Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors David Ebaugh a,⇑ , Bryan Spinelli a , Kathryn H. Schmitz b a Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA 19102-1192, United States b Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104-6021, United States article info Article history: Received 22 November 2010 Accepted 3 June 2011 abstract Over 2.6 million breast cancer survivors currently reside in the United States. While improvements in the medical management of women diagnosed with breast cancer have resulted in a 5-year survival rate of 89%, curative treatments are associated with a high prevalence of shoulder and arm morbidity, which, in turn, can negatively impact a woman’s quality of life. Breast cancer survivors frequently experience shoulder and arm pain, decreased range of motion, muscle weakness, and lymphedema. These symptoms can lead to difficulties with daily activities ranging from overhead reaching and carrying objects to caring for family and returning to work. Despite health care professionals awareness of these problems, a significant number of breast cancer survivors are confronted with long-term, restricted use of their affected shoulder and upper extremity. This problem may partially be explained by: (1) an incomplete understanding of relevant impairments and diagnoses associated with shoulder/arm pain and limited upper extremity use, and (2) the limited effectiveness of current rehabilitation interventions for managing shoulder pain and decreased upper extremity function in breast cancer survivors. Because breast cancer treatment directly involves the neuromusculoskeletal tissues of the shoulder gir- dle, it is understandable why breast cancer survivors are likely to develop shoulder girdle muscle weak- ness and fatigue, decreased shoulder motion, altered shoulder girdle alignment, and lymphedema. These impairments can be associated with diagnoses such as post-mastectomy syndrome, adhesive capsulitis, myofascial dysfunction, and brachial plexopathy, all of which have been reported among breast cancer survivors. It is our belief that these impairments also put women at risk for developing symptomatic rota- tor cuff disease. In this paper we set forth the rationale for our belief that breast cancer treatments and subsequent impairments of shoulder girdle neuromusculoskeletal tissues place breast cancer survivors at risk for developing symptomatic rotator cuff disease. Additionally, we identify knowledge gaps related to the cur- rent understanding of relevant shoulder girdle impairments and their association with symptomatic rota- tor cuff disease in breast cancer survivors. Ultimately, information from studies designed to meet these gaps will provide a scientific basis for the development of new, or refinement of existing, examination, intervention, and prevention techniques, which should lead to improved clinical outcomes in this population. Ó 2011 Elsevier Ltd. All rights reserved. Introduction and overview In the United States approximately 200,000 women are diag- nosed with breast cancer each year [1]. Improvements in the med- ical management of these women have resulted in a 5-year survival rate of 89 percent, and currently over 2.6 million breast cancer survivors reside in the United States [1]. While survivorship has increased, shoulder and arm morbidity has become a significant complication following curative treatment. Wide preva- lence ranges for shoulder/arm pain (9–68%), restricted motion (1–67%), decreased strength (9–33%), and lymphedema (6–70%) have been reported in the literature [2–6]. Different diagnoses such as rotator cuff disease, myofascial dysfunction, adhesive capsulitis, axillary web syndrome, post-mastectomy syndrome, brachial and cervical plexopathy, neuropathy, and lateral epicondylitis have also been used to describe shoulder and arm morbidities amongst breast cancer survivors [7,8]. Breast cancer survivors who suffer from shoulder and arm mor- bidity have significantly reduced functional use of their upper extremity [9–11]. Common problems include difficulties lifting and carrying objects, combing hair, reaching overhead to put an 0306-9877/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.mehy.2011.06.015 ⇑ Corresponding author. Address: Department of Physical Therapy and Rehabil- itation Sciences, Drexel University, 245 North 15th Street, MS 502, Philadelphia, PA 19102-1192, United States. Tel.: +1 215 762 1957; fax: +1 215 762 3886. E-mail address: debaugh@drexel.edu (D. Ebaugh). Medical Hypotheses 77 (2011) 481–487 Contents lists available at ScienceDirect Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy