz M.B., Cakr T., Toraman N.F. Addition of Suprascapular Nerve Block to a Physical Therapy Program Produces an Extra Benefit to Adhesive Capsulitis: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2015 Oct;94(10 Suppl 1):912-20. abstract
- Uppal H.S., Evans J.P., Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop. 2015 Mar 18;6(2):263-8. http://doi.org/10.5312/wjo.v6.i2.263
- Stubblefield M.D., Keole N. Upper body pain and functional disorders in patients with breast cancer. PM R. 2014;6(2):170-183. https://doi.org/10.1016/j.pmrj.2013.08.605
- Hoogvliet P., Randsdorp M.S., Dingemanse R., et al. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med 2013;47:1112–19. http://dx.doi.org/10.1136/bjsports-2012-091990
- Dong W., Goost H., Lin X.B., et al. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2016 Aug;50(15):900-8. http://dx.doi.org/10.1136/bjsports-2014-094387
- Mincey B.A., Duh M.S., Thomas S.K., et al. Risk of cancer treatment-associated bone loss and fracture among women with breast cancer receiving aromatase inhibitors. Clin Breast Cancer. 2006 Jun;7(2):127-32. https://doi.org/10.3816/CBC.2006.n.021
- Andersen L.L., Kjaer M., Sogaard K., et al. Effect of two contrasting types of physical exercise on chronic neck muscle pain. Arthritis Rheum. 2008 Jan 15;59(1):84-91. https://doi.org/10.1002/art.23256
- Liu L., Huang Q.M., Liu Q.G., et al. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015 May;96(5):944-55. https://doi.org/10.1016/j.apmr.2014.12.015
Helo my name is lisa bishop i suriver best canser nerley 3years i am getting relly bad pain in my neck shoulder going in to my head giveing headack thumbing pain i had ct scan nufing showed up is now geting wores were giveing my bad headack cant see my hands go funny i get headacks any way just wonder have any actdive al they gave me is codedline i have little bby 11months so bit hard pick him of if have any actdive to help would be grate …
Hello Lisa,
I’m so very sorry to hear of your symptoms and neck shoulder and head pain, following your breast cancer treatment 3 years ago. Neck and shoulder pains are quite common after these types of surgeries and radiation, given there is often changes to the mechanics of the shoulder joint due to scar tissue and tightness from radiation, and so on. Headaches can also be attributed to this, and/or, perhaps a side-effect of a medication? If you have had estrogen positive (ER+) breast cancer and are taking an estrogen modifying drug, some of these may have side-effects including joint pain, headaches, etc. Speaking to your medical oncologist (if this is who is following you currently) would be a good place to start given your symptoms, and, consulting with a physiotherapist who has cancer rehab/neck/shoulder experience could be beneficial to address any muscle or joint issues that may be contributing. Particularly with a young baby, and the related challenges of holding them, feeding them, etc, it’s entirely possible that these symptoms are being aggravated by the activities needed to care for your baby. Again, a physiotherapist could help assist you with these symptoms, and given you strengthening and strategies to treat them. Wishing you the very best Lisa!
Lindsay Davey
My name is Toinette. I had a lumpectomy Dec 11/17 & had 20 radiation treatments February/2018.
IDC R breast stage 1 grade 1. My shoulders (plural) are equally affected. However, the attention is given to the right side. Is this normal? I don’t understand?
Hello Toinette!
Thank you for your comment. It’s common for your shoulders to become sore, tight, and painful, through this treatment experience. There are a few different shoulder conditions that can stem from breast cancer treatment, including surgery, radiation, and simply deconditioning and disuse. Postural effects are also often felt on both sides, even though you just had treatment on the one side. If you are seeing a physiotherapist or massage therapist for your shoulder needs, I would recommend you make them aware that both of your shoulders are experiencing dysfunction and/or pain, and have it addressed. If your shoulders are having more general ‘joint pain’, it’s possible that it’s due to a medication that you may be on, as many hormone targeted therapies used with breast cancer patients do have this side effect. You could speak to your medical oncologist about this as well. I hope this helps answer your question Toinette! Wishing you all the best, Lindsay Davey
Hi, I had a small cancerous lump removed 3 years ago followed by minimal breast removal and lymph node removal & radio. I had severe pain following surgery (to the point of being violently sick just thinking about getting dressed) due to nerves finding new pathways but this subsided after a month or 2, then after I had radio, I had bad burns under my armpit. About a year after treatment I noticed I could no longer straighten my arm fully, so being hyper mobile I literally lay on the floor and gently stretched the muscles so I could lift my arm. Over the last 6 to 9 months I have had physio as I had started to developed scoliosis, and this caused me pain in the other shoulder, and even tho I can straighten my arm, my movements are restricted in comparison to my other arm. Like putting a coat on, I have to remember to put my bad arm in first as it won’t bend as much as the good one, putting my bra on and doing it up behind me hurts, and I sometimes can’t do it, as my arm won’t go there. It feels very tight, and hurts if i raise it up high. What can I do to loosen it back up, it doesn’t hurt when resting and aches the times I am trying to do things, it’s more I can’t do them, my arm just won’t comply!
Hello Jayne,
I’m so sorry to hear of the intense pain you experienced on account of your breast cancer treatment. Radiation tissue damage is certainly something that can be treated, even after a period of time has passed, and I would encourage you to seek out a qualified therapist to release the armpit tissue if this is still restricting you, and if your physiotherapist does not feel comfortable addressing it. If the restriction stems from a mechanical issue at the shoulder joint itself, the tissue restriction from the radiation could still be a contributing factor, so it is worth mentioning to your physiotherapist if they have not tried a release here to date. We see a lot of shoulder joint impingement conditions following breast cancer treatment, and with good manual therapy, exercise, and the resolution of any residual radiation effects, we do see excellent results in our patients. Wishing you the best of luck in our on-going recovery Jayne! Lindsay Davey
Hi my name is Tracey and I’m currently undergoing radiotherapy after a mastectomy and lymph nodes removal. I have developed tendonitis in my right shoulder and it is so bad I am in constant pain. I am taking cocodamol and oramorph but find when my arms are up in position it is still agony. They have talked about steroid injection but this can’t be done straight away and also takes time to work. I’m also trying Ibuprofen but this is limited to 1 dose before treatment because I have a heart condition. Is there anything else that will help! Thanks
Hello Tracey, thank you for your comments and question. I’m very sorry to hear that you, like many of our patients, are experiencing tendonitis at your shoulder, concurrently to your radiation therapy. Certainly doesn’t make things easier, particularly trying to achieve the position needed for the radiation. A steroid injection can be symptomatically helpful in some patients, but I would highly recommend you visit with a physiotherapist to release the tissues that are tightening as best you can (while respecting your skin in the radiation field of course), deal with any cording that may have developed/may be contributing, and get the exercises started that can help maintain integrity in your rotator cuff and shoulder blade muscles, so that you optimize the joint mechanics as best you can. You might wish to consider whether a topical anti-inflammatory cream could help, or taping techniques to offload the irritated tendon at the shoulder, to get you through the radiation phase, at least. I wish you all the best with the remainder of your radiation Tracey, and a speedy return to full function soon thereafter. Lindsay Davey
I recently had a lumpectomy and have not yet had radiation. My tumor was small 5mm. I am experiencing more pain two weeks after since I have returned to normal activities and am using my keyboard mouse for work. I was not given any particular restrictions but I am wondering if I may be harming myself from computer work since it is the same side as the surgery.
Hello Margie,
Thank you for your question. It’s possible that at two weeks after surgery, a return to activities can be aggravating your surgical site a bit, yes. As long as it’s not increasing in it’s weeping of fluid, does not feel hot/red, and that you don’t detect any indication of infection, likely paring down your activities a bit will help with the discomfort. Computer work isn’t typically a major aggravating factor for a small lumpectomy incision, but if you have found this correlation to your pain increasing, then perhaps you can incorporate more breaks into your work day, or pause for a few days and see if things improve. Naturally, our advise is always to speak to your doctor about any new symptoms, but discomfort at two weeks post-op with a return to more activities is not unusual. Again, ensuring there is no infection at the surgical site is always a prudent thing to evaluate whenever pain increases. I hope this helps Margie, wishing you all the best with the upcoming radiation and your recovery. Sincerely, Lindsay Davey
Good Day Ma,
I have a friend who detected a lump in her breast and went for surgery last year
August for it removal, but after the surgery she started experiencing difficulty in using her legs i.e she has not been able to walk since then even till now. what could have been the cause? and what is the remedy?
Hello,
I am so sorry to hear of the symptoms your friend is experiencing since her breast lumpectomy last year. There should be no reason that her leg function was affected by that procedure, so I would certainly recommend she consult with her physician to ensure there is nothing else going on. They may wish to pursue further imaging to rule out any pathology at her spine, for example. If it is however deemed to be weakness and deconditioning, which can certainly happen following cancer treatments, then consulting with a physiotherapist to develop a home exercise program (strengthening and aerobic components, ideally) would be an excellent idea to recondition her and restore her to an improved level of function. As I say, an inability to walk stemming from a breast lumpectomy is not a normal side-effect and I highly recommend she pursue this with her physician team members. Wishing her well, Lindsay Davey
Hi, what about chest muscle pain? One month ago I had bi-later mastectomy and currently have tissue expanders in place. I seemed to be healing well, but yesterday started getting severe chest muscle pain (right side) and achy sensation in my right arm. When I gently press above and below my expanders, I feel sharp pain. Thoughts? Advice? Thx!
Hello Beth,
Thank you for your comment. Chest muscle pain after reconstructive surgery, particularly the implantation of tissue expanders, is certainly normal. Nerve recovery will be on-going and now that you’re one month post-op, can actually start to increase a bit, as you heal. Nerve pain can take on several different forms – sharp pains, electric type pain, deep pain, tingling. If your expanders are underneath your pectoral muscles, it is also common for the pecs to start to be painful as you start to use your arms more, which would also make sense with your timing post-op. You could certainly put a call into your surgeon’s office to speak to one of his or her nurses in case they are concerned, but in our experience this is part of the healing stages and not unusual. If you see any redness or heat eminating from the area or have fever or general malaise, you would want to make sure there isn’t an infection going on, but if again, pain can indicate a slight muscle strain given the reconstruction involve/was close to the pecs, and/or that some nerve recovery is beginning to occur.
I hope this has been helpful Beth! Hang in there. Best wishes in your continued recovery! Lindsay Davey
There is an inaccuracy in the article. Tamoxifen, unlike Aromatase Inhibitors, does not cause bone loss or dispose women to osteoporosis. In fact as a SERM (selective estrogen receptor modulator) tamoxifen actually blocks estrogen from breast tissue but sends it to the bone and to the uterus. So tamoxifen does not cause osteoporosis or thinning bones. Tamoxifen is mainly recommended to premenopausal women, as its risk of causing uterine cancer increases with usage in post-menopausal women.
Hello Alanna,
Thanks for your comment. You are correct, Tamoxifen is bone-protective in post-menopausal women, however the opposite is true for pre-menopausal women. In pre-menopausal women Tamoxifen promotes bone loss and can increase the risk of fracture. I will make a note in the article that Tamoxifen does not have the same detrimental affects post-menopause.
Thank you for your help!
Ryan
I was wondering if you ever heard of the Tenex procedure? I have slight tear and Tendonitis in my right shoulder and it causes horrible pain. It wakes me up at night. I’ve had the shots and shock treatment and am currently using Diclofenac cream. My doctor wants to do the Tenex procedure. Supposedly its a non invasive procedure, small needle that debris all the bad stuff. I’m just worried because I had breast cancer on the right side, lumpectomy, 18 lymph nodes removed and radiation over 20 years ago. I don’t want to get lymphodema. There’s always that risk. Just wondering if you have heard of anyone getting this procedure who has had breast cancer before and what were their results
Hello Jennifer,
Thank you for this valid question. I have heard of this procedure, or similar intervention for chronic tendonitis, yes. I can’t say that I have treated anyone with lymphedema in the same limb as this treatment was used however, nor on a limb that has had lymph nodes removed (but no lymphedema). Based on what I know of the procedure, and given your surgeon would use sterile techniques to avoid any chance of infection, I don’t think your risk of lymphedema would be markedly increased by moving forward with this procedure. It is a small, local insertion of a needle and then ultrasonic treatment to break down the scar tissue. The tendons at the shoulder are quite accessible and I don’t suspect it would be any more risky than a break in the skin of another nature (burn, wound, and so on). Given it is such a small point of insertion, it would be unlikely that infection risk would be that increased, in my opinion. You would want to take caution to observe the area for the days after the procedure and apply polysporin or whatever else the surgeon suggests to mitigate infection risk, but lymphedema doesn’t typically onset after small procedures such as this in the affected arm, particularly when you don’t already have any lymphedema in the limb. There is no guarantee of course, but given the pain you’re likely in, and the confidence you have in your surgeon, I would suggest that the risk of lymphedema onset is low, from this procedure. I hope that helps Jennifer! Best wishes! Lindsay Davey
Thank you Lindsay for the information. Once I have this procedure done I will post how it went for others if they are interested.
Thank you Jennifer! That would be helpful indeed. Best of luck with it!
Lindsay Davey
Hello! I have had a bilateral mastectomy, right lymph node resection with 7 removed, chemo and radiation. I am having muscle pain and spasms that seem to be under my pectoralis muscle on the right. it is very intense. When this starts, that area and my arm gets very tight and uncomfortable. Is this something you have seen before? Thank you.
Hello Amanda,
I’m happy to try my best to help. Muscle pain and spasms in/around the chest and pectoral muscles on the same side is common, often a response to surgery and/or radiation. Depending on how long after your surgery/radiation it has been, it could be nerve regeneration in the area that is causing this feeling of tension and pain. If the pecs themselves are tight/demonstrate radiation tissue changes, it can be quite effective to see a massage therapist or physiotherapist to release this muscle and render the tissue quality more supple and closer to it’s pre-radiation state. I hope this helps Amanda. Best wishes in your on-going recovery! Sincerely, Lindsay Davey
Hi!
I finished radiation treatment in December for stage 2 IDC. Radiation was my last treatment as I had surgery then chemo first. Since finishing radiation, I have had muscle soreness which I’ve been able to improve with physiotherapy. What I am having trouble finding a solution to is the tennis elbow that I’ve developed. What are the best methods to alleviate tennis elbow post radiation?
Hi Melanie,
Thank you for your message. Unfortunately, the fact that you’re experiencing tennis elbow following radiation is likely unrelated to the radiation itself (unless it is in fact a cording feature, and you’re feeling pain at the elbow area). Tennis elbow is something readily dealt with using classic musculoskeletal physiotherapy approaches, which involves manual therapy, stretching, strengthening, and taking NSAIDS/using ice/resting/bracing as needed, to calm symptoms down if acute. I would encourage you to seek the help of a physiotherapist so that you can get started on the home exercises in order to get some relief quickly. Thankfully, as I say, tennis elbow isn’t a classic radiation-driven condition following breast cancer, so it should resolve with the standard physiotherapy approaches that are tried and true for this condition. Best of luck Melanie!
Lindsay Davey
I had a bilateral mastectomy for DCIS on the right side and unexpectedly they found ILC stage 1 on the left. No lymph node involvement. Not sure my future treatment. Question I have is I have two painful cord like veins or nerves running down my right side below my rib cage toward my hip. Any idea what this might be? I had this happen before when I had a breast lift years ago.
Hello Juli,
Thank you for your comments and question. This is a feature called ‘cording’ which you may have heard of, but perhaps have not associated with the trunk/rib cage area. Cording is typically thought of to affect mainly the arm, or armpit (can be known as axillary web syndrome in severe cases), but it can absolutely present on the ribcage as well. This is true both following breast cancer surgery/lymph node surgery, or, as you have experienced previously, due to breast lift (or other augmentation procedures of the breast). Cording is something that can be released, either by a therapist familiar with breast surgery and related truncal cording features such as yours, or, yourself. Typically it involves a fascial or skin stretch type maneuver involving the area where the cord courses on the trunk, sometimes with the fascia further wound up via a twist to the body and/or the arm being reached overhead. You may find that the cord(s) releases (sometimes with the feeling of a small ‘pop’) during a task in your daily life, which sometimes happens in our patients, rather than a release experienced in the soft tissue stretch method I described above. Either way, these cording features don’t typically last all that long after surgery, but if you haven’t had luck with stretches or tugs on the skin as yet, I would recommend you seek help with a massage therapist or physiotherapist comfortable with this type of technique, to hopefully release the adhesions. I hope this helps Juli. Wishing you all the best! Lindsay Davey
I had a lumpectomy and radiation 20 yrs yrs ago and have achy breast and pain in my rib cage every since. Sometimes the pain feels like a cramp in the breast when I’m reaching out or reaching in back of me. The pain causes me to hold my arm into my breast until the cramping is gone. Is this normal?
Hello Shelia,
Thank you for your question. It’s not uncommon if you were never treated for the tissue changes that are common in the breast after lumpectomy and radiation, that you would continue to have symptoms, even 20 years later. If a NEW symptom in the breast has onset, we always recommend you pursue this with your doctor to ensure there is nothing more serious going on. However, radiation and surgery to the breast can certainly cause an ache in the area, and if it’s related to an outreached arm movement, you likely have some fascial restrictions of the soft tissue (related to the radiation, most likely, which can create a stickiness/adhesions in the tissue). A cramping feeling could also be related, as the twist motion of that action requires the intercostal muscles and some abdominal muscles to activate, which in a tensioned position. I would see a physiotherapist or massage therapist to address any soft tissue restrictions that may still be present in the breast or trunk area, and with any luck, learning how to release these or getting some hands-on help to do so, will really help.
Wishing you the best of luck Shelia,
Lindsay Davey
Hi,
I had partial mastectomy with tissue rearrangement and mastopexy in left breast on January 7. I developed pain on my back abs front diametrically opposite to each other towards the middle of chest. Then seroma detected 4 weeks after surgery, with abscess drained at 5 weeks and treated by antibiotics. The incision is in my far left, tumor was at 3 o’clock position. Since healing from infection I’m facing dull pain deep in the chest, with feeling tightness and compression as if something heavy on my inside. I feel something pulled hard to close my incision. The pain radiates yo my shoulder, back, neck, face, head all on the left. My left arm feels weak. I’ve had an episode of pain running down my left arm in the middle of night while sleeping. On waking up/sitting up the pain receded leaving numbness and tingling for a while before that also dissipated leaving me feeling weak. I went to ER immediately. They did X-ray, EKG, CT Scans of chest and neck, plus blood tests. Everything came back normal, No pulmonary embolism. I did EKG once before at Primary care office and it was normal. The surgery team is tight lipped and won’t say anything. They washed their hands off and sent me to Primary Care for my symptoms. Radiation treatment has been postponed due to ongoing symptoms. Hormone treatment has not begun as it was waiting on Radiation Treatment. Mine was Stage 1A ER/PR +ve HER2 -ve, oncotype 13. I’m looking for a diagnosis for my symptoms. Does this sound like musculoskeletal issues? No one is taking responsibility which is alarming to experience in my cancer journey!
Hello Anu,
I’m very sorry to hear of such a complicated road since your surgery and reconstruction, and the lack of definitive answers that have been offered to you as to what the pain is. The very good news is that your scans are all clear, which rules out sinister pathology, though I know this is a small consolation to the pain you’re experiencing. We see patients with pain syndromes after surgery/recon, typically in my experience from a few different possibilities, all musculoskeletal (or scar tissue) in nature. Patients with post-op complications such as yours (the seroma is usually not a huge factor in this type of pain, but an infection/abscess can be) can indeed present with on-going pain of a neuropathic nature for sometimes weeks or months post-op or post-radiation. What we tend to hear from their team members is it is thought to be nerve pain, stemming from the multitude of nerves that are disrupted in this type of surgical procedure, made worse by the infection, and/or myofasscial pain from all the tissue adherence that is likely present on the chest wall. The drain sites are often an area of pain in some patients, with wide-sweeping referral patterns I have found, in some cases. If your arm feels weak and you are not using it normally (or aren’t able to), this could also be a layer contributing to the pain, as if the shoulder/blade weakens, you can get other muscular contributing factors to a myofascial pain profile, so to speak. So I would guess that you are having nerve-related pain, with musculoskeletal pain overlayed, and I would highly suggest you see a physiotherapist trained in cancer rehab/breast cancer rehab/lymphedema even, so that they can address and release any scar tissue that is superficial enough to reach, thus, should lessen your nerve pain by untethering the tissue and also render your arm less ‘weak’ feeling (since the scarring all works to make it difficult to reach overhead). I hope that helps Anu. Some patients pursue a nerve-based pain medication to get them through their recovery phase (such as gabapentin, for example), which you could discuss with your team member. Even a topical cream with analgesic in it to enable soft tissue massage/release techniques to be tolerated more easily. I wish you well Anu, and I am hopeful you can find someone to provide the hands-on soft tissue and scar release that is likely playing a role (if not the major role) in your pain experience. Best wishes, Lindsay Davey
I had a lumpectomy in my left breast and lymphnodes from the left armpit followed by Brachytherapy and now on letrozole for just over a year with 4 more years to go. I started getting pain in my shoulder and an mri confirmed a torn rotator cuff. I also have pain in my left elbow,left thumb is frozen,and left achilles tendon is weird. Can all of these be caused by my meds and will they improve after I am off letrozole?
Hello Vicki,
Thank you for sharing your history and your question is a valid one. While I am not a medical oncologist and can’t speak to the side-effects of Letrozole with any authority, we certainly do hear of joint pain/issues from our women on the aromatase inhibitors, the family of drugs to which Letrozole belongs. The shoulder pain and even pain referring down to the elbow could certainly be related to the rotator cuff, which, is commonly somewhat deteriorated in many women irrespective of drug therapy such as this. The left shoulder is also under novel strains and positional constraints after breast surgery and radiation, and this can pre-dispose it to issues in the years that follow this type of treatment, unfortunately. Or, if a rotator cuff was already somewhat strained or showed some early deterioration already, this treatment course and/or possibly the Letrozole could contribute to it tipping over an edge, so to speak and manifesting symptomatically now. The left thumb (likely a CMC joint effect or tendonitis/tenosynotivis, or both) and left achilles issues – your medical oncologist would be the best person to weigh in but yes, we do see issues such as these, particularly in the same upper extremity (left thumb in your case) during these drug therapy years in ER+ breast cancer patients. As with any orthopaedic issue that is evident in our cancer patients as they recover from acute treatment, typically standard orthopaedic physiotherapy, bracing, exercise, and manual therapy approaches, do work well. It’s possible that some of your symptoms could self-resolve in time, or, once you’re off the Letrozole, but I would certainly encourage you to pursue therapy for these issues now, so that you can reduce your symptoms as soon as possible. I wish you the very best Vicki, and rest assured, you are not alone with these sorts of issues at play. I’m very sorry to hear you are experiencing multiple joint issues at present, and hope you can get some relief soon.
Best wishes in your on-going recovery, Lindsay Davey
Hello, I was diagnosed with triple negative breast cancer , a lump the size of a lemon and it had spread to my lymph nodes, I successfully had four sessions of doxorubicin every 14 days followed by 12 weekly sessions of taxol, I then has a total mastectomy on my right side followed by 25 sessions of radiotherapy, I finished the treatment around two months ago. I have muscle , joint and tendon pain after resting and achey legs when sleeping, I also have a lack of strength, I can walk but I can’t jog or run at all, the body just doesn’t respond. I do a physical job and have continued to work through most of my treatment, any idea what the aches are related to and how long it may take to get better
Hello Claire,
Thank you for sharing your story and your questions. It sounds like you are experiencing what many women do following your course of treatment for TN breast cancer. The joint and muscle effects of your chemotherapy, radiation, and general deconditioning, are very normal. Treatment-related fatigue is also a very common side-effect from these treatments, and can further tax the body whereby it feels sluggish, weak, and unable to tolerate previous levels of exercise or activity/work. All of these symptoms are generally thought (and the evidence supports) to improve with exercise – a progressive walking program is highly effective, even though I appreciate you may feel that even walking is challenging right now. The research supports the goal of 20-30 minutes of moderate intensity activity/walking, 3 – 5 days/week, to help combat the effects of chemotherapy and radiation induced deconditioning and other side effects. If your joint pains are persisting and quite difficult to tolerate, I would certainly discuss this with your medical oncologist who may suggest some other supportive agents to help. At only 2 months following the end of your radiation therapy, I am not surprised to hear you are still experiencing these sorts of symptoms. My best advice is to start a daily walking protocol, whatever you can do, knowing that this typically is what helps woman manage these types of symptoms best. I hope that helps Claire, all the best, Lindsay Davey
Recently diagnosed with IDC with option given of lumpectomy. I am choosing mastectomy instead to avoid (if possible) the need for radiation. My goal is to maintain function, strength and range of motion as much as possible. Although reconstructive surgery, either immediate or post-recovery, is possible, how damaging is the reconstructive process? I’d rather be flat and be able to lift grandkids, go kayaking and garden once I’m recovered. Thank you for your site – its very helpful.
Hello Elizabeth, Thank you for these comments, and I think your question of reconstruction is a valid one. I hope that the mastectomy does result in the avoidance of radiation in your case, and being as proactive as you are being in terms of maintaining your strength, range of motion, and function, bodes very well for your outcome. The reconstructive process can take many paths, as you know, and really does vary a great deal between individuals in terms of their side-effects, post-op challenges, recovery time, and so forth. The version of reconstruction (implant versus flap) and timing (immediate versus delayed), as well as a long list of patient-specific factors, all play into the eventual outcome expectation and it’s very difficult to generalize as you can imagine. We don’t tend to see a worsening of lymphedema or increased risk of lymphedema in the arm or trunk following reconstruction, that much I can say. I will also say that remaining flat after mastectomy is a valid option and certainly a faster recovery generally speaking than those who have a reconstruction at the outset. If you are unsure, perhaps starting with a mastectomy and seeing how you feel once recovered from that surgery, is one option that may enable you to make a more informed decision. It’s of course a very individual decision and I’m sure your plastic surgeon will help discuss all the options with you so that you can come to a decision that feels right for you. I hope your recovery from surgery, whatever it may entail, is smooth and that your post-op exercises and mobility focus will render a return to your previous level of range and function in short order. Best wishes Elizabeth! Lindsay Davey