Shoulder and arm exercises after breast cancer surgery

Arm and shoulder exercises help you get back the movement you had before surgery [1]. Breast Cancer Now warns that "Muscles and joints can seize up very quickly if they're not used" [1].

They can also ease tight scars and cording, prevent long-term stiffness and reduce the risk of lymphoedema [1]. The NHS lists "frozen shoulder or loss of mobility in your shoulder" among the possible complications of a mastectomy [3].

A Cochrane review of 24 studies with 2,132 participants concluded that exercise "can result in a significant and clinically meaningful improvement in shoulder ROM" (range of movement) in women with breast cancer [7].

Usually the day after your operation, ideally having started them before surgery [1].

Starting very early also increased wound drainage in the Cochrane review, so the authors said it "may need to be carefully weighed against the potential for increases in wound drainage" [7]. That is why your surgical team sets the pace.

Usually, yes, if the movement stays comfortable and the drain tubing is not pulled [2]. Some people go home with a drain still in [2]. An NHS hospital leaflet from Hull University Teaching Hospitals says exercises "can still be carried out, but just make sure you are keeping it at a comfortable range of movement that doesn't cause pain or discomfort and the drain tubing is not pulled" [2]. Ask your breast care nurse what applies to you, especially before the advanced exercises.

The NHS says drains are temporary and "will usually be removed within a few days or weeks" [3].

Breast Cancer Now's programme, "developed with the help of breast surgeons, breast care nurses and physiotherapists", has nine exercises in three groups [1]. Your hospital will give you its own sheet with step-by-step instructions; follow that sheet, because programmes differ between hospitals.

Warm-up and cool-down [1]

1. Shoulder shrugs
2. Shoulder circling

Basic exercises [1]

3. Bent arms forward
4. Bent arms sideways
5. Back scratching
6. Winging it

Advanced exercises [1]

7. Wall climbing
8. Arm lifts
9. Elbow push

Hospital programmes can look different. The Hull leaflet, for example, starts "the day after your surgery (day 1)", asks for "5 repetitions of every exercise" three times a day, and for an early lifting exercise says "Only raise up to shoulder height" [2]. It says getting your movement back "should take about 4 to 6 weeks" [2].

They should stretch, not hurt: "You should not feel pain when doing the exercises. However, a stretching or pulling sensation is normal" [1]. Stop and get advice if the pain gets worse during the exercises or carries on afterwards (see below) [1].

Follow your own surgeon's plan. Breast Cancer Now says that if you have recently had a reconstruction, "talk to your surgeon, breast care nurse or physiotherapist before you start any exercises" [1].

The research has a gap here: the UK PROSPER trial of exercise after breast surgery excluded women having immediate reconstruction [6]. Ask your team what you can do in week one, when you can lift your arm above shoulder height, and when you can return to strength work.

Cording, also called axillary web syndrome (AWS), is a tight cord under the skin of the armpit that may run down the inside of the upper arm [5]. The cords often make it painful to lift your arm out to the side and limit how far your shoulder moves [5].

It is more likely if more lymph nodes were removed [5]. A review in Breast Cancer: Targets and Therapy reported rates of 36% to 72% after axillary lymph node dissection and 11% to 58% after sentinel lymph node biopsy, most often starting 2 to 8 weeks after surgery [5].

Cording does not clear up in everyone: it can persist for years after surgery or come back after it has gone [5]. Contact your breast care nurse or physiotherapist as soon as possible if you notice it [1]. The review recommends physiotherapy as a safe and effective main treatment, with gentle hands-on techniques [5].

Stiffness can come from the surgery, from radiotherapy, or from a frozen shoulder [1][3]. Breast Cancer Now says "Arm stiffness and weakness can happen after radiotherapy", so keep doing the exercises for as long as you still feel tightness [1].

A frozen shoulder means "your shoulder is painful and stiff for months, sometimes years" [8]. The NHS lists surgery that stops you moving your arm normally as a risk factor, and warns that keeping the shoulder still "will make the pain worse" [8]; see a GP if pain and stiffness do not go away [8]. See also exercise during radiotherapy.

Breast Cancer Now advises keeping your arm moving, not resting it. It says "Keeping your arm and shoulder moving can help reduce the risk of lymphoedema" and that "Most people who have had lymph nodes under their arm removed don't develop lymphoedema" [9].

Build up new activity gradually and "Stop if you have any discomfort or notice swelling" [9]. Get advice from your breast care nurse, treatment team or GP if your arm, hand, breast or chest swells, or rings, a watch or your bra feel tighter [9]. Our guide to lymphoedema exercises covers weights and compression.

Gradually, after the first few weeks. The NHS advises no heavy lifting or strenuous activity for 2 to 3 weeks after a mastectomy [3].

With a physiotherapist, strength work can be added in stages. In the UK PROSPER trial of 392 women at higher risk of arm problems (reconstruction excluded), a physiotherapist-led programme began 7 to 10 days after surgery with exercises to restore shoulder movement, and added strengthening exercises from one month after surgery [6]. It improved arm function at 12 months, with "No increase in complications, lymphoedema, or adverse events" [6].

Stop the exercises and speak to your surgeon, physiotherapist or breast care nurse as soon as possible if you have [1]:

• a seroma (a collection of fluid under the wound)
• a wound infection or problems with wound healing
• pain that gets worse during the exercises or continues once you've finished

Start again only when they say it is safe [1]. Guy's and St Thomas' NHS Foundation Trust lists the signs of a wound infection as skin around the wound that "is red or sore, or feels hot and swollen", liquid (often green or yellow pus) coming out, the wound opening, or feeling "generally unwell" or having a temperature [4]. If you notice any of these, "contact your hospital doctor or a GP straight away" [4].

The NHS says to call NHS 111 now if you have recently had a mastectomy and have "sudden pain or swelling", "bleeding from your wounds" or "sudden loss of feeling in your arm" [3]. Call 999 or go to A&E if you have severe difficulty breathing, pain in your chest or upper back, a very fast heartbeat, or someone has passed out [3].

If your movement is not coming back, if you have cording, or if you had shoulder problems before surgery [1]. If you are concerned about your range of movement, speak to your breast care nurse or physiotherapist [1]. The NHS says that in some areas you can ask to see a physiotherapist without seeing a GP first [8]. Once your wounds have healed and your movement is back, clinical exercise physiologists (CEPs), university-qualified health professionals who specialise in prescribing exercise [10], can build a longer-term strength programme around your treatment. See who is on a cancer rehabilitation team and cancer rehabilitation in London.

Request a match with a verified clinical exercise physiologist through The Health Nav.