Physiotherapy for Breast Surgery
Issue date: October 2023
Review date: October 2025
Ref: A-592/JH/Physiotherapy/Physiotherapy for Breast Surgery
PDF: Physiotherapy for Breast Surgery final October 2023.pdf [pdf] 348KB
About this booklet
This booklet has been created for patients who have had breast surgery (this includes lumpectomies, mastectomies, radical mastectomies, and reconstruction) and contains information about your recovery and some common symptoms that can occur during your treatment.
It is an evidenced based booklet which incorporates the Pink Ribbon Rehabilitation program and PROSPER program.
Everyone is different, and not everyone will experience the symptoms that are discussed in this booklet. The information should help you identify some of the symptoms and prevent them from becoming problematic. It is important you discuss your concerns and any symptoms you are experiencing with your Physiotherapist or healthcare professional to allow them to monitor your symptoms and provide you with appropriate advice and support. If you do not have a Physiotherapist, please speak to your Breast Cancer Team or your GP who will be able to refer you to an appropriate professional.
You will also be able to find useful links for additional information in the useful information and resources section.
The exercise program has a guide on the exercises and repetitions you should do during each stage of your rehabilitation, but your Physiotherapist will talk you through the program, what exercises they recommend you do, the number of repetitions and frequency they recommend you undertake them. Your Physiotherapist will be happy to discuss any concerns and answer any questions you may have, so please do not hesitate to discuss any questions you may have. You are welcome to bring someone with you to your appointments for support. We ask that you wear a strappy top so your Physiotherapist can assess your shoulder, arm, and chest area if you are happy with this, however if you are not, please inform your Physiotherapist.
Tissue healing and my recovery
Your wound can take 2-3 weeks for it to heal externally after surgery and up to 6 weeks for internal stitches to dissolve. As your tissues repair your scar can sometimes feel tight, causing stiffness and discomfort. We will discuss more about your scar in the next section and how to help with these symptoms.
Weeks 1- 4 post surgery
Once you return home it is important to use your arm for everyday movements and light tasks. It is important you avoid heavy tasks such as vacuuming or carrying heavy bags of shopping until your wound is fully healed.
Try to vary your tasks and avoid repetitive activities as you will find your arm will fatigue faster than before. Remember to pace yourself and be realistic about you can do in a day, you will need to factor periods of rest as you will likely feel tired as your body heals.
It is safe for you to do gentle exercise such as walking straight after your surgery which can help with your recovery, overall fitness, fatigue, and sleep. Start gently with short walks and gradually increase the distance or speed, aiming for light to moderate exercise so you are a little out of breath, but can still hold a conversation.
4 -12 weeks
Your wound should be healed, and the internal tissues will be healing. Your pain should start to improve as your range of movement in your arm increases. Your Physiotherapist will be focusing your rehabilitation on improving your flexibility, regaining your full range of movement and strength.
You can do more demanding and repetitive activities, but it is important you reintroduce them gradually, slowly increasing the time and effort required to undertake the task ie household chores such ironing, vacuuming.
From about 6 weeks you can start to return to more intensive whole-body exercise that you did before your surgery such as yoga, swimming, and jogging, as long as your wound has fully healed and your healthcare professionals have advised it is safe for you to do so.
Make sure your take your time and slowly reintroduce anything that involved taking weight through your arms or use of a weight slowly. If you would like further advice, please discuss this with your Physiotherapist.
Note: Swimming is a good exercise once your wound has healed but isn’t advised during chemotherapy or radiotherapy. If you have any concerns or questions, please speak to a healthcare professional who will be able to advise you on appropriate exercise you can undertake.
12 weeks onwards
Many people are back to full physical activity but may need to continue to improve on your general strength and flexibility and this is what your rehabilitation program will emphasis on. It is important to keep doing your stretches and try to make them part of your daily routine.
Evidence and guidelines recommend aiming for 30 minutes of exercise 5 times a week, incorporating strength sessions 2-3 times a week.
It is important you discuss your physical activity levels with your Physiotherapist, especially if you are planning on returning to high levels of strength and endurance for your hobbies or work.
Pain
It is normal to experience some pain in the first few weeks after surgery and if you are experiencing pain, take regular pain medication to make you feel more comfortable. If you are struggling with pain, please speak to a healthcare professional who will be able to help with this.
Some people find it beneficial to take pain relief 30 minutes prior to starting their exercises as this can be uncomfortable in the first few weeks after your surgery.
Altered sensation and nerve pain
Many women experience altered sensation such as tingling, numbness, pins and needles, or intermittent sharp pains. This can occur over the breast/chest area, upper and inner arm after surgery and should settle down over time as your tissue start to heal. However, it can take up to 18 months for full sensation to come back, and in some instances, some people to do regain full sensation. If you experience this speak to your Physiotherapist who will be able to provide you with advice on sensation work and liaise with your GP regarding appropriate pain medication such as neuropathic pain medication to help if it persists.
Swelling and seroma
Following any surgery bruising and swelling is expected around the incision in the first few weeks. This is part of the normal healing process and will typically settle without treatment.
Some people develop a seroma, which is a small build of fluid under your wound/ incision. This can be uncomfortable and should not interfere with your rehabilitation, however if you are unsure, please speak to your cancer nurse or Physiotherapist who will be able to assess you and provide advice on how to manage the swelling.
Scar massage
Scars heal in several different ways, but the appearance and flexibility of your scar may be improved by massage, helping it become smoother and more supple. Your Physiotherapist will teach you how to perform the massage on your scar and will advise you when to start this. It is generally recommended you do this twice daily 3-5 minutes a day once your wound has fully healed.
Before starting any massage make sure you can feel the scar and surrounding area. If you can’t or have altered sensation, make sure you are checking the area before and after ensuring the is no redness, or skin break down. YIt is also important you check your pressure on an area you can feel, as you may use a harder pressure accidentally which can cause some irritation. If you are unsure, please speak to your Physiotherapist.
Only undertake scar massage when the wound is fully healed and dry.
Image from How to Massage Scar Tissue After Breast Surgery | Breast Advice (stephenmcculley.co.uk)
Use a plain water-based moisturiser/ cream. Press down gently on the area using your fingertips or thumb, moving your fingers/thumb in small circular, vertical, or horizontal movements. Ensure you cover the scar and surrounding tight tissues.
NOTE: Do not massage your scar whilst you’re having radiotherapy, you will be advised by the oncology team to keep the skin hydrated with non-perfumed moisturiser.
You will be able to restart scar massage after completing your radiotherapy once your skin has fully recovered from any skin irritation caused from the radiotherapy, but if you are unsure, please speak to a healthcare professional for advice.
Cording
Cording is also known as Axillary Web Syndrome (AWS) and happens in some women where tight bands (cords) of tissue appear under the armpit and can stretch down the arm past the elbow and into the wrist. Cording can develop any time after surgery and can often feel like a tugging, tight sensation which can be uncomfortable. The cause is unknown, but it is more common after surgery in the axilla (armpit), and can also happen after radiotherapy. If you develop cording continue with your stretches and your Physiotherapist will show you how to massage the cords and affected area which can help, if indicated.
If you are unsure if you have cording, please speak to a healthcare professional for advice.
Lymphoedema
Is a build-up of fluid that causes swelling commonly in the chest/breast area, arm or hands and will often feel heavy, tight, or swollen. It can happen due to trauma to the lymphatic system due to surgery, radiotherapy, or can be triggered by injury or infection. Only a small number of women develop lymphoedema, and it is more likely to occur if you have had lymph nodes removed or have had radiotherapy.
Things you can do to reduce the risk of developing lymphoedema include.
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Do your arm exercises regularly. Make them part of your daily routine.
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Avoid having injections or blood taken from the affected arm.
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Avoid lifting heavy objects, undertaking repetitive tasks or strenuous activities.
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Avoid sunburn or burning the arm.
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Avoid waxing or using a razor blade under the arm. Instead try hair removal creams or electric razors.
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Try to avoid cutting the arm. If you do ensure you wash the arm thoroughly and apply antiseptic creams. If you are concerned seek medical advice.
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Wear long sleeves and gloves when undertaking dirty or rough work such as gardening.
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Use an aqueous moisturising cream to prevent the skin becoming dry and cracked.
If you develop lymphoedema it is safe for you to exercise, and you should still do as many of the prescribed exercises as you can. You can still undertake physical activities you were doing before you developed lymphoedema, but you will need to start slowly and build up your time and intensity gradually, ensuring you monitor how your arm responds. If you are unsure or notice your lymphoedema increases stop what exercises you are doing and seek advice from a healthcare professional. If you have lymphoedema you will be referred to the lymphoedema team. If this has not happened, please speak to one of the team who can organise this for you.
Tiredness and fatigue
Feeling exhausted, fatigued, extremely tired that you have no energy is very common during and after treatment and is often multifactorial. Unfortunately, Cancer Related Fatigue (CRF) can last months to years, so it is important to inform a healthcare professional so you can get the correct support. It can interfere with your ability to undertake daily tasks, returning to work, and can become frustrating as you may have finished your treatment but still feel very tired. If you are experiencing this, it is important that you.
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Speak to a healthcare professional as they will be able to provide you with advice, support, and investigate if there is a cause such as anaemia.
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Pace your day and any activities you are doing.
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Try to get rest between activities.
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Avoid doing too much too soon. It is important that you slowly increase your activity levels and listen to how tired you are feeling, as doing too much can make you more tired. However, doing too little can affect your mood, fitness/energy levels and sleep which can make you more tired.
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Try to do light to moderate intensity exercise/ physical activities which you enjoy can help. Try to get friends and family members involved for additional motivation.
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Be kind to yourself. It is common to go through a whirlwind of emotions throughout your treatment. If you experience this speak to a healthcare professional who will be able to provide you with support and signpost you to services which will be able to provide you with tailored advice and additional support through this time.
Goals
We encourage everyone to set some goals to help show you, your success through your rehabilitation and have future targets of what you want to achieve. Having a clear plan of how you will achieve your goals can be helpful to monitor your progress and identify any challenges and solve any potential problems.
Think of up to three goals you want to achieve and discuss them with your Physiotherapist once you are ready.
1)……………………………………………………………………………………………………………………………………………………………………………………
2)……………………………………………………………………………………………………………………………………………………………………………………
3)……………………………………………………………………………………………………………………………………………………………………………………
Advice about exercises
It is normal when doing your exercises to feel a stretch, tightness, and discomfort, and this should get easier over time. The exercises should never cause you severe pain, if they do we recommend you stop doing the ones that are causing you pain and contact your Physiotherapist who will be able to advise you.
You may feel a muscular ache afterwards and this is normal when you start any new exercise.
Remember to do your exercises slowly and gently and to do your warm-up exercises first.
It is important that you continue to do your exercises to maintain the benefits, so try and make them part of your daily routine.
Remember to rest and pace yourself each day, be realistic about how much you can do at any one time. Exercise can help with tiredness and fatigue, but it is important not to overexert yourself.
Before doing your exercises
It can be helpful to take pain relief 30 minutes prior to starting your exercises, but please ensure you follow the medication instructions and do not take more than the recommended dose as prescribed for you.
Ensure you have enough space to undertake your exercises.
Wear comfortable clothes that allow you to freely move your arm.
Involve your friends and family with your exercises, they may want to join in if they know you need to do them daily.
Break your exercises up throughout the day. You don’t need to undertake them all in one go.
Try to do your stretches twice a day and incorporate your other exercises in with these.
Exercise and being active is important to maintain your level of fitness and can help with your mood, energy levels and sleep.
When to start the exercises
Below is a guide as to when you should start the stages of the exercise program. This is a guide, and you may find that you are able to progress through the stages quicker or slower than the guide suggests, this because people recover at different speeds. It is important that you do not progress onto the next stage of the exercise program if you are finding the exercises in the stage you are on uncomfortable/ difficult. If you have any concerns or are unsure, please contact a healthcare professional for advice.
As you progress through the stages it is important that you continue to do the warmup and stretches, and then pick 2-3 of the exercises in the stage you are on, to do at one time, and repeat them 1-2 a day. You do not need to complete the entire stage in one go, it is generally better if you spread the stage out through your day so make it more comfortable and manageable to fit into your day.
Stages of the program
Start the warmup exercises and beginners stretches the first week of your surgery.
Start the beginner range of movement exercises from 2 weeks after your surgery.
Start the isometric strengthening exercises from 4 weeks.
Start the resistance band exercises from 6 weeks.
Start light free weights exercises from 8 weeks.
If you have any questions or concerns regarding the exercise program, please seek advice from a Physiotherapist.
All exercise images are from https://www.hep2go.com
Warm up
Posture correction
Whilst sitting on a chair imagine you have a piece of string at the top of your head that is slowly being pulled up. Sit tall, tucking your head and chin in, at the same time as drawing your shoulders back and down towards the centre of your back. Hold for a count of 20-30 seconds, relax, and repeat 3-5 times.
Shoulder Circles
Keeping your arms loose and relaxed by your side, slowly shrug your shoulders up towards your ears, and rolls them forward and down and back in a circular motion. Repeat for 20-30 seconds.
Thoracic Rotation
Sitting comfortably with your arms folded across your chest. Slowly rotate your trunk to your right, hold for a count of 10, and slowly rotate your trunk to your left, again holding for a count of 10. Repeat 3-5 times in each direction.
Neck movements
Sitting or standing comfortably slowly move your neck to:
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Look up to the ceiling and then down to the floor.
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Look over your right and left shoulder.
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Tilt your head to your right shoulder, and then to your left shoulder.
Repeat each movement 5-10 times.
Stretches
Note: All stretches should be comfortable to undertake, if you find they are painful or you are holding your breath, ease off the stretch.
Some of the stretches have beginners, intermediate and advanced stages. Start off at the beginning stretch and don’t move onto the next stage until the stage you are on is easy, or not giving you a good stretch.
Beginners’ chest stretch
Roll a small towel into a long roll, and place this along your spine whilst lying on your bed or on a mat on the floor. Relax, allowing your shoulders to draw back towards the bed/floor. You should feel a gentle stretch across your chest and into the front of your shoulders. Hold for a count of 20-30 seconds and repeat 3 times.
Intermediate chest stretch
Roll a small towel into a long roll, and place this along your spine whilst lying on your bed or on a mat on the floor. Place your hands up behind your head and relax allowing your shoulders to draw back towards the bed/ floor. You should feel a stretch across your chest and into the front of your shoulders. Hold for a count of 20-30 seconds and repeat 3 times.
Advance chest stretches
Standing in a doorway raise your arm up so your forearms resting against the frame. Slowly lean into or take a small step through the doorframe, so you feel a stretch across your chest and into your shoulders. Your legs should control the intensity of the stretch by bending or straightening your knee through the doorway. Hold the stretch for 30 seconds and repeat 3 times.
Have your arms relaxed by your side with your palms resting against the doorframe. Slowly lean into or step through the doorframe so you feel a stretch across your chest and into your shoulders. Your legs should control the intensity of the stretch by bending or straightening your knee through the doorway. Hold the stretch for 30 seconds and repeat 3 times.
Child pose
While on all fours on your bed or on the floor on a mat, slowly lower your buttocks to your feet until you feel a stretch across your back. Hold for a count of 20-30 seconds, relax, and repeat 3 times.
Beginniers Side flexion stretch
Standing with your arms relaxed by your side. Slowly glide your hand down your leg so you feel a stretch down the side. Make sure you don’t bend forward. Hold the stretch for 20-30 seconds and repeat 3 times on each side.
Intermediate side flexion stretch
Standing with your legs shoulder width apart. Raise your arm up above your head and lean over to your side ensuring you don’t bend forward. You should feel a stretch down your side and into your arm. Hold for a count of 20-30 seconds, repeat 3 times on each side.
Range Of Movement Exercises
Note: Some of the range of movement exercises have beginners, intermediate and advanced stages. Start off with the beginner exercises and don’t move onto the next stage until the stage you are on is easy. Repeat each range of movement exercise 5-10 times, 1-2 a day.
Thoracic extension
Sitting on a chair with good posture and your arms behind your head, slowly raise your arms, head, and chest as one unit up, so you extend your back, then return to your starting position.
Trunk rotation
Lying on your side, with your arms stretched out in front of you, slowly twist your trunk and rotate your spine, with your upper arm and head following the spine. Return to your starting position.
Shoulder flexion Beginner
Lying on your back with either your hands glasped together or holding onto a broom. Slowly raise your arms up above your head to were is comfortable, and slowly lower back down towards your side.
Shoulder Flexion Intermediate
In standing with either your hands glasped together or holding onto a broom. Slowly raise your arms up above your head to were is comfortable, and back down towards your side.
Advanced Shoulder Flexion
Advanced: standing slowly raise your arm up above your head to were is comfortable and back down towards your side. Note if you find this too uncomfortable, you can walk your hand up and down a wall to begin with.
Beginner Shoulder Abduction
Lying on your back holding a broom, slowly use the unaffected arm to guide the affected arm up and out to the side. Slowly return the arm back to the starting position.
Intermediate shoulder Abduction
In standing holding onto a broom, slowly use the unaffected arm to guide the affected arm up and out to the side. Slowly return the arm back down to your side.
Advanced Shoulder Abduction
In standing slowly raise your arm up and out to the side and slowly return the arm back down to your side.
Shoulder extension
Standing with your arm down by your side, slowly extend your arm back behind you, and then return it back to your side.
Shoulder external rotation
Lying on your side with the affected arm on top, place a rolled-up towel rolled up under your affected arm. With the arm relaxed resting on your stomach, slowly raise your forearm so it is horizontal, and slowly lower back to your stomach.
Isometric Strength Shoulder Exercises
Note: For these exercises you will need to stand near a wall and have a towel to place against the wall for comfort. You will be applying a light pressure into the wall for 5-10 seconds to get the rotator cuff muscles in the shoulder to contract. Repeat each exercise 5-10 times, 1-2 a day.
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Face a wall and gently apply a light pressure pushing your fist into the wall. Relax and repeat.
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With your back toward the wall, apply a light pressure by pushing your elbow into the wall. Relax and repeat.
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Facing with your affected arm towards the wall, apply a light pressure pushing the forearm out into the wall. Relax and repeat.
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With your affected forearm resting again a wall or doorframe, apply a light pressure pushing the forearm into the wall. Relax and repeat.
Resistance Band Strength Exercises.
Note: For these exercises you will need a light resistance band (depending on the brand this is normally a yellow or red band). However, if you have an allergy to latex you will need to ensure you have a latex free band. If you are unable to get a latex free band move onto the free weight exercises but ensure you use a very light weight. Once you have a band you will need to tie a knot into one end of the band and place it in a closed door, that no one will walk through whilst you’re doing the exercises. When returning to the starting position of each exercise make sure you control the speed and do not let the band bounce your arm back to the starting position. Repeat each exercise 5-10 times, 1-2 a day.
Shoulder Extension
Facing the door, holding onto the end of the band, slowly extend your affected arm down and back. slowly allow the arm to return to the starting position.
Shoulder Abduction
With your unaffected arm furthest away from the door. Slowly take the arm out and up to the side, and slowly return the arm back to the side.
Shoulder Adduction
With your affected arm closes to the door, take a sidestep away from the door. With your arm out to side slowly pull the arm down to your side.
Shoulder Flexion
Standing with your back to the door, slowly straighten the arm up and out in front of you towards the ceiling. Slowly lower the arm back towards your side.
Shoulder External Rotation
Standing with your affected arm furthest to the door, with a rolled-up towel under your affected arm. Keeping the towel in place between your arm and chest, slowly take the forearm away from your stomach and out to the side. Slowly, return the forearm so it is resting on your stomach.
Shoulder Internal Rotation
Standing with your affected arm closest to the door, with a rolled-up towel under your affected arm. Keeping the towel in place between your arm and chest, slowly take the forearm towards your stomach. Slowly allow the forearm to return to the starting position with your fist facing forward.
Serratus Anterior Row
Sitting facing a table, wrap the band around a table leg. With both elbows bend to 90 degrees, with your arms close to the chest, slowly extend the arms back keeping the elbows bent, as if rowing backwards.
Free Weight Exercises
Note: For these exercises you will need to use a light weight, for example, something that weighs around 500g. You can slowly increase this weight to 1kg when you feel comfortable and continue to increase your weight with the guidance of your Physiotherapist. Repeat these exercises 5-10 times, 1-2 a day.
Shoulder flexion
In standing with the weight in your affected hand and your thumb pointing up towards the ceiling, slowly raise your arm up from your side towards the ceiling, and slowly back down towards your side.
Shoulder Scaption
Standing with the weight in your affacted hand and your thumb pointing up towards the ceiling, slowly raise the arm out slightly to the side and up towards the ceiling (aiming as if you are pointing to the corner of a room/ 45 degree angle), and back down towards your side.
Side Lying External Rotation
Lying on your side with the affected up on top. Place a towel under the affected arm, holding the weight. Start with your forearm resting down by your stomach, slowly raise the forearm up so it is horizontal, and then slowly lower the arm back toward your stomach.
Serratus Anterior Row
Standing, lean forward and us your unaffected arm to support and stabilise yourself. Holding the weight in your affected arm, start with the arm straight down by your side, bend the elbow back, as if rowing backward or starting a lawnmower. Slowly straighten the arm down towards your side and repeat.
Useful information and resources:
Breast Cancer Now
Cancer Research UK
http://www.cancerresearchuk.org/
Macmillan Cancer Support
http://www.macmillan.org.uk/information-and-support/index.html
