Elsevier

Medical Hypotheses

Volume 77, Issue 4, October 2011, Pages 481-487
Medical Hypotheses

Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors

https://doi.org/10.1016/j.mehy.2011.06.015Get rights and content

Abstract

Over 2.6 million breast cancer survivors currently reside in the United States. While improvements in the medical management of women diagnosed with breast cancer have resulted in a 5-year survival rate of 89%, curative treatments are associated with a high prevalence of shoulder and arm morbidity, which, in turn, can negatively impact a woman’s quality of life. Breast cancer survivors frequently experience shoulder and arm pain, decreased range of motion, muscle weakness, and lymphedema. These symptoms can lead to difficulties with daily activities ranging from overhead reaching and carrying objects to caring for family and returning to work.

Despite health care professionals awareness of these problems, a significant number of breast cancer survivors are confronted with long-term, restricted use of their affected shoulder and upper extremity. This problem may partially be explained by: (1) an incomplete understanding of relevant impairments and diagnoses associated with shoulder/arm pain and limited upper extremity use, and (2) the limited effectiveness of current rehabilitation interventions for managing shoulder pain and decreased upper extremity function in breast cancer survivors.

Because breast cancer treatment directly involves the neuromusculoskeletal tissues of the shoulder girdle, it is understandable why breast cancer survivors are likely to develop shoulder girdle muscle weakness and fatigue, decreased shoulder motion, altered shoulder girdle alignment, and lymphedema. These impairments can be associated with diagnoses such as post-mastectomy syndrome, adhesive capsulitis, myofascial dysfunction, and brachial plexopathy, all of which have been reported among breast cancer survivors. It is our belief that these impairments also put women at risk for developing symptomatic rotator cuff disease.

In this paper we set forth the rationale for our belief that breast cancer treatments and subsequent impairments of shoulder girdle neuromusculoskeletal tissues place breast cancer survivors at risk for developing symptomatic rotator cuff disease. Additionally, we identify knowledge gaps related to the current understanding of relevant shoulder girdle impairments and their association with symptomatic rotator cuff disease in breast cancer survivors. Ultimately, information from studies designed to meet these gaps will provide a scientific basis for the development of new, or refinement of existing, examination, intervention, and prevention techniques, which should lead to improved clinical outcomes in this population.

Section snippets

Introduction and overview

In the United States approximately 200,000 women are diagnosed with breast cancer each year [1]. Improvements in the medical management of these women have resulted in a 5-year survival rate of 89 percent, and currently over 2.6 million breast cancer survivors reside in the United States [1]. While survivorship has increased, shoulder and arm morbidity has become a significant complication following curative treatment. Wide prevalence ranges for shoulder/arm pain (9–68%), restricted motion

Diagnosis and treatment of symptomatic rotator cuff disease

Information gathered from the history and physical examination is used to help determine if an individual has symptomatic rotator cuff disease, and if so, attempt to establish the extent of the disease (i.e. tendonitis or tendon tear). Overall, individuals with symptomatic rotator cuff disease complain of shoulder pain, limited motion, and/or weakness as well as decreased functional use of their upper extremity. Pain tends to be located to the anterior or anterolateral aspect of the shoulder

Etiological factors associated with rotator cuff disease

The rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, and teres minor) are essential for normal function of the shoulder girdle (Fig. 1). These muscles are important for the production and control of glenohumeral joint motions including but not limited to shoulder flexion, abduction, internal, and external rotation. Additionally, these muscles are essential for establishing an optimal relationship between the humeral head and glenoid fossa, which in turn, helps to maintain the

Breast cancer and symptomatic rotator cuff disease

The information in this section is separated into subsections to allow us to discuss how each factor could, in and of itself, contribute to the development of symptomatic rotator cuff disease. Although the information in each subsection is presented separately, it is important to recognize that each factor is likely to influence another (i.e. altered resting shoulder alignment and shoulder range of motion) with the end result being a combination of factors contributing to the development of

Conclusions and future research

Shoulder and arm morbidity present a significant problem for women who have had curative breast cancer treatment. While recognition of this problem and the negative effects it has on upper extremity function and health related quality of life is important, the identification of, and referral for, shoulder and arm impairments is not happening frequently enough [90]. Although the reasons for this problem have not been identified it is reasonable to believe that patients and health care providers

Conflicts of interest statement

None declared.

References (90)

  • S. Tempelhof et al.

    Age-related prevalence of rotator cuff tears in asymptomatic shoulders

    J Shoulder Elbow Surg

    (1999)
  • J.S. Rietman et al.

    Long term treatment related upper limb morbidity and quality of life after sentinel lymph node biopsy for stage I or II breast cancer

    Eur J Surg Oncol

    (2006)
  • D.D. Ebaugh et al.

    Three-dimensional scapulothoracic motion during active and passive arm elevation

    Clin Biomech (Bristol, Avon)

    (2005)
  • P.W. McClure et al.

    Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo

    J Shoulder Elbow Surg

    (2001)
  • K. Endo et al.

    Radiographic assessment of scapular rotational tilt in chronic shoulder impingement syndrome

    J Orthop Sci

    (2001)
  • L.J. Hebert et al.

    Scapular behavior in shoulder impingement syndrome

    Arch Phys Med Rehabil

    (2002)
  • J.J. Lin et al.

    Functional activity characteristics of individuals with shoulder dysfunctions

    J Electromyogr Kinesiol

    (2005)
  • Institute, N.C. Surveillance epidemiology and end results. Cancer of the Breast....
  • T.S. Lee et al.

    Prognosis of the upper limb following surgery and radiation for breast cancer

    Breast Cancer Res. Treat.

    (2008)
  • S. Vignes et al.

    Factors associated with increased breast cancer-related lymphedema volume

    Acta Oncol

    (2007)
  • J.M. Armer et al.

    A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population

    Lymphat Res Biol

    (2005)
  • R.H. Ronka et al.

    Breast lymphedema after breast conserving treatment

    Acta Oncol

    (2004)
  • A.L. Cheville et al.

    Barriers to rehabilitation following surgery for primary breast cancer

    J Surg Oncol

    (2007)
  • Stubblefield MD, Custodio CM. Upper-extremity pain disorders in breast cancer. Arch Phys Med Rehabil 2006;87(3 Suppl...
  • N. Devoogdt et al.

    Short- and long-term recovery of upper limb function after axillary lymph node dissection

    Eur J Cancer Care

    (2011)
  • S. Hayes et al.

    Objective and subjective upper body function six months following diagnosis of breast cancer

    Breast Cancer Res Treat

    (2005)
  • R.L. Thomas-Maclean et al.

    Arm morbidity and disability after breast cancer: new directions for care

    Oncol Nurs Forum

    (2008)
  • A.G. de Boer et al.

    Cancer survivors and unemployment: a meta-analysis and meta-regression

    JAMA

    (2009)
  • E. Quinlan et al.

    The impact of breast cancer among Canadian women: disability and productivity

    Work

    (2009)
  • R.L. Ahmed et al.

    Lymphedema and quality of life in breast cancer survivors: the Iowa Women’s Health Study

    J Clin Oncol

    (2008)
  • D.J. Dawes et al.

    Impact of lymphoedema on arm function and health-related quality of life in women following breast cancer surgery

    J Rehabil Med

    (2008)
  • C.H. Kroenke et al.

    Functional impact of breast cancer by age at diagnosis

    J Clin Oncol

    (2004)
  • Y.L. Michael et al.

    The persistent impact of breast carcinoma on functional health status: prospective evidence from the Nurses’ Health Study

    Cancer

    (2000)
  • I.L. Nesvold et al.

    Arm/shoulder problems in breast cancer survivors are associated with reduced health and poorer physical quality of life

    Acta Oncol

    (2009)
  • A. Trentham-Dietz et al.

    Health-related quality of life before and after a breast cancer diagnosis

    Breast Cancer Res Treat

    (2008)
  • J. Engel et al.

    Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients

    Breast Cancer Res Treat

    (2003)
  • J.A. Petrek et al.

    Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis

    Cancer

    (2001)
  • A. Sagen et al.

    Changes in arm morbidities and health-related quality of life after breast cancer surgery - a five-year follow-up study

    Acta Oncol

    (2009)
  • J.L. Westrup et al.

    Risk of decline in upper-body function and symptoms among older breast cancer patients

    J Gen Intern Med

    (2006)
  • E.J. Yang et al.

    Longitudinal change of treatment-related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study

    J Surg Oncol

    (2009)
  • P.K. Levangie et al.

    Magnitude of late effects of breast cancer treatments on shoulder function: a systematic review

    Breast Cancer Res Treat

    (2009)
  • R.J. Tsai et al.

    The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors

    Ann Surg Oncol

    (2009)
  • K.A. Meeske et al.

    Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women

    Breast Cancer Res Treat

    (2009)
  • R. Ghazinouri et al.

    Shoulder impairments in patienst with breast cancer: a retrospective review

    Rehabilitation Oncology

    (2005)
  • A. Gyedu et al.

    Evaluation of muscle atrophy after axillary lymph node dissection

    Acta Chir Belg

    (2009)
  • Cited by (70)

    • Examining assessment methods of scapular motion: Comparing results from planar elevations and functional task performance

      2020, Clinical Biomechanics
      Citation Excerpt :

      Treatment for breast cancer can cause tissue damage, tissue tightness or fibrosis, or nerve damage to the muscles and tissues around the shoulder and axilla (Bentzen et al., 1989; Hack et al., 1999; Stubblefield and Keole, 2014; Yang et al., 2010), which can be responsible for restricted range of motion, ultimately leading to altered postural alignment and shortened chest muscles. These alterations can change both movement patterns and force generation surrounding the shoulder, as well as decrease the size of the subacromial space, which is a risk factor for rotator cuff disease (Ebaugh et al., 2011). While numerous studies have reported clinical problems after treatment (Assis et al., 2013; Hayes et al., 2005; Kootstra et al., 2013; Kuehn et al., 2000; Lang et al., 2019c), few have measured resulting biomechanical compensations at the shoulder in breast cancer survivors.

    View all citing articles on Scopus
    View full text