Diane Short, a patient who underwent a successful lumpectomy 18 months ago, found herself experiencing symptoms of adhesive capsulitis, or “frozen shoulder.” However, she had no previous knowledge that this condition existed and was treatable. This complication is not uncommon, but it can be misdiagnosed or ignored if a patient is not persistent with his or her post-surgery care provider. Often, a patient may feel that the pain or discomfort is normal following a lumpectomy and may wait to disclose the severity or details of the symptoms, resulting in unneeded suffering for months or years.
Diane explains, “No one ever called my symptoms ‘frozen shoulder,’ but my pectoral muscle was very sore, and I was unable to raise or straighten my right arm above my head. When I tried to raise it, I would have a sharp pain in my shoulder. I had a hard time reaching up in the cabinets or hanging or getting down items in a closet. I would shift my body and use my other arm or get a stepstool to get to what I needed. It seemed like I had no strength to lift or carry items. I finally asked my surgeon about physical therapy options a few months later. He set me up with a physical therapist.”
It is important for patients to continually ask their doctors clarifying questions and communicate with them both before and after a procedure. Patients may have to be their own advocates and ask for options to alleviate their pain or improve their mobility.
Adhesive capsulitis is a pattern of restriction of the shoulder joint due to pain caused from an injury or surgery.1 A patient who experiences this, like Diane, will refrain from moving the arm and shoulder in order to avoid additional pain and discomfort. The joint then becomes “frozen” or stiff from lack of use and inflammation.
It is fairly common for patients to experience pain, joint restriction, and functional limitations after surgeries related to breast cancer, although it is also not uncommon after a stroke, rotator cuff injury, or other arm injuries. Muscle weakness, swelling, numbness, and tingling may also persist. Typically, these symptoms are more prevalent after a mastectomy than a lumpectomy because more tissue is removed. Also, the complications may be more intense, depending on whether or not any lymph nodes are removed.
When a patient suffers from “frozen shoulder,” the shoulder capsule thickens and becomes tight. Stiff bands of tissue called adhesions develop. In many cases, there is less synovial fluid in the joint.
The primary symptom of this condition is being unable to move your shoulder, either on your own or with the help of someone else. It develops in three stages:
- Freezing: In the "freezing" stage, you slowly experience more and more pain. As the pain worsens, your shoulder loses range of motion. The freezing stage typically lasts from six weeks to nine months.
- Frozen: The condition’s painful symptoms may actually improve during this stage, but the stiffness remains. During the four to six months of the "frozen" stage, performing normal daily activities may be very difficult.
- Thawing: Shoulder motion slowly improves during the "thawing" stage. A complete return to normal or close to normal strength and motion typically takes anywhere from six months to two years.
Prompt, proactive care can greatly reduce the symptoms of “frozen shoulder.” Typically, a patient can begin physical therapy as early as two days post-surgery. According to Harrison Hunt, PT, DPT of Rehabilitation Associates of Central Virginia, “It is critically important to have a physical therapist that evaluates the whole patient versus just their diagnosis, listens closely to their patients, understands their history and has the clinical experience to manage their conditions completely.”
Therapists agree that early physical therapy significantly improves a patient’s joint mobility and overall recovery time and ultimately decreases the cost of healthcare associated with post-operative limitations. As the American Cancer Society explains, “It’s important to complete exercises [after breast cancer surgery] to get the arm and shoulder moving again. Exercises help to decrease side effects of surgery and help patients get back to usual activities.”
A thorough evaluation needs to be completed at a physical therapist’s office in order to discuss the patient’s medical history and assess their posture, range of motion, strength, balance, and functional level; this will allow the physical therapist to determine the best plan of care. During the following appointments, the focus shifts to teaching exercises and hands-on treatments targeting the joint as well as strength deficits that were found during the initial evaluation.
Therapists also integrate functional training to develop the use of the painful area in order to improve the patient’s daily living or working activities. Additionally, different types of manual therapy may be used to improve soft tissue, scar or joint restriction, and some therapists may use modalities such as electrical stimulation to increase circulation and decrease pain.
A physical therapist can teach patients range-of-motion exercises to assist them in recovering their mobility. However, the degree to which patients are willing and able to commit to consistently performing the exercises, both in the office and at home, will affect their results.
Diane reveals that she is doing much better today, 18 months after she had the procedure and 10 months after she began physical therapy, but she must continually perform the exercises she learned. “If I do too much,” she explains, “I will feel [pain] in the shoulder, especially if I haven't kept up with what I should be doing. The pectoral muscle is still sore, and it might be a while before that pain is no longer there.”
“It is important for patients to talk their doctor or physical therapist about concerns early. Waiting too long can cause the problems to become chronic, which delays the body’s response to physical therapy,” explains Harrison F. Hunt, PT, DPT of Rehabilitation Associates of Central Virginia.
“Continue to inform your doctors how you are feeling or ask if there is a treatment that would help with any pain,” Diane advocates. “It's important that you continue to ask questions until you are satisfied.”
Patients can learn about physical therapy treatments by calling a local physical therapy office, talking to their physicians, or getting in touch with the American Physical Therapy Association. Another great source of information is other women who have undergone breast cancer surgeries or breast cancer support groups in your area.
Physical therapy offers patients who are recovering from breast cancer surgeries an option to proactively enhance their speed and quality of recovery. Patients and providers who are looking to eliminate or minimize post-surgery “frozen shoulder” symptoms may begin treatment shortly after surgery, once a proper evaluation can be completed.
The Mayo Clinic. www.mayoclinic.org
Frozen Shoulder. American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org
American Cancer Society. www.cancer.org
Rehab Associates of Central Virginia, www.racva.com