This page was reviewed under our medical and editorial policy by
Daniel Liu, MD, Plastic and Reconstructive Surgeon
This page was reviewed on February 8, 2022.
Recovery after any type of surgery may be difficult, but a mastectomy may leave some patients with longer-term pain beyond the recovery stage. When postoperative pain in the chest, armpit or arm doesn’t go away after a few months, it may be postmastectomy pain syndrome, or PMPS.
Here’s how to tell whether this may be happening and, more importantly, how to find relief.
It’s normal after a mastectomy, especially with breast reconstruction, to be dealing with stiffness, swelling or a wound that drains fluid as the patient recovers, in addition to the mental toll the procedure may take. The patient will likely have pain immediately after surgery as well. But prolonged discomfort and pain could mean more than a lengthy healing process. It could signal PMPS.
Despite its name, it’s possible to develop this condition after breast-conserving surgeries, like lumpectomies, as well.
There’s no standard agreement on how long a woman experiences pain after breast surgery for it to be considered PMPS. Experts are looking at how to better define and diagnose PMPS. For instance, research clinicians in the Canadian Journal of Surgery have proposed that PMPS be defined as moderate to severe nerve-like pain in the breast or underarm area that lasts more than six months and felt about 50 percent of the time, sometimes brought on by shoulder movements.
The exact cause of postmastectomy pain syndrome isn’t known, but the most common theory is that it happens when a nerve—or nerves—become damaged during surgery. If left untreated, PMPS may not only be painful, but it may also affect the use of a woman's arm and its range of movement, and also affect her mental health.
Because PMPS is nerve pain-specific, the symptoms tend to involve shooting pain, stabbing pain, prickling pain, tingling, itchiness or numbness. It may be challenging for providers to distinguish neuropathic pain from other types of pain, so it’s helpful to write down symptoms as the patient experiences them. Be as specific as possible when describing how the pain feels, how often it happens and when it happens.
Symptoms of PMPS may include:
Between 20 percent and 30 percent of people have PMPS after mastectomy, and some studies report this number may be higher. No standard definition of PMPS exists, but as clinicians work to create one, that number may become more precise.
A woman may be more likely to have persistent postmastectomy pain, including pain from lymphedema (swelling due to undrained lymph fluid) and musculoskeletal pain, due to the following factors.
Age: While no specific age bracket is associated with having PMPS, a research review in the Canadian Medical Association Journal found that younger age is linked to a greater likelihood of persistent pain. So, a woman who is 40 may have a higher risk of post mastectomy persistent pain than a woman of 60.
Race or ethnicity: Racial and ethnic minorities are more likely to experience persistent postmastectomy pain, possibly because specific groups—namely African Americans and Hispanics—tend to be diagnosed at more advanced stages of breast cancer.
Treatment type: A woman is more likely to have PMPS if she had a surgery that removed tissue in the upper outside portion of the breast or the underarm area, or if she had an axillary lymph node dissection (ALND) that removed 10 to 14 lymph nodes to check for cancer. Women who were treated with breast cancer radiation therapy after surgery are also more likely to have PMPS.
Mental health: There’s some evidence that having a condition like anxiety or depression prior to surgery increases the likelihood a woman will have persistent pain after, according to a study in the Journal of Pain.
Previous pain: Evidence also points to a connection between pre-existing pain, such as headaches or low back pain, and the chance a patient will have persistent postsurgery pain.
If a woman is experiencing pain after a mastectomy or lumpectomy, she should talk to her cancer care team. The team may provide the help she needs to be as comfortable as possible during recovery. It’s important to address PMPS with medications and treatments that work specifically for nerve pain. Standard painkillers and even strong opioid medications don’t work well for this type of pain, though NSAIDs (non-steroidal anti-inflammatories like aspirin), may help other types of discomfort the patient experiences.
Some current treatments for PMPS include those listed below.
Physical therapy: While PMPS is regarded as a neuropathic disorder, musculoskeletal dysfunction and myofascial pain may contribute to chronic PMPS. Physical therapy programs using strengthening exercises and massage are helpful in improving shoulder pain by reducing myofascial trigger points.
Medications: As their names suggest, antidepressants and anti-epileptic medications are typically used to treat depression and epilepsy, but their utility goes beyond those uses—they’re also used to treat PMPS.
Topical capsaicin: This is an ointment, cream or other substance that may be applied to the skin. Capsaicin is found in chili peppers and works by decreasing activity, and therefore the sensation of pain, in nerve cells.
Nerve blocks and neurolysis: Pain management specialists are helpful in identifying specific trigger points along the chest wall or spinal nerves, intervening with non-surgical methods to address peripheral nerve pain. Thoracic paravertebral nerve blocks have shown immediate but short-term pain relief (lasting less than a month) in the majority of patients. Neurolysis with steroid injection may offer less profound but longer-lasting pain relief (lasting about six months).
Autologous fat grafting: It’s a relatively new therapy and still being studied, but fat grafted from other parts of the body and injected into the breast may reduce pain by providing cushioning, while also having an anti-inflammatory effect on the tissue around it.
Autologous breast reconstruction: Abnormal scarring of the chest wall and armpit following breast cancer surgery not only leads to stiffness and decreased mobility, but it may also compress local peripheral nerves. Surgical removal of scar tissue, combined with reconstruction using the patient's own tissue, may help decompress those nerves and provide relief.
Patients may also find relief with supportive care services, such as acupuncture, yoga or therapeutic massage, but researchers are still assessing whether these or other therapies are helpful to nerve-related pain. Be sure to discuss these ideas with the care team and ask for referrals to providers experienced with PMPS.