Adhesive capsulitis after breast surgery

🩺 Case Scenario: Frozen Shoulder Post-Mastectomy (Left Shoulder) in a 48-Year-Old Woman

📌 Patient Profile

  • Name: Mrs. A. (initials only)

  • Age: 48 years

  • Gender: Female

  • Occupation: Homemaker

  • Medical History: Left breast mastectomy (8 months ago) with axillary lymph node removal, mild lymphedema

  • Lifestyle: Active before surgery, but restricted movement since mastectomy

📌 Presenting Complaint

Mrs. A. complains of:

  • Severe stiffness in left shoulder developing gradually after surgery

  • Pain in the shoulder during overhead reaching, grooming, and cooking

  • Difficulty wearing blouses/dresses due to restricted abduction

  • Pain level: 7/10 on VAS during movement, 4/10 at rest

📌 Clinical Examination

🔹 Inspection

  • Surgical scar on the chest wall (well-healed)

  • Mild lymphedema of left upper limb

  • Guarded posture (holding arm close to chest)

🔹 Palpation

  • Tightness over pectoralis major and anterior capsule

  • Mild tenderness around the deltoid region

🔹 Range of Motion (ROM)

  • Flexion: 80°

  • Abduction: 70°

  • External Rotation: 30°

  • Internal Rotation: 40°

🔹 Special Considerations

  • History of mastectomy → risk of scar adhesions and lymphedema

  • Capsular pattern observed (ER > ABD > IR restriction)

Diagnosis: Adhesive Capsulitis (Frozen Shoulder) of the left shoulder, post-mastectomy complication

📌 Pathophysiology

  • Post-mastectomy, scar tissue and radiation therapy can lead to fibrosis of the capsule and surrounding soft tissues.

  • Protective posture → disuse of the arm → joint capsule contracts → frozen shoulder develops.

  • Lymphedema may worsen shoulder stiffness.

📌 Physiotherapy Management Plan

🔹 Stage 1: Painful (Freezing Stage)

Goals: Reduce pain, prevent stiffness progression, manage lymphedema

  • Modalities:

    • Moist heat before therapy (if no contraindication)

    • Gentle scar tissue mobilization

    • TENS for pain management

  • Exercises:

    • Gentle pendulum exercises

    • Assisted ROM with stick (within pain-free limits)

    • Hand pumping and elevation for lymphedema control

    • Breathing exercises for relaxation

🔹 Stage 2: Frozen Stage (Common Post-Mastectomy Phase)

Goals: Increase mobility, reduce capsular tightness, improve function

  • Manual Therapy:

    • Glenohumeral joint mobilizations (Grade II–III)

    • Scar mobilization to release adhesions

    • Pectoralis muscle stretching

  • Exercises:

    • Wall climbing (flexion, abduction)

    • Pulleys for assisted flexion

    • Gentle yoga stretches (thread-the-needle, chest openers)

    • Theraband scapular strengthening

  • Home Program:

    • Daily stretching at least 2–3 times/day

    • Encourage functional use of the arm (dressing, light cooking tasks)

🔹 Stage 3: Recovery (Thawing Stage)

Goals: Restore full ROM, strengthen, return to daily life activities

  • Progressive Resistive Exercises:

    • Theraband external rotation & rows

    • Light dumbbells (1–2 kg) for shoulder flexion and abduction

    • Proprioceptive training with ball exercises

  • Functional Training:

    • Dressing, grooming, overhead reaching

    • Household activities involving lifting and reaching

  • Patient Education:

    • Frozen shoulder may last 12–18 months, but compliance improves outcome

    • Lymphedema care (compression sleeves, elevation, gentle massage)

    • Importance of early shoulder exercises post-mastectomy to prevent recurrence

📌 Progress Notes (Expected)

  • Week 2–4: Pain reduces to 5/10; better pendulum exercise tolerance

  • Week 6–8: Flexion 110°, abduction 90°, able to do light household chores

  • Month 3: ROM continues improving; scar softening

  • Month 6: Near full ROM, independent in ADLs (Activities of Daily Living)

📌 Discussion & Learning Points

  • Post-mastectomy patients are at high risk of frozen shoulder due to scar tissue and protective immobility.

  • Early mobilization after surgery is the best prevention.

  • Physiotherapy should include pain relief, scar mobilization, gradual stretching, and strengthening.

  • Psychosocial support is equally important (as mastectomy impacts mental health too).

📌 Key Takeaway for DPT Students

“In post-mastectomy frozen shoulder, always consider scar tissue management, lymphedema care, and gradual mobilization as part of rehab.”

FAQs

1. Why does frozen shoulder occur after mastectomy?

Due to post-surgical pain, scar tissue formation, and avoidance of arm movement, the shoulder can become stiff and immobile.

2. How can frozen shoulder be prevented after breast cancer surgery?

  • Start gentle arm exercises early (as advised by doctor)

  • Avoid prolonged immobilization

  • Maintain good posture

  • Physiotherapy follow-up is crucial

3. Is it safe to do shoulder exercises after mastectomy?

Yes ✅ but only under medical and physiotherapist supervision, especially if lymph nodes were removed.

4. How long does it take to recover from frozen shoulder after mastectomy?

Usually 6–12 months, depending on pain, scar tissue, and consistency in physiotherapy.

5. Can physiotherapy improve quality of life after mastectomy?

Yes, physiotherapy helps restore movement, reduce pain, and improve daily activities — also boosting confidence and independence.

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