Breast Cancer Patients - Musculoskeletal Problems Experienced

Original Editor - Lucinda hampton

Top Contributors - Chloe Waller, Lucinda hampton and Kim Jackson  

Introduction

Breast cancer and its treatment, usually localised surgery with chemotherapy, radiotherapy and endocrine therapy, increase the risk of musculoskeletal problems, especially in the upper limb. Research suggests 67% of women may have shoulder or arm problems up to 3 years after treatmentThese include:

• Acute or chronic pain
• Muscle weakness
• Osteoporosis and osteoporotic fractures - certain treatments, such as aromatase inhibitors, or chemotherapy-induced ovarian failure, decrease estrogen and lead to bone loss
• Reduced shoulder range of motiondue to pain or fear of movement leading to adapting a flexed protective posture or avoidance of use, leading to muscles shortening (especially pectoralis major) and tightening of the joint capsule.
• Secondary to above, there is risk of shoulder conditions such as symptomatic rotator cuff disease, scapula winging, adhesive capsulitis or shoulder impingement
• Lymphoedema
• Increased body mass index (BMI), which can lead to or exacerbate other musculoskeletal conditions
• Scar adhesion

Post-Mastectomy Pain Syndrome (PMPS)

Pain which lasts longer than what is usually expected following various breast cancer surgery types. Generally neuropathic in nature, and can be due but not limited to:

• Brachial nerve damage, *Intra-operative compromise of cutaneous innervating,
• Neuroma formation,
• Fibrotic entrapment. Patients often report neurological symptoms such as numbness or pins and needles, stabbing and burning pain to the same side as surgery in or around the surgical sites.

These symptoms can be exacerbated through a lack of pacing, or by lying on the side of surgery. Therefore, patient education, soft tissue massage, and other desensitising techniques are essential . Other common problems include:

• Subacromial Impingement Syndrome.
• Frozen Shoulder (frozen shoulder) – idiopathic or traumatic (post-surgery).
• Rotator Cuff pathology (e.g Symptomatic Rotator Cuff Disease)
• Myofascial Dysfunction Lateral epicondylitis.
• Scapular winging secondary to damage of long thoracic nerve during surgery.
• Pain

Associated Neuromusculoskeletal Conditions Post Treatment

Neuromusculoskeletal conditions are common following surgery, some of which are illustrated in figure 1.4. Treatment protocols shall not be discussed, and the reader should refer to the basic principles of rehabilitation of musculoskeletal conditions. In light of this, it is important to briefly discuss a few points to consider.

• Depending on the type of surgery that the patient needs to undertake, radiotherapy may be necessary following surgery.
• A typical radiotherapy session will require the patient to position the treated arm to 90° flexion and abduction, as well as maximal external rotation, for up to 30 minutes 
• Shoulder mobility is commonly affected post-surgery ; ;  so it is vital that physiotherapy aims to restore this to improve patient functional ability and to be able to place the shoulder in the required positions for radiotherapy.
• Active, active assisted, and passive ROM exercises for the shoulder girdle are therefore good practice. Physiotherapy should aim to restore full shoulder ROM as well as minimising associated upper extremity morbidity .
• Manual therapy techniques with the aim of further increasing available ROM have been shown to not be of any significant benefit when used in conjunction with active upper limb exercises .