TheHEALTH November/December 2025 | Page 15

November-December. 2025 | The HEALTH
OPINION

15

Healing beyond the scar

• Gentle, guided shoulder exercises soon after surgery can stop frozen shoulder from developing and preserve flexibility.
• Shoulder pain may stem from nerve injury, lymphatic blockage, or musculoskeletal stiffness- understanding the cause ensures proper treatment.
• A multidisciplinary approach involving rehabilitation physicians, physiotherapists, and occupational therapists helps survivors regain strength, comfort, and confidence. can also make positioning difficult during radiotherapy sessions, which may be required after surgery.
After an axillary node dissection, about 15 per cent of patients develop lymphedema, a swelling of the arm that can appear weeks or even years after surgery. When lymph nodes are removed or damaged, lymphatic fluid cannot drain properly from the arm.
This leads to a build-up which causes swelling of the whole upper limb or up to the neck. Patients often describe the arm as feeling heavy, tight, or aching.
LYMPHATIC COMPLICATIONS
Lymphatic blockade may also appear as axillary cording or axillary web syndrome. Lymphatic cords manifest as thick rope-like structures in the armpit or elbow.
Patients commonly describe tightness in the axilla, which causes pain and a stretching sensation during shoulder movement.
BY DR SALMAH ANIM ABU HASSAN

SHOULDER pain is a common and often distressing problem experienced by patients after breast cancer surgery. It can arise from several different causes and is influenced by the type and extent of surgery performed.

Depending on the stage of the disease, patients may undergo procedures ranging from breast-conserving surgery to total mastectomy. In addition, lymph node excision may be required, either through a sentinel node biopsy or a more extensive axillary clearance.
While essential for cancer treatment, these procedures may cause shoulder pain due to nerve injury, musculoskeletal problems, or lymphatic blockage. Understanding these causes is necessary for early detection, treatment, and prevention.
NERVE-RELATED PAIN
During lymph node removal, nearby nerves such as the intercostobrachial and intercostal nerves may be injured. These nerves provide
sensation to the inner arm and chest wall, respectively.
When damaged, patients may experience numbness, prickling, or burning sensations over the affected areas.
In rare cases, injury to the long thoracic nerve can lead to weakness of the shoulder blade muscles, known as scapular winging. Injury to this nerve makes it challenging to lift the arm.
THE FROZEN SHOULDER
Another common cause of pain is frozen shoulder, also known as adhesive capsulitis. This is a preventable condition that develops when the shoulder remains immobile for too long after surgery.
Many patients are hesitant to move their arm due to pain and fear of disrupting the surgical wound. Over time, this leads to shoulder stiffness and reduced flexibility- especially when reaching overhead.
Interestingly, although the surgery is usually on one side, the stiffness can sometimes affect both shoulders due to general inactivity. Frozen shoulder not only limits daily activities such as dressing and grooming but
Dr Salmah Anim Abu Hassan is an Assistant Professor and Rehabilitation Physician at Sultan Ahmad Shah Medical Centre in IIUM, Kuantan. She is trained in Interventional Physiatry and holds a special interests in pain management in women’ s health.
" A key role of the rehabilitation physician is to initiate pain management, which is often the main barrier to early recovery."
- Dr Salmah Anim Abu
Hassan
TREATMENT AND REHABILITATION
Effective treatment of shoulder pain after breast cancer surgery requires a multidisciplinary rehabilitation approach.
In Malaysia, rehabilitation physicians( specialists in physical medicine and rehabilitation) work closely with physiotherapists, occupational therapists, and oncologists to create individualised treatment plans tailored to each patient’ s needs.
The main goals of rehabilitation after breast cancer surgery are to help patients regain comfort, movement, and independence as they recover. Rehabilitation aims to restore normal shoulder and arm mobility, reduce stiffness, and prevent long-term limitations.
It also focuses on relieving pain in the chest wall, shoulders, neck, and back, which are common after surgery.
A key role of the rehabilitation physician is to initiate pain management, which is often the main barrier to early recovery. This may include prescribing pain medications, performing nerve blocks, and guiding therapeutic exercises to improve shoulder movement and strength.
Physiotherapists play a crucial role in helping patients regain shoulder mobility through safe, progressive range-of-motion exercises, postural retraining, and manual lymphatic drainage to reduce swelling.
Early physiotherapy not only preserves flexibility but also prevents frozen shoulder and reduces the risk of lymphedema.
Occupational therapists complement this process by addressing function and independence in daily life.
They provide custom-made compression garments for lymphedema management, assess how pain and weakness affect self-care and work, and teach practical activity modification and energy conservation techniques. These strategies help patients return to their usual routines with greater comfort and confidence.
Early pain management, guided exercise and through a structured rehabilitation program, breast cancer survivors are empowered to regain physical strength, physical independence, and rebuild their quality of life throughout their journey towards recovery.- The HEALTH