Wistozky, EM Chapter Six v.4
Author-1: Eric M. Wistozky, MD
Associate Director, Cancer Rehabilitation
MedStar National Rehabilitation Hospital
Chapter Six
Managing Muscle Pain
MUSCLE PAIN KEY POINTS





May occur in up to 50% of people after breast cancer treatments
Common causes include radiation fibrosis, myofascial pain, rotator cuff
tendinitis, tennis elbow, and myalgias
Exercise is often an effective treatment
Psychological interventions can be beneficial
Many different over-the-counter and prescription medications can help
1
1
INTRODUCTION
2
Muscle pain can be a serious and debilitating condition for some breast-cancer survivors. This
3
chapter will discuss why breast-cancer patients may develop muscle pain and how it can be
4
managed through conservative rehabilitation interventions. The first section of this chapter will
5
define pain. The different causes of muscle pain in breast cancer will then be explained. Lastly,
6
the multitude of conservative treatment options for muscle pain will be discussed.
7
SECTION I: WHAT IS PAIN?
8
Pain is an unpleasant sensation that is sent to your brain. Pain is something that you perceive.
9
It is a highly personal experience. This is why two people exposed to the exact same injury or
10
surgery may have a very different experience and perceive it in a different way. Have you ever
11
heard someone say that they have a “high pain tolerance”? Well, that person’s brain may just
12
perceive pain differently than someone else. Just like two people may react differently to being
13
pinched, two people may react differently to the exact same breast surgery. That is why it is
14
important to not put too much stock into another person’s experience. Your experience is your
15
own and may be completely different from else’s experience.
16
Keep in mind that there may be minimal pain after breast cancer treatment. You may
17
have a little pain for a short time, or a lot of pain for a long time, or somewhere in between. Up
18
to 50% of people after breast surgery may continue to have pain 2 years after breast surgery.
19
One study showed 17% of women with pain 12 years after breast surgery. This is dependent
20
on many factors, particularly the type of surgery and other treatments such as chemotherapy
21
and radiation. Studies have shown that younger patients have a higher occurrence of persistent
22
pain, as do people who are overweight. Less invasive surgery results in a lower risk of pain, but
2
23
those with less invasive surgery still do develop pain. Up to 80% of patients after less invasive
24
breast surgery may have nerve pain symptoms as some point. Up to 23% of patients may have
25
an uncomfortable feeling that the breast is still there, also called “phantom pain”.
26
Acute pain generally refers to pain in the first month after surgery. The amount of acute
27
pain may depend on the type of surgery, the extent of the cancer, and if you have any surgical
28
complications. Good pain control during this period is very important because it has been shown
29
that people with more severe acute pain have a higher likelihood of having chronic persistent
30
pain.
31
Chronic pain is typically defined as pain which persists for greater than six months.
32
Unfortunately, it is difficult to predict who may develop chronic pain. Pain that can be due to the
33
trauma of surgery, over time can lead to persistent pain due to increased sensitivity of the
34
surgical area. The brain can become overly sensitive as well, so even though the surgical area
35
has healed completely, the brain may still perceive pain. This type of pain becomes very difficult
36
to treat.
37
The identification of pre-operative pain (pain before surgery) is very important. Some
38
types of pain that exist before cancer treatment can be worsened by breast surgery,
39
chemotherapy, and radiation. This is why it is important to discuss these problems with your
40
cancer doctors before treatment. If these problems can be addressed before cancer treatment,
41
there will be a decreased chance of pain after treatment. A physiatrist can manage these
42
problems before cancer treatment, which will decrease the severity of acute and chronic pain.
43
Here is an example:
44
45
A patient was recently diagnosed with right breast cancer. When her surgeon evaluated
her, he noticed that her left shoulder motion was severely impaired due to pain. This was a
3
46
major concern considering that she would have great difficulty functioning after surgery if her
47
right arm was recovering from surgery while the left shoulder was already severely impaired.
48
The patient was referred to a physiatrist who diagnosed the patient with rotator cuff (definition.
49
See page 4) and biceps tendinitis (inflammation of the tendon). Given that the patient was
50
having surgery in a few weeks, the physiatrist performed injections of the rotator cuff and biceps
51
tendons which resulted in an immediate decrease in pain and improvement in motion. The
52
patient was also sent for a specific rehabilitation program with a physical therapist. The
53
combination of these treatments improved her left arm function which significantly helped her
54
functional recovery from breast surgery.
55
SECTION II: MUSCLE PAIN IN BREAST CANCER
56
There are many possible causes of muscle pain in breast cancer. Most of these problems occur
57
either due to surgical trauma, changes in body posture, or radiation. This section will discuss
58
these common causes of muscle pain.
59
Radiation Fibrosis
60
Radiation can lead to the chronic production of scar tissue (also called fibrosis) in the area of
61
radiation. This can cause tightness of muscles in the radiation path. Because they are under
62
the breast tissue, the chest muscles are most likely to be affected by this. When these muscles
63
get tight, they change the motion of the shoulder and can lead to other problems like rotator cuff
64
injury, which is discussed below. Because the rib muscles are involved in breathing, if these
65
muscles are overly tight or painful, even deep breaths can be uncomfortable. This can be
66
particularly problematic, as it may decrease the ability to exercise. Women often develop poor
67
posture after breast surgery, which makes this problem worse.
4
68
How is this managed? The first thing to do is “open up” the chest wall. These muscles
69
can be loosened by stretching the chest wall and improving posture. This will decrease pain
70
and prevent other shoulder problems, like rotator cuff tendinitis (huh?). “Myofascial release” is
71
often extremely helpful for this as well. This involves deep hands-on work, typically performed
72
by a physical therapist, to break up the scar tissue from radiation and “loosen up” these
73
muscles.
74
Myofascial Pain
75
This is a fancy term for muscle pain. The hallmark of true myofascial pain is the presence of
76
“trigger points”. These are tight bands of muscle tissue that you can feel. Have you heard
77
someone say they have a “knot” in their muscle? Well that knot may be a trigger point. When
78
pressed, these trigger points often radiate pain to other areas. This problem is also more
79
common after radiation.
80
The management of myofascial pain is very similar to what was discussed above for
81
radiation fibrosis. In addition to stretching and myofascial release, another treatment for this
82
problem is the “trigger point injection”. This involves using a very small needle to break up
83
some of these tight muscle areas. This treatment can be very effective for some patients. It is
84
typically a minimally painful procedure.
85
Rotator Cuff
86
The rotator cuff is a group of tendons that moves and stabilizes the shoulder. Wear and tear of
87
these tendons is common after breast cancer treatment. When the tendons are newly injured or
88
inflamed we call this tendinitis (itis = inflammation). After a while the problem is not really
89
inflammation of the tendon, but actually just wear and tear of the tendon. In that case, it is
5
90
called tendinopathy or tendinosis. Regardless of what you call it – it hurts! It can limit overhead
91
movement of the arm and it may hurt to sleep on the affected shoulder. When chest muscles
92
are too tight due to surgery and radiation, this can put more pressure on the rotator cuff,
93
resulting in pain. After breast surgery and radiation, there can be a tendency to overuse these
94
tendons, or to use them improperly.
95
So how is this managed? After a physiatrist diagnoses a rotator cuff problem, a specific
96
rehabilitation program will be prescribed. Stretching the tight chest wall muscles helps.
97
Strengthening the muscles around the shoulder blade takes the pressure off the rotator cuff
98
tendons, and helps the shoulder move normally. If this doesn’t work, cortisone injections
99
around the rotator cuff may be helpful.
100
Tennis elbow
101
What does tennis have to do with breast cancer? Well, a common problem that occurs in tennis
102
players can occur in breast cancer survivors. Tennis elbow is caused by overuse of tendons
103
that start at the elbow and extend to the wrist. Repetitive movement at the wrist can lead to this
104
elbow pain. Breast cancer survivors may have a tendency to overuse their elbows and wrists,
105
since they are avoiding using their shoulder due to pain. This can result in tennis elbow (also
106
called lateral epicondylitis).
107
Tennis elbow can often be treated successfully with rehabilitation techniques. A special
108
brace called a counterforce brace can be helpful. Physical or occupational therapists can help
109
stretch and slowly strengthen the appropriate muscles to decrease pain. If these techniques
110
don’t work, injections by a physiatrist are also an option.
111
Myalgias
6
112
Myalgias, or achy muscles, are a potential side effect of chemotherapy treatments. They can
113
also be caused by medications that many breast cancer patients are on, such as tamoxifen or
114
aromatase-inhibitors. These medications are extremely important because they may decrease
115
the risk of cancer recurring. However, they can have the side effect of achy joints or muscles
116
anywhere in the body.
117
For most people, these symptoms can be reduced by simple over the counter
118
medications like acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs)
119
like ibuprofen or naproxen. Topical pain medications, which are applied to the skin may also be
120
used. If these medications are not effective, nerve stabilizing medications (like gabapentin or
121
pregabalin) can be helpful as well. Nerve stabilizing medications and their side effects are
122
discussed in more detail in the “Managing Nerve Pain” chapter.
123
Exercise may be an important component of managing these symptoms. Specifically,
124
aerobic exercise (such as walking, running, biking, swimming) appears to be the most helpful.
125
A physical therapist can direct a program of slowly progressive stretching and strengthening
126
program which can help these symptoms. A physiatrist’s evaluation can determine what kind of
127
exercise is safe and help to design the appropriate program.
128
SECTION III: EXERCISE FOR PAIN
129
Exercise has not been clearly proven to improve pain in breast cancer survivors, but it certainly
130
helps with fatigue, mood, endurance, body image, and a sense of well being. There are also
131
many indirect effects of exercise which should help with pain. Weight loss may decrease joint
132
pain by decreasing the load on the body’s joints. Exercise helps with mood and sleep, both of
133
which can be correlated with pain. More specific information about exercise will be discussed in
7
134
the exercise chapter in this book (chapter 14). Again, as not all types of exercise are safe from
135
everyone, a physiatrist’s evaluation can help determine what type of exercise is safe.
136
SECTION IV: PSYCHOLOGICAL INTERVENTIONS FOR PAIN
137
The majority of cancer patients experience some form of depression or anxiety. This is
138
generally due to fear of death, anxiety about diagnostic tests, fear of painful and invasive
139
procedures, and the fear of cancer coming back after it is successfully treated. It has been
140
shown that anxiety and depression may contribute to pain.
141
Many different psychological strategies can be helpful and need to be patient specific.
142
Simple education about the cancer itself, cancer treatments, and expectations can often
143
decrease anxiety. A simple lack of understanding of the disease can lead to fear. The cancer
144
patient often feels out of control. Knowledge about the disease is empowering and helps the
145
patient regain control. Coping skills can be learned, which can help during the navigation of the
146
cancer treatment course. Many people feel somewhat depressed or anxious during or after
147
cancer treatments, which is often called an adjustment disorder (adjusting to a difficult life
148
circumstance). If the depression or anxiety is more severe it may require treatment with talk
149
therapy or medications.
150
A pain psychologist can be critical to helping with depression and anxiety’s effects on
151
pain. Many patients who have had chronic pain that were not helped by exercises, physical
152
therapy, medications, or injections have improved significantly by working with a pain
153
psychologist (a PhD psychologist with special training in the treatment of pain). Being sent to a
154
pain psychologist does NOT mean you are crazy. The pain psychologist can implement mental
155
techniques to help you decrease your perception of pain. Remember from the beginning of this
156
chapter – pain is a perception! Hypnosis is one such technique that can help reduce pain. One
8
157
advantage of hypnosis is that one can be taught to do it at home. It has been found to be useful
158
for both acute and chronic pain. Learning imagery skills can help you will your mind into
159
perceiving less pain. These techniques can be helpful even if there is no anxiety or depression.
160
By using the power of the mind, pain can be decreased.
161
If you feel these techniques could be beneficial to you, ask your physiatrist to find you a
162
pain psychologist. A more detailed discussion of psychological ramifications of breast cancer
163
will be discussed in chapter 15.
164
SECTION V: MEDICATIONS FOR MUSCLE PAIN
165
Pain symptoms can often be managed with over-the-counter medications. Please keep in mind
166
that even over-the-counter medications can have side effects and interact with other
167
medications you are taking. Therefore, please talk to your doctor before using any over-the-
168
counter medication regularly.
169
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
170
These medications, such as ibuprofen and naproxen can be very effective for pain. They are
171
anti-inflammatories, so they can be helpful if inflammation is part of the cause of pain. Caution
172
is recommended if you have a history of acid reflux, stomach ulcers, heart, or kidney problems.
173
Taking these medications with food can often be helpful to prevent an upset stomach. Again,
174
always discuss the use of these medications with your doctor.
175
Acetaminophen
176
This medication (most commonly known as Tylenol) is another helpful over-the-counter pain
177
medication. It is not an anti-inflammatory like ibuprofen. Acetaminophen has been shown to be
9
178
particularly effective for headaches, which are common in those with cancer. The big concern
179
about this medication, is that it can affect the liver. PLEASE consult your doctor to make sure
180
your liver is healthy and that this medication will not interact with other medications you are
181
taking.
182
Topical Medications (medications applied to the skin)
183
I find these medications particularly helpful for those with breast cancer. These are pain
184
medications that can be rubbed on to the painful area. People love these medications for many
185
reasons. First of all, the “massaging” effect of rubbing a pain medication into the uncomfortable
186
area is comforting. When you are applying the medication to your own body by hand, it really
187
makes you feel like you are in charge of your own pain relief. Secondly, these topical
188
medications rarely cause side effects or interact with other medications. Oral pain medications
189
commonly have side effects and cancer patients are sick of dealing with side effects. In
190
addition, if you are on other medications, you may not want to take yet ANOTHER medication or
191
deal with potential interactions between your medications.
192
Another reason why topical medications are effective, is that most of this pain is caused
193
by very superficial structures that are affected by radiation or surgery. Therefore, the topical
194
medication can penetrate directly to the area causing pain, which can be very effective. Studies
195
have shown that these medications may penetrate 1-2 inches under the skin. Why take a pain
196
medication by mouth that goes throughout the whole body, when you can apply medication
197
directly to the site of pain?
198
There are several options for topical pain medications. Some are over the counter and
199
some require a prescription. Over the counter medications usually contain ingredients like
200
capsaicin, menthol, and aspirin. These have been shown to be effective to some degree. Use
10
201
caution when using an aspirin-containing medication if you already taking aspirin or any other
202
blood thinning medication. A prescription option that is commonly used is a topical anesthetic
203
(lidocaine) which numbs the painful area. This can be given in the form of a cream, gel, or
204
patch, which can often be very effective. Another commonly used prescription topical pain
205
medication is a topical anti-inflammatory. This is like taking an NSAID (discussed above), but
206
topically. These are available as gels, creams, liquids, or patches.
207
Another option is a topical compound. What is great about a compound is that you can
208
combine multiple medications into a cream to treat pain. Pain, especially in breast cancer, often
209
has many causes. There is typically pain due to muscle spasm, inflammation, and nerve
210
irritation. If there are multiple causes of the pain, why treat just one of those causes? A topical
211
compound can combine medications that treat all the causes of your pain with a very low
212
likelihood of any side effects. Many doctors may not have experience prescribing compounds,
213
so you can ask your doctor to refer you to another specialist that is comfortable prescribing
214
these.
215
Opiates
216
Opiates are the “strong” pain medications that most people know of as percocet, vicodin,
217
oxycodone, oxycontin, morphine, etc. These medications are very commonly prescribed to
218
cancer patients, for two reasons. Pain in cancer is thought to be very severe, so doctors often
219
want to pull out the “big guns” to treat pain. Secondly, cancer patients may have a decreased
220
life expectancy, so why not give them the strong stuff? There are a few reasons why these
221
sentiments may be incorrect:
222
223

Cancer doctors are often using less invasive methods for cancer treatment.
Surgeries are becoming less extensive and radiation fields are getting smaller.
11
224
Therefore, theoretically, the pain caused by these interventions may be less
225
severe for some people.
226

As mentioned above when talking about topical compounds, the specific cause of
227
pain should be addressed. Opiates are not specific for any certain type of pain.
228
If your pain is from muscle – a muscle pain medication can be used. If your pain
229
is from nerve – a nerve pain medication can be used. Just because the opiates
230
are “strong”, doesn’t mean they will work the best for these specific causes of
231
pain.
232

In many cases, the argument to give cancer patients strong pain medications
233
because they are going to die, is out the window. Many cancer patients are living
234
longer and longer. The death rate from cancer is declining every year as
235
treatments get better and better. The life expectancy, especially for many breast
236
cancer patients, is now quite good. After cancer treatment, patients may live
237
many years or may have a completely normal life expectancy. Therefore, it may
238
be more appropriate to consider other medications that are less addictive for the
239
long-term.
240

These medications can have serious potential side effects. In addition to the
241
potential for addiction mentioned above, they can cause severe constipation,
242
depression, can alter bodily hormone levels, and can even result in overdose and
243
death.
244
As you can see, pain in cancer can often be treated without opioid medications.
245
However, there certainly are cases when opioids may be appropriate. A physiatrist will treat
246
their patient as an individual to determine the best treatment plan for that person.
12
247
SECTION VI: INJECTIONS FOR MUSCLE PAIN
248
When other conservative treatment options fail, injection can be a last resort. There are many
249
minimally invasive injection options available which can be helpful for pain. What’s important to
250
keep in mind, is that the injection should be specific to what your doctor feels is the cause of
251
your pain. This is why it is important for your doctor to send you to a specialist, such as a
252
physiatrist, who can examine you to determine the exact cause of your pain.
253
254
255
One of the most commonly used procedures for muscle pain is the trigger point injection,
which was discussed above on page 4. Other options include:

Tendon injections: If the cause of the pain is due to a tendon problem, such as in
256
rotator cuff tendinitis or tennis elbow, an injection around the tendon, in conjunction
257
with rehabilitation techniques, can often be very helpful. Most commonly these
258
injections are done with anesthetic and corticosteroid (cortisone-a type of steroid). A
259
few corticosteroid injections are typically safe and effective, but having too many of
260
these injections around the same tendon, can potentially weaken the tendon over
261
time and worsen the problem. There are other newer injection techniques which
262
may help to regenerate wear and tear of a tendon (so called “regenerative
263
procedures” such as platelet-rich plasma and prolotherapy), but these need more
264
research before becoming the standard of care. At this time, most insurance
265
companies do not cover these injections.
266
Botulinum toxin injections: These injections, most commonly known as botox, can
267
be helpful to relax tight muscles or trigger points. If muscle pain continues despite
268
rehabilitation, medications, and trigger point injections, these injections can be an
269
option. More research is needed to recommend these injections as a standard
13
270
treatment, but there are some reports of success in cancer patients. Also, insurance
271
does not always cover these injections.
272
CONCLUSION
273
There are many potential causes of muscle pain in breast cancer patients. Ideally,
274
addressing pain which exists before cancer treatment, will help with long-term outcomes.
275
When your doctor assesses your pain, it is important to have a specific diagnosis of the
276
cause of your pain. The physiatrist can be critical to determining a precise diagnosis. Once
277
a diagnosis has been determined, a specific treatment plan can be designed. Often,
278
successful treatment can take place without invasive interventions, and often without any
279
medications. You don’t have to live with this pain forever, and often there are many things
280
that can be done to help you.
281
Important Points to Remember
282

There are many potential causes of muscle pain in breast cancer patients.
283

Effective treatment of pain begins with a correct diagnosis.
284

A physiatrist is trained to make a precise diagnosis and prescribe a comprehensive
285
treatment plan that often involves a team of knowledgeable health professionals.
286

Good pain control early reduces the likelihood of having chronic persistent pain.
287

Successful treatment can often occur without invasive interventions or medications.
14
288
Glossary
289
Acute - Having a sudden onset, sharp rise, and short course.
290
Aerobic - Exercise which involves increasing oxygen consumption for the body, such as
291
running, walking, swimming, etc.
292
Chronic - Marked by long duration or frequent recurrence.
293
Compound - A cream formed by combining multiple different components.
294
Fibrosis - Collection of scar tissue.
295
Hypnosis - A trance-like state that resembles sleep but is induced by a person whose
296
suggestions are readily accepted by the subject.
297
Inflammation- A response to injury marked by blood vessel dilation, white blood cell infiltration,
298
redness, heat, and pain that serve as a mechanism to eliminate noxious agents and damaged
299
tissue.
300
Myalgias - Pain in one or more muscles.
301
Myofascial - Pain related to muscle and its surrounding tissue.
302
Physiatrist - A physician who specializes in physical medicine and rehabilitation. This physician
303
non-surgically manages functional, neuromuscular, and musculoskeletal impairments with a
304
focus on improving function and quality of life.
305
Tendinitis - Inflammation of a tendon
306
Tendinopathy - Degeneration of a tendon.
15
307
Tendinosis - Degeneration of a tendon.
308
Tendon - A tough band of tissue that connects a muscle with bone.
309
Topical - Designed to be applied on the surface of the body such as an ointment or a cream.
16
310
Symptom Index
311
Tightness
312
Knots
313
Achy
314
Headaches
315
Muscle spasm
17
316
Additional Reading/Resources: Unfortunately, there are not many good articles for the
317
general reader about muscle pain in breast cancer survivors. The web-links below can be
318
helpful. Also, listed are two excellent publications in the scientific literature on this topic.
319
http://www.cancer.net/survivorship/rehabilitation
320
http://www.cancer.net/survivorship/late-effects
321
Ebaugh D, Spinelli B, Schmitz KH. Shoulder impairments and their association with
322
symptomatic rotator cuff disease in breast cancer survivors. Med Hypotheses, 2011 Oct; 77(4):
323
481-7.
324
325
Gartner R, Jensen M, Neilsen J. Prevalence of and factors associated with persistent pain
326
following breast cancer surgery. JAMA 2009;302(18):1985-1992.
18