Q&A

On Cancer: Relieving Pain and Other Symptoms after Breast Cancer Surgery

By Christina Pernambuco-Holsten, MA  |  Monday, August 25, 2014
Pictured: Michael Stubblefeld Physiatrist Michael Stubblefield

If you’re experiencing pain or physical limitations after surgery for breast cancer, you’re not alone. Even as doctors at Memorial Sloan Kettering and other institutions work to refine surgical approaches to treatment, up to half of all breast cancer survivors feel pain or discomfort in their upper bodies, such as muscle spasms, tightness, soreness, or swelling.

Taken together these side effects are known as postmastectomy reconstruction sydrome, or PMRS, and experts at our Sillerman Center for Rehabilitation are highly skilled in caring for women with this condition.

To learn more about PMRS, we spoke with MSK physiatrist Michael Stubblefield, who specializes in identifying and treating the long-term complications many cancer survivors face.

First of all, what is postmastectomy reconstruction syndrome?

Postmastectomy reconstruction syndrome is essentially a blanket term used to describe the various neuromuscular, musculoskeletal, pain, and functional problems that can affect the upper body following treatment for breast cancer. If you’ve undergone mastectomy, axillary lymph node dissection, breast reconstruction, or radiation therapy, the symptoms you’re having may be connected to PMRS.

I should also mention that sometimes the disorder is called “post-mastectomy syndrome” or “post-mastectomy pain syndrome.” I prefer the term PMRS because the condition is not always painful and many woman who develop PMRS have undergone breast reconstruction.

Can you say more about the symptoms of PMRS?

The symptoms vary widely and depend on the type of surgery the patient had and whether she received any additional treatments such as radiation therapy. Medical status and other factors unique to each person, such as how a patient’s body scars and heals, also play a role.

For example, a woman whose intercostobrachial nerve [a nerve in the armpit] was affected during surgery may have some barely noticeable numbness in her inner arm, while another woman may develop a condition called intercostal brachial neuralgia, which can be extremely painful with burning, tingling, and other unpleasant neuropathic sensations.

Physical therapy is the mainstay of treatment for most patients.

– Michael Stubblefield, Physiatrist 

Some patients with implants describe tightness and painful spasms of the chest wall, soreness of the muscles, trouble breathing, and a variety of other sensations that can range from inconvenient to disabling.

Women who have had TRAM [transverse rectus abdominus myocutaneous], or other myocutaneous flaps in which the patient’s own tissue is used during the reconstruction, may experience muscle spasms, or neuropathic pain in the area where the tissue was removed. Radiation therapy can cause radiation fibrosis [scarring and hardening of tissue] leading to additional nerve damage and tightening of the chest wall muscles. Shoulder pain and dysfunction are also a common complication of PMRS.

How is postmastectomy reconstruction syndrome diagnosed?

A rehabilitation physician [also called a physiatrist] with experience treating the condition can usually make a diagnosis by reviewing your medical history and performing a basic physical exam. Sometimes additional assessment, such as electromyography to detect abnormal nerve and muscle function, is needed. Imaging such as MRI of the cervical spine, brachial plexus, or shoulder is also helpful in certain situations.

Determining the cause of PMRS can be complicated, and we are still working to understand the underlying reasons why it develops.

What are some of the ways you treat PMRS?

The treatment of PMRS depends on the patient’s symptoms. Physical therapy is the mainstay of treatment for most patients. A skilled therapist may also use such techniques as myofascial release to loosen scarred tissues, neuromuscular reeducation, stretching, and strengthening.

In addition to physical therapy, lymphedema therapy may help people who suffer from lymphedema [swelling caused by removal of lymph nodes] or cording [thick, rope-like structures that form under the skin of the armpit], which are also common complications of PMRS.

Pain medications, usually nerve stabilizers such as pregabalin (Lyrica®) or gabapentin (Neurontin®), are useful in treating neuropathic pain and spasm. Botulinum toxin (Botox®) and other injections can be extremely effective in reducing or eliminating painful spasms.

Comments

I had a double mastectomy and reconstruction in 2013 at MSKCC and I did go thur physical therapy but I notice that I still have difficulty with certain movements. For example recently ideas traveling and it was extremely difficult for me to put my carry on into the overhead but taking it down wasn't an issue. I have been working out and use no weights or 2.5lbs and I experience soreness /fatigue feeling from my shoulder to my elbow . I also feel this at times when running/walking a distances .Not i do not do any weight bearing chest exercises per my plastic surgeons recommendation. Should I go back to physical therapy ?
Thank you

M, we are not able to answer personal medical questions on our blog. We recommend you speak with someone from your MSK healthcare team about your concerns. Thank you for your comment.

It seems to me that most physicians and breast cancer survivors are not aware of this condition. Thank you once again for bringing awareness to the public. Where can I get more information?

Dear Teresa, great question. We checked in with Dr. Stubblefield, and he said the best source is PubMed, a database of biomedical literature maintained by the National Institutes of Health. You can go to http://www.ncbi.nlm.nih.gov/pubmed and search for "post-mastectomy syndrome."

I worked with a PT trained in
Myofacial release for 4 months. I believe that PMPS is caused by nerve cauterization during surgery. The pain we feel is a result of neuroma formation, not scar tissue and adhesions. That is why PT doesn't work. Only treatment is meds and injections in chest. Please refer to the research article do e at the University of San Francisco by Dr. Kathy Tang. This is a breakthrough in treatment of PMPS. I had one set of these trigger point injections and improved 85%! PT makes it worse.

I worked with a PT trained in
Myofacial release for 4 months. I believe that PMPS is caused by nerve cauterization during surgery. The pain we feel is a result of neuroma formation, not scar tissue and adhesions. That is why PT doesn't work. Only treatment is meds and injections in chest. Please refer to the research article do e at the University of San Francisco by Dr. Kathy Tang. This is a breakthrough in treatment of PMPS. I had one set of these trigger point injections and improved 85%! PT makes it worse.

Dear Madelyn, thanks very much for your comment. We shared it with Dr. Stubblefield, who responds: "There are many individual components that comprise the post-mastectomy reconstruction syndrome. A breast cancer survivor can experience one or more of these disorders. Neuroma of the intercostobrachial or other nerves is only one small component of the syndrome. Lidocaine injection into the stump of the intercostobrachial nerve may be useful for some patients but is at best only a temporary solution as the anesthetic quickly wears off with recurrence of symptoms. Other cutaneous nerves cannot be reliably injected which is why myofascial release is an important modality for the vast majority of PMRS survivors. Also, neuroma injection will not be helpful for denervated pectoral or serratus anterior muscles, graft harvest sites, radiation fibrosis, shoulder dysfunction, and numerous other components of the syndrome." Thanks again for sharing your experience.

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