Mastectomy, lymphoedema and cancer surgery

1Definition

Mastectomy is surgical removal of the breast, usually for breast cancer. It is often combined with removal or sampling of the lymph nodes in the armpit (axilla).

Lymphoedema is chronic swelling caused by protein-rich fluid collecting in the tissues because the lymphatic system cannot drain it. After breast cancer treatment it affects the arm, hand, breast or chest wall on the operated side.

2Classification and grading

Types of breast surgery

Lymphoedema stages (International Society of Lymphology)

Lymphoedema is commonly diagnosed when the affected arm is 2 cm or more larger in circumference at any point, or about 10% or more larger in volume, than the other arm.

3Causes and risk factors

Breast cancer risk factors

• Female sex, increasing age, family history, BRCA gene mutations.
• Early first period, late menopause, no children or a first child after 30, not breastfeeding.
• Obesity after menopause, alcohol, inactivity, hormone therapy, previous chest radiation.

Lymphoedema risk factors

• Axillary node clearance (more nodes removed, higher risk) and radiotherapy to the axilla.
• Infection or seroma in the arm or wound; obesity; reduced arm use; cellulitis.
• Heavy, sudden overuse of the arm without building up gradually.

4Pathophysiology to impairments

1. Surgery cuts skin, fascia, muscle attachments and lymph vessels, and removes axillary nodes.
2. Pain and fear make the patient hold the arm against the chest, so the shoulder stiffens (capsule and scar tighten), especially in flexion, abduction and external rotation.
3. Scar and radiotherapy fibrosis tie down the chest wall and axilla.
4. Lymph drainage is reduced. When the lymph load is more than the remaining vessels can carry, protein-rich fluid collects: lymphoedema. The protein attracts water and later causes fibrosis and infection risk.
5. Nerve injury during axillary surgery: long thoracic nerve (serratus anterior, so winging of the scapula), thoracodorsal nerve (latissimus dorsi), intercostobrachial nerve (numb inner upper arm).
6. Axillary web syndrome: tight, painful cords from the armpit down the inner arm in the first weeks, from damaged lymph vessels; they limit abduction.
7. Posture: the shoulder on the operated side rises and rolls forward; weight imbalance after removing a large breast can strain the neck and spine.
8. Chemotherapy and radiotherapy add fatigue, low blood counts, nerve damage in the hands and feet, and skin and lung changes.

5Clinical features after surgery

• Pain and tightness across the chest wall and axilla; drains in the first week.
• Limited shoulder elevation, abduction and external rotation (S17: "shoulder joint restriction").
• Swelling of the arm or hand on the operated side (S17: "mild oedema"; W20: "swelling in right upper limb").
• Numbness of the inner upper arm; scapular winging if the long thoracic nerve was injured.
• Cord-like bands in the axilla (axillary web syndrome).
• Fatigue, nausea and hair loss during chemotherapy; skin redness during radiotherapy.
• Anxiety, low mood, altered body image.

6Investigations

7Medical and surgical management

• Surgery: mastectomy or breast-conserving surgery, sentinel node biopsy or axillary clearance, with or without reconstruction.
• Chemotherapy: before (to shrink the tumour) or after surgery (W20 case).
• Radiotherapy to the chest wall, breast or axilla.
• Hormone therapy (tamoxifen, aromatase inhibitors) for hormone-positive cancers; aromatase inhibitors cause joint pain and bone loss.
• Targeted therapy such as trastuzumab, which can affect the heart.

8Complications and prevention (7 marks in S20)

9PT assessment

• Subjective: type of surgery and side, number of nodes removed, drains, reconstruction; chemotherapy or radiotherapy plans; pain, heaviness, numbness, tightness; hand dominance; occupation and household load (cooking, washing, lifting); children; patient's goals.
• Observation: wound, drains, posture (shoulder height, protraction), scapular winging, swelling, skin colour.
• Shoulder range: goniometry of flexion, abduction, external rotation, both sides.
• Strength: shoulder and scapular muscles, grip.
• Arm measurements: circumference at fixed points (for example every 4 cm from the wrist), compared with the other arm; volume calculation; pitting test; skin and tissue texture.
• Sensation of the inner arm; axillary cords on palpation.
• Outcome measures: DASH (arm function), shoulder ROM, arm volume, FACT-B (quality of life), fatigue scale, 6MWT.

Clues in the story (W21): heaviness of the arm and sleeves or rings that feel tight are early signs of lymphoedema, so measure both arms the same day. Redness, heat and fever in the arm suggest cellulitis, which needs urgent medical treatment before any massage or bandaging. Neck pain after surgery usually comes from guarding: a raised, protracted shoulder and a stiff neck.

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (W20, 5 + 5 + 5 marks)

"A 40 year old female, right handed, teacher by occupation has undergone right modified mastectomy three weeks back and is receiving chemotherapy. She has swelling in right upper limb and pain in right shoulder. She is married, has two children and wishes to resume her job. Discuss ICF with clinical reasoning. Plan her short term and long term physiotherapy management."

11Problem list and goals

12PT management

Before surgery

• Measure shoulder range and both arms (baseline for lymphoedema).
• Teach the first-week exercises, breathing exercises and posture; explain drains and what to expect.

Days 1–7 (drains in)

• Deep breathing, supported cough, early walking.
• Hand pumping (open and close the fist), wrist and elbow movements, neck and shoulder shrugs; 10 repetitions several times a day.
• Shoulder flexion and abduction kept to about 90° while drains are in.
• Rest the arm on a pillow when lying, with the hand slightly higher than the elbow.

After drains are removed

• Full active and active-assisted range: wand (stick) exercises, wall climbing with the fingers, pulley, hands behind the head, hands behind the back. Hold stretches 20–30 seconds, 3–5 repetitions, 2–3 times a day.
• Scapular setting, retraction and posture correction; serratus anterior work if winging.
• Scar massage once the wound is fully healed; stretches for axillary cords.
• Continue stretching through radiotherapy to prevent fibrosis.

From about 6 weeks: strength, fitness and return to work

• Progressive resistance training of the arms, shoulders and legs: start light under supervision and progress slowly.
• Aerobic exercise such as brisk walking or cycling.
• Work-specific practice: board writing, cooking, lifting children, carrying.

Exercise during chemotherapy and for cancer-related fatigue

Lymphoedema: complete decongestive therapy (S21, 7 marks)

Bandages used for lymphoedema (3 marks in S23)

• Short-stretch (low-stretch) bandages: the main lymphoedema bandage. They stretch only a little, so they give low pressure at rest (safe to wear at night) and high pressure when muscles contract against them, which pumps fluid out of the arm.
• Multilayer lymphoedema bandaging: tubular stockinette next to the skin, narrow gauze bandages on each finger, padding (soft synthetic wool or foam) to even out the arm's shape and protect bony points, then several layers of short-stretch bandage with more pressure at the hand than the upper arm.
• Adjustable compression wraps (hook-and-loop, Velcro-type): the patient can put them on and tighten them herself; useful for self-management and maintenance.
• Long-stretch (high-stretch, elastic) bandages are not used for lymphoedema: they keep high pressure even at rest and can act like a tourniquet.

Also: elevate the arm when resting; deep diaphragmatic breathing (helps central lymph flow); pneumatic compression only as an add-on. A 33-year-old receptionist (S21) needs workstation advice too: arm supported on the desk, regular movement breaks, sleeve during work.

Breast prosthesis (3 marks in S17)

• Temporary soft prosthesis (light, fibre-filled) worn in a soft bra from soon after surgery, because it does not press on the scar.
• Permanent silicone prosthesis fitted once the wound has healed and swelling has settled (often around 6–8 weeks, or after radiotherapy skin has recovered). It matches the weight of the other breast. Worn in a mastectomy bra with a pocket; partial and adhesive types exist.
• Why it matters: restores body symmetry and balance, prevents the shoulder rising and the spine tilting, helps clothes fit, improves confidence, and protects the chest wall.

By impairment

Rationale of physiotherapy after MRM (7 marks in S25 and W25)

13Precautions (3 marks in S21)

14Education and lifelong arm care

S19 asked "Why and how does she need to take care of her hand life long?"

Why: the lymph nodes removed from the armpit do not grow back. The arm always has less capacity to drain fluid, so any extra load (infection, burn, injury, heavy unaccustomed work) can start lymphoedema, even years later.

How:

• Keep the skin clean and moisturised; dry well between the fingers.
• Wear gloves for cooking, gardening and washing vessels. Use oven gloves and long-handled spoons (important for the tiffin cook).
• Treat every cut, scratch or insect bite at once with antiseptic; see a doctor if it becomes red or hot.
• Avoid tight bangles, rings, watches and tight blouse sleeves on that arm.
• Build up heavy tasks slowly; take breaks; carry loads with both hands or a trolley.
• Stay active and keep a healthy weight.
• Measure or check the arm regularly; report heaviness, tightness or swelling early.
• Wear the compression sleeve if prescribed, especially for long travel or heavy work.

15Prognosis and discharge criteria

Prognosis for shoulder function is good when exercise starts early. Lymphoedema is a lifelong risk, and once established it can be controlled but rarely cured. Cancer prognosis depends on stage and tumour type.

Discharge from physio: full functional shoulder range; independent home programme; knows arm care and lymphoedema warning signs; compression garment fitted if needed; back to work and household roles.

16Exam corner

Past questions (MUHS, 2016–2026)

• W16 Q3(b), 5 + 5 + 5 marks45-year-old female farm labourer, right MRM 2 days ago; one of the earning members; wants to return to farm work. Functional diagnosis, short- and long-term management.
• S17 Q4(b), 5 + 7 + 3 marks45-year-old female teacher, married with 2 children, radical mastectomy 15 days ago; mild oedema of the operated arm and shoulder restriction. ICF; long-term management; prosthesis.
• S19 Q4(b), 15 marks40-year-old Sunita, right radical mastectomy 3 days ago; right-handed; cooks tiffin boxes for ten clients morning and evening. Immediate and late complications and prevention; rehab with reasoning; why and how to care for the arm lifelong.
• W20 Q3(b), 5 + 5 + 5 marksThe worked example in section 10.
• W21 Q3(b), 15 marks40-year-old woman, right MRM 2 days ago; neck pain and heaviness of the right arm, VAS 6/10; her sleeves look tight. Subjective and objective evaluation parameters; functional diagnosis; management.
• W24 Q3(b), 15 marks55-year-old cook, right-hand dominant, right MRM 2 days ago. Functional diagnosis and physiotherapy management.
• 7-mark questionsPhysiotherapy after radical mastectomy (S16, S18). Complications after MRM (S20). Physiotherapy for a 33-year-old receptionist with lymphoedema (S21). Physiotherapy after MRM (W19, S26). Rationale of physiotherapy after MRM (S25, W25).
• 3-mark questionsPrecautions after radical mastectomy (S21). Three goals of physiotherapy in radical mastectomy (W22). Three types of bandages used for lymphoedema (S23).

Technique cards for this topic: breathing exercises, exercise physiology, swelling and posture.

Keywords to underline

MRM axillary clearance drains 90° until drains out full ROM axillary web syndrome lymphoedema complete decongestive therapy MLD compression progressive resistance training prosthesis lifelong arm care

Answer skeleton: mastectomy long answer

1. Restate: age, side and hand dominance, type of surgery and day, chemo or radiotherapy, job and home load.
2. [ICF, 5] ICF diagram; one-line diagnosis; reasons (guarding, nodes removed, chemotherapy).
3. [Short-term, 5] By day: breathing, hand pumping, shoulder to 90° with drains, posture; then full ROM after drains out.
4. [Long-term, 5–7] Stretching, scar care, strengthening, aerobic exercise, lymphoedema prevention and decongestive therapy, prosthesis, return to work.
5. [Add-on, 3] Prosthesis, precautions or lifelong arm care, as asked.

Draw these

• The rehabilitation timeline (section 12)
• An arm outline with measuring points every 4 cm (for lymphoedema)

Viva questions

1. What is the difference between radical and modified radical mastectomy?
2. Why is shoulder elevation limited in the first week?
3. Which nerve injury causes winging after mastectomy?
4. What are the stages of lymphoedema?
5. What are the components of complete decongestive therapy?
6. Is weight training safe after breast cancer surgery?