Shoulder Pain, Among Other Things
I wasn’t going to write a post this week. I’ve just finished up the latest round of doctor visits, tests and diagnostic images that are required now to make sure that breast cancer has not returned. According to all this recent rigamarole, so far, it hasn’t. So, I get to breathe again. Until next time.
Doesn’t mean all my problems are resolved. Fatigue and brain fog still lurk. A little stress can throw me under the bus again. The month-long cancer check-up extravaganza was stressful. So, I’m tired. During a good week, among the thirty or so hours of work I put in, I’ve been able to add one session of intense physical exertion, like spending an hour mowing the lawn or going to the gym. I can usually only pick one thing per week, though, which puts a crimp in getting through my overlong to-do list. But one session a week is better than none. If I’m lucky, I will only have to take a long nap after I exert myself thus. If I’m not, I will have to spend the next few days mostly in bed, saddled with fatigue — again. If, like this week, I have some extra stress, from seeing my breast surgeon yesterday, I find myself knackered again and have to postpone some project I’d like to accomplish, like working on some photographs or writing a blog post. My brain just doesn’t work as well after a shot of stress, and my body ends up once again feeling starved of energy. But I eventually get over it. It’s tedious, and folks who haven’t been through cancer treatment — including my breast surgeon — don’t really get it. But after three years, I’m used to that.
The Gift That Keeps On Giving
Chronic, long-term pain and weakness can also sap your energy. So, I’ve been trying to make the effort to address my shoulder and chest pain. Sometimes, I can get away with a few short bursts of high exertion, like trying to do my shoulder exercises. A lot of us have shoulder problems after cancer treatment. And I’ve been wanting to write another post about how to deal with them. So, I’m going to give it my best shot. Recently, I came upon a great review study about this issue. It was published in the journal, Archives of Physical Medicine and Rehabilitation in 2006, and the link will take you to a PDF of the article. The review found that as many as 7 in 8 women end up with problems affecting their arms, shoulders, necks and chests after breast cancer treatment. The article describes several of these, in order to point the way to the effective treatment of them.
As a physical therapist, I’m familiar with a number of these disorders, because I’ve treated many of them in my patients over the years. There is a difference, however, between the effect of these disorders in people who have not had cancer treatment and those of us who have. And the main difference is one of chronicity. In other words, if they occur as a result of breast cancer treatment, then very often, they never really go away, a fact to which I can personally attest. The first thing you need to do if you have a problem is to take it seriously and go to a doctor, who will, hopefully, also take it seriously.
Following is a descriptive list of the problems highlighted in the study:
- Cervical radiculopathy — pain, numbness, weakness in the shoulder, arm or even the hand and fingers, caused by a pinched nerve in the neck. This can mimic brachial plexus problems or neuropathy from chemo. It can come and go, worsen depending on positioning or activity, and can lead to other problems. If there is a pinched nerve in the neck, this can generally be seen in an MRI. Anti-inflammatories and knowledgeable physical therapy can help.
- Peripheral neuropathy — miserable. Causes pain, numbness and weakness that is usually distal, meaning at the end of the arm, in the wrist, hand and fingers. Neuropathy is a common side effect of chemotherapy, often resulting from taxanes in particular. The study states that oral glutamine, at 10g taken 3 times a day starting after each chemo session, may help prevent neuropathy. After neuropathy takes hold, however, it can be debilitating, and treatment can be difficult. An interesting study of treatments for neuropathy was published last week by CureTogether. The treatments were rated by patients, and found that some of the most prevalent treatments, like oral neurontin, were rated poorly, while less common treatments, like low dose naltrexone, water exercise, and physical therapy, were rated as “surprisingly effective.” It’s a tough, chronic problem for many, but perhaps this study will give you some ideas to take to your doctor.
- Rotator cuff tendonitis — our rotator cuff is a group of tendons that come from muscles that originate around the shoulderblade. They merge at the shoulder, forming a cuff that attaches around the shoulder joint to the top of our humerus, or upper arm bone. They help us move and lift our arms in every direction. Their function is also dependent on the muscles of the chest, or pectoralis muscles, which attach in our armpits and upper arms, as well as our shoulderblade, or scapular muscles, which help stabilize things so we can move our arms in so many directions. So, it stands to reason that treatments like surgery and radiation in the area of our chests and armpits can throw everything off and lead to pain every time we try to reach, lift, push, pull or otherwise move our shoulders. This is my most prevalent and stubborn shoulder problem. Oral anti-inflammatories, ice, and even an injected anti-inflammatory (with scrupulous sterile technique so as not to set off any lymphedema) can help alleviate acute symptoms. But in order to get this under control, physical therapy — preferably by someone who also has knowledge of lymphedema and axillary cording — and/or a gradual program of stretches and strengthening exercises is the only way that chronic problems relating the rotator cuff can be managed and mitigated over the long haul.
- Adhesive capsulitis — often called ‘frozen shoulder,’ this is a very common problem after breast surgery, reconstructive surgery, lymph node dissection and radiation. It can accompany lymphedema, infection, tumor recurrence or metastases. It presents as significantly restricted active and passive range of motion in the shoulder, especially when rotating the arm or lifting it out to the side. Resolution can sometimes be spontaneous, but it is very much dependent on whether acute cancer treatment is finished. It can also occur simultaneously with cervical radiculopathy or rotator cuff tendinopathy. All of these problems need to be addressed by adequate management of pain and inflammation, as well as physical therapy and careful, persistent exercise.
- Lateral epicondylitis — restricted shoulder movement can lead to compensatory motions in the elbow and wrist that can lead to pain and inflammation in these two areas as well. I had elbow pain and persistent lateral epicondylitis myself during my first year after radiation. Fortunately, I managed to stop it from getting worse, but I still have my shoulder problems. Ice, anti-inflammatories, wrist or elbow splints, and physical therapy or occupational therapy can help. Use of splints or compression bands may not be permitted, however, if active lymphedema is present, or if peripheral neuropathy is too painful to tolerate wearing a wrist splint.
- Postmastectomy syndrome — this is a messy, complex problem that visits a lot of us after any sort of breast surgery, including lumpectomy, partial mastectomy, axillary node dissection or reconstruction. It can present as a kind of hypersensitivity in the chest, armpit and shoulder, and is not unlike the phantom pain the occurs for people who have a limb amputated. I’ve remarked in previous posts that the euphemistic medical terms used for the removal of breast tissue should all just be called amputations. Here’s yet another reason for calling a spade a shovel. Pain meds, therapy to improve range of motion, and time comprise the treatment for this.
- Edema & Lymphedema — the medical term for swelling is edema. A certain amount of swelling always accompanies injury or surgery. It’s part of the normal inflammatory process by which our immune systems bring white blood cells to the area to help repair it. However, because it’s literally ‘hot,’ as in flame, as in inflammation, it’s also a nice little laboratory for the formation of problems like cellulitis or other infections, blood clots, seromas, and tissue necrosis. When our circulatory vessels get clogged up and overwhelmed by dealing with all this, the fluid can get backed up in the armpit or arm or even the torso next to the surgical site, signalling the onset of lymphedema, another kettle of fish entirely. Lymphedema deserves its own post, but here are a few resources. A good, downloadable booklet, published by Breast Cancer Care, UK, can be found at this link, Lymphedema-Management. And an excellent website that provides thorough information about the diagnosis, prevention and management of lymphedema is StepUp-SpeakOut.org.
- Brachial plexopathy — in our armpits, we have an arrangement of nerves called the brachial plexus. These nerves allow movement and sensation to the muscles of our arms, chest and hands. Anything that puts pressure on this plexus can cause pain, weakness and numbness in the arm, hand, collarbone area or even the neck. True brachial plexus disorder is rare in the general population, but after breast cancer treatment, it can arise from scar tissue after breast surgery or node dissection, or from lymphedema that causes congestion in the area and puts pressure on the nerves. On the other end of the spectrum, it can in some cases be related to invasive tumors to the lymph nodes or other tissue in the area. It can even be related to metastatic cancer. However, it can also arise as a late-term effect of radiation, which may take months or years after treatment to rear its ugly head. Differential diagnosis needs to be thorough, to rule out other causes or recurrent cancer.
- Rib fractures — fractures of the ribs can occur after radiation or after the insertion of breast tissue expanders in previously radiated tissue. A summary page, prepared for the site UpToDate by radiation oncologist Lori J. Pierce, lists all the potential early and late effects of radiation after surgery for early breast cancer, including rib fractures. An interesting side note is that one of the editors listed for this part of the site was my radiation oncologist, who did NOT, by the way, discuss any of these potential side effects with me before I received radiation, and who was singularly unhelpful when I developed a respiratory infection and extreme fatigue while I was having it. I’m not going to “out” this person here, so you’ll just have to muse on this for yourself. An abstract prepared by plastic surgeons at UC-Davis Medical Center explains what happens with tissue expansion after radiation. An older study, published by the Danish Cancer Society, discusses late-effect rib fractures and other damage resulting from radiation after mastectomy. You’ll probably need an X-ray to determine whether you have a rib fracture, and there’s not much you can do for one, except to take pain meds, try not to cough or lift, and wait for it to heal. It can take several months for one of these to resolve.
- Pathological fractures — more urgent and insidious are fractures, sometimes occurring in the upper arm, that are pathological fractures associated with bone metastases. Not to make us all nuts, but if we experience any fracture after a diagnosis of breast cancer, we need to have it thoroughly checked out to rule out bone mets. Which is why I get a little peeved at the folks who push aromatase inhibitors without thorough evaluation and informed consent, which are drugs known to cause osteoporosis, which can cause fractures, which can make us insane with worry that we might have bone mets. Not to mention the fact that osteoporosis by itself is no picnic and is another issue about which I need to write another post.
What To Do?
If you develop one or more of the above problems, you should first talk to your surgeon or oncologist. If you get no help there, at least ask for a referral to an orthopedist or neurologist who is familiar with cancer treatment problems so you can get a clear differential diagnosis. If you’re lucky, the place where you’ve had cancer treatment will have good ancillary cancer care services and/or a complete referral database, which will steer you toward help with fatigue, cognitive problems, depression, neuropathy, orthopedic issues, rehab therapies, pain management and other issues that arise during and after acute treatment.
If you have relatively minor pain or you know you have shoulder rotator cuff soreness or impingement or you’ve had rehab therapy previously and need a tune-up, there is a downloadable PDF at the beginning of the next paragraph, which diagrams the exercises I’ve been doing for my shoulder, among others, which I have also taught to countless shoulder patients in the past. Do not do these if you have lymphedema — you need to be supervised by a rehab therapist before performing any resistance or strengthening exercises when you have active lymphedema. If you can find a piece of Theraband or Theratubing, that is helpful, but you can also do the exercises in this PDF without it, by just getting into the positions shown and moving your arms in the correct motion. Standard Theraband comes in different colors that signify different levels of resistance. You should only start with yellow or red in the beginning and only progress to green when you are feeling stronger. If you obtain resistance tubing that is made by some other company, it may be coded differently, so make sure you start with the easiest, or lowest, resistance color.
Therapeutic Shoulder Exercise Pictures: You want to feel some effort when you do these exercises, but you don’t want to feel pain. A little soreness that goes away after one or two repetitions is okay, because that means you are loosening up, bringing more oxygen to your muscles, and more joint fluid is being squirted into the area to lubricate things. You may also want to take your anti-inflammatory or pain med before starting. Start with the exercises on pages 1-3 and page 5 first. Do not do the page 4 exercises yet. Try 10 repetitions, and make sure you do them all with both arms, even your ‘good’ arm. Put an ice pack on your shoulder afterward for about 10 minutes to get rid of any minor inflammation you may stir up with the exercises. Consistency is the key. You need to try to do these every day or at least every other day to make a difference. If any one of them hurts while you are doing them, stop! The exercises that show the person lifting the arm need to be done exactly as shown; do NOT lift your arm any higher than about 90 degrees, or chest/shoulder height. Going higher will only worsen the problem you are trying to fix. If you do well with 10 reps, you can try going up to 15. The rule of thumb with how many repetitions to do is to start low and go slow!
If you can get through these for a week or two, and you can do 20 reps of each, then you can add the exercises on page 4 and gradually add the ones on pages 7 through 9. Ice afterward. If you skip too many days between doing your routine, you may wake up with worse stiffness. This is usually a normal rebounding type of reaction, and if you go back to the beginning and gradually work your way back, you’ll be okay. If you experience worsening pain after doing any exercises for a few days, stop doing them and see your doctor or rehab therapist.
My shoulder has gotten a lot better since I’ve been doing my exercises, but I wasn’t even able to start these exercises until about a year or so after cancer treatment, because I had so much pain, I had to rest my shoulder for a long while, get my soft tissue massaged and worked on for a while, and get the pain, axillary cording, and inflammation under control first. Fatigue also got in my way. So don’t be frustrated if you need some formal treatment before you can continue on your own. In my own case, I realize after three years that I will always have to do shoulder rehab, because the damage to my chest muscles from radiation is permanent and always worsens if I stop my exercises. If you have cervical radiculopathy, or any of the other problems described above or in the review study, you need to be properly diagnosed first, be under a doctor’s care, and if advised, receive formal physical therapy before trying anything on your own.
Good luck! I’m off to take a nap now.
Other posts you may find helpful:
Adapting: Practical Stuff for Hands and Arms
Back Talk 101
Back Talk 201
Losing It and Trying to Get It Back
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