INTRODUCTION

There are approximately 387,850 women diagnosed with invasive breast cancer requiring surgery each year in the United States (2). Nationally, 30% of all new cancer diagnoses are breast cancer, and 54% of those are women under 65 years (2). Women are eager to resume normal daily activities after surgery, but many have long-term pain and movement limitations that inhibit functional movement. The tightening around the surgical site can cause pain in the shoulders, neck, low back, hips, ribs, and even breathing dysfunction (5,10,14). The accumulation of fascial tension is gradual and such effects may take months to get to a level that only causes discomfort when doing daily activities. Gong et al. reported that approximately 28.2% of patients experienced post-mastectomy pain syndrome (PMPS) as early as three months after surgery; it has also been reported that about 60% of women who initially experienced PMPS continued to report symptoms 7 – 9 years post-surgery (14,33). Despite evidence that the combination of myofascial work and exercise is more successful in restoring tissue-based limitations than exercise or tissue work alone, there is no set program for this population before or after surgery (5,10,29). The various types of breast cancer surgery (BCS) are listed in Figure 1.

FASCIAL AND MYOFASCIAL WORK

Myofascial work is commonly known as a technique that focuses on applying fascial holds while moving the tissue at varied pressures and depths (3,7). It refers to a range of manual therapy techniques aimed at assessing and releasing restrictions in the fascial system with the goal of restoring mobility, reducing pain, and improving function. These interventions typically involve sustained pressure and movement through soft tissue to influence the tone, hydration, and alignment of fascia and the underlying musculature. As the fascial system is a continuous three-dimensional network of connective tissue that envelops and interconnects all muscles, bones, and organs, addressing fascial restrictions can have widespread effects throughout the body. The Fascia Nomenclature Committee, developed by the Fascia Research Society, defines the fascial system as “the three-dimensional continuum of soft, collagen-containing, loose and dense fibrous connective tissues that permeate the body... with no discontinuity in its path, with layers of different characteristics and properties overlapping,” (3). This integrated perspective supports the rationale behind myofascial interventions as a means of improving postural integrity and reducing biomechanical stress across multiple regions.

SUPPORT FOR FASCIA FOCUS TECHNIQUES

Self‐myofascial release (SMR) is a popular intervention used by both rehabilitation and fitness professionals to enhance myofascial mobility. Common SMR tools include the foam roller and various types and sizes of roller massagers. Evidence exists that suggests these tools can enhance joint range of motion (ROM) and the recovery process by decreasing the effects of acute muscle soreness, delayed onset muscle soreness (DOMS), and post-exercise muscle performance (4,6,7,11,18,20,23,31). SMR uses an individual’s own bodyweight to apply pressure to the soft tissues with foam rollers and small balls (6,7,31). Direct pressure on the soft tissues combined with micro-movements stretch and compress the tissue, increasing viscosity in adhered areas upon release, decreasing friction between the tissues (28). SMR’s effectiveness in athletic recovery when added to an exercise regimen has been well demonstrated (6,7,12,18,20,23,28,31); with the addition of active movement of a joint when rolling, as opposed to holding the limb still, being the most effective at improving mobility (6). Restoring viscosity to the tissues improves arthrokinematics, and thus may improve function (21).

Benefits of fascia-focused therapy can include (26):

• • Reduced joint stress (-39%)
  • Reduced chronic pains (-73%)
  • Reduced trigger point tenderness (-45%)
  • Reduced scar size (-24%)

It has been documented that only 8.9% of women who have had BCS meet the current guidelines on aerobic and resistance exercise (19,34). Furthermore, only 40% of oncologists routinely recommend exercise to patients, and only 9% of women who have had BCSs are referred to exercise professionals for continued care (9,32,34). In addition, the combination of fascia work via self-myofascial release and exercise has not been widely utilized despite evidence that decreased mobility due to scarring greatly affects the quality of life (QOL). Therefore, there is a significant need for prehabilitation and post-rehabilitation programs for women who have had BCS.

BEST PRACTICES FOR THE PERSONAL TRAINER

The personal trainer can play an integral role in the journey of their breast cancer clients. This article provides education for personal trainers to help improve mobility and movement patterns to avoid chronic pain, reliance on pain medication, and diminish the risk of future injuries while improving QOL.

WORKING WITH THE HEALTHCARE TEAM

Many reconstruction options involve surgery in other areas, which can affect movement efficiency. It is strongly recommended that a personal trainer becomes familiar with the different types of breast cancer surgeries (Figure 1) and reconstruction techniques (Figure 2) to be able to communicate with the client and their healthcare team adequately. The medical team may include an oncologist, surgeon, reconstruction surgeon, radiologist, physical therapist, lymphedema specialist, massage therapist, and primary care physician, all of whom may want to see notes on sessions completed. The client should get clearance from a physician before beginning any exercise program.

PREHABILITATION

If a client has an opportunity to do prehabilitation before the surgery, they can possibly diminish the forward pull of the upper quadrant (common for most people using phones, computers, and driving) to be able to move in a more neutral alignment (27). A movement analysis must first be done to observe the range of motion and restriction of the upper body including shoulder flexion, extension, internal and external rotation, and abduction. The client should be able to do each movement (with a neutral head position) without harmful kinematic compensation that alters scapula rotation in overhead tasks such as initiating with their upper trapezius/levator (22). While earlier research has raised questions about the relationship between posture, musculoskeletal health, and pain (24), more recent studies have demonstrated clear links between forward head posture (FHP), rounded shoulders like upper crossed syndrome (UCS), and musculoskeletal dysfunction—often affecting an individual’s ability to comfortably perform activities of daily living (13,25). For example, Lotfian et al. found that individuals with FHP exhibit significantly reduced neck extensor endurance and higher levels of pain and disability compared to those with neutral head posture (25). Additionally, Gholami et al. identified a strong association between UCS and upper limb pain, impaired daily function, and decreased quality of life in working women (13). These recent findings underscore the clinical relevance of postural dysfunction, albeit its correlation to pain is not agreed upon. However, a 2024 meta-analysis by Mohammad Pour and colleagues confirmed that targeted therapeutic exercises can effectively improve FHP, reduce thoracic kyphosis, and alleviate related symptoms (27).

Noting the movement compensations will let the personal trainer know what muscles need to move more freely and what has to be strengthened (8). For example, it is common for many people’s shoulders to be anteriorly rotated and tipped with a forward head because of texting, computer work, and driving. Resolving this prior to surgery may be helpful to improve the starting position of the shoulder girdle, as well as get the client comfortable and familiar with the movements. The commonly short areas involved in rounded shoulders and forward head posture include the pectoralis major and minor, anterior scalene, serratus anterior, subscapularis, levator scapulae, sternocleidomastoid, upper trapezius, and posterior cervical spine muscles (15). This disruption of the length-tension relationship leaves the posterior shoulder muscles, such as the middle, lower trapezius, rhomboids, and latissimus dorsi, in a lengthened position, causing a decrease in proper muscle activation. This muscle imbalance alters the scapular and glenohumeral orientation and kinematics, which may contribute to an increased risk of neck, shoulder, nonspecific arm pain, and nerve impingement issues (8,13,16,22,25).

A protracted shoulder has also been implicated in the restricted sliding of the cords of the brachial plexus, thus increasing strain on the various nerves passing through the shoulder region, especially the median nerve (30). Additionally, with this increased kyphosis at the thoracic spine, the anterior longitudinal ligament and the upper abdominal muscles may be shortened, resulting in increased stress throughout the back, and possibly inhibited breathing. In some cases, the brachial plexus in the lateral neck can also be pinched, causing numbness in the fingers.

Fascial tissues may lose elasticity and become “sticky” or “dehydrated,” contributing to impaired gliding and functional restriction. Self-myofascial release (e.g., foam rolling) appears to acutely restore tissue slide and range of motion, consistent with a theoretical reduction in viscosity or improved tissue hydration (4,7). A few examples of self-myofascial work are provided in Figures 3, 4, and 5. Placing the client’s hand (gently) or a tennis ball in a door jamb on the area and doing small jostling movements in the desired direction will help hydrate and loosen the area (Figure 3). This should be a small, backward, circular movement for 30 – 60 s, cueing activation of the mid back. Follow with a gentle stretch focusing on slow deep breaths and relaxing the area (Figure 4). Repeat the ROM analysis with coaching to avoid compensation. Repeat until the client can do the movement without compensating, to a pain-free range of motion. It is believed that once the movement patterns are cleaned up, strengthening the previously inhibited or over-stretched muscles can begin. Researchers have suggested that SMR followed by stretching and training the opposing muscle stability can be performed twice weekly for a sustained period (6,8,10). The client will likely do the exercises in their previous compensation patterns as the brain still thinks it has to move that way unless re-patterning is part of the process. A slow tempo is necessary to help the client become more mindful of the new desired movement strategy.

POST SURGERY

LONG-TERM PLAN

During the initial recovery phases after cancer treatment, many patients are referred to physical therapy. However, insurance coverage for rehabilitation is inconsistent, and some treatments may not be covered at all. As a result, patients looking to return or begin exercising may seek the help of a personal trainer for 1 – 7 years post-breast cancer treatment. The muscle imbalances described above lead to alteration in the scapular and glenohumeral orientation, as well as kinematics, thus possibly increasing the risk of developing neck, shoulder, and nonspecific arm pain (13,16,25). These issues are exasperated by the gradual locking down of the upper quadrant as scar tissue forms years after surgery services have been completed. The muscular system and shoulder girdle continue to be pulled forward as the tightening from the scarring increases over the years.

The long-term effects of post-surgical scarring are widespread and often not addressed as part of a post-operative rehabilitation program. Ideally, once the wound has healed and post operative rehabilitation has been completed, a combination of fascia work and exercise should be done and continued as part of a maintenance plan. Post-mastectomy pain syndrome has been seen 1.7 – 7 years after surgery, suggesting that a long-term recovery plan is needed (17). Personal trainers can help women who have had BCS regain mobility and confidence with self-myofascial release and movement retraining long after medical services have ended.

As with the prehabilitation program, a movement assessment is recommended first. Afterward, slow and gentle SMR can be done with a mobility ball around the painful area with micro-movements and breathing by the client. A ball may be used in a door jamb for the pectoralis major and minor and a soft foam roller for the side of the rib cage, teres, and latissimus dorsi. This should be a pain-free experience. Focusing on breathing and small oscillating type movements is key to helping the tissue let go and relax to reestablish sliding and gliding; it should not be painful, which can cause tension and guarding. As mobility and strength improves, the shoulder blade squeezes (Figure 5) can be done with a band to strengthen the weak or elongated muscles as done in prehabilitation sessions. The focus is on improving movement patterns, using a slow tempo and starting with low repetitions and isometric holds (e.g., 5x5 s holds).

INTEGRATION EXAMPLES

After mobility and stability are restored, functional movement can be improved to reintegrate the upper quadrant into daily life movement patterns without compensation. Once all the pieces can work separately, teaching them to all work together without compensating is important. An example would be a squat and band row combined, or a one-arm band push or pull without the upper trap hiking the shoulder up. A squat and overhead press with proper shoulder mechanics and without arching the back is also important as it mimics picking something up and putting it on a shelf.

CONTRAINDICATIONS

As with any SMR protocol, be sure the client is cleared by a physician and does not have a history of or warning signs of blood clots. Although not a contraindication, long after post-operative services have been completed, the client’s skin might still be very sensitive if radiation was also involved, so it is important to choose appropriate tools that are gentle and pain-free. Lymphedema is also an issue that is best handled by a specialist if presented by the client. In most cases, movement is helpful, but caution must be taken when doing any tissue manipulation with those who have a history of lymphedema.

This article originally appeared in Personal Training Quarterly (PTQ)—a quarterly publication for NSCA Members designed specifically for the personal trainer. Discover easy-to-read, research-based articles that take your training knowledge further with Nutrition, Programming, and Personal Business Development columns in each quarterly, electronic issue. Read more articles from PTQ »

Related Reading

Kiyono, R, Onuma, R, Yasaka, K, Sato, S, Yahata, K, and Nakamura, M. Effects of 5-week foam rolling intervention on range of motion and muscle stiffness. Journal of Strength and Conditioning Research 36(7): 1890-1895, 2022.