Tietzes syndrome after radical mastectomy & reconstruction?

by Erika

I was diagnosed with breast cancer (BRCA1 Stage II - 2.5cm tumor in axilliary-breast area) at the tender age of 28 while I was 20 weeks pregnant. I underwent chemotherapy while pregnant and delivered a healthy baby girl on Thanksgiving day of that year.

I did another round of chemo followed closely by a bilateral radical mastectomy and immediate implant/expander reconstruction. During the reconstruction my pectoral major muscle was dissected away from my sternum in order to place an implant/expander under the muscle.
That's when it all began. As my expanders were expanded and my pectoral muscle stretched I noticed pulling, heaviness, and pain in my collar-bone and chest wall. My medical care team indicated that discomfort was normal during expansion and dismissed it. I was told that having the expanders changed for implants would relieve the "normal" pain from the expanders & I'd feel 100% better after surgery.
I had the surgery & if anything, the pain increased. The discomfort was so bad that I not only sought a "pain management" doctor, but also chiropractic care.
The "pain management" consisted of steriod injections into my costosternal spaces, oral narcotics, and gentle muscle relaxers. I asked for physical therapy or exercises to perform myself to help the pain, but no one was willing to listen. Because I work full time, I was unwilling to take the narcotics during the day, plus they've never seemed to help me.
The chiropractor was able to give me some relief, but not consistently or for any length of time.
At some point during this I began having nerve symptoms (burning, tingling, pins & needles, numbness, etc) as well as circulatory issues (absent or limited pulse upon certain shoulder movements and cold fingers/hands) most notably on my left (tumor) side. So I sought more medical care & my options were narrowed to 1) living with the pain, 2) having surgery with no implants/expanders/breasts, 3) having surgery to change the implants to smaller ones, or 4) having surgery of another type of reconstruction (autologous). I sought another medical team & the options were primarily the same. I chose autologous reconstruction even though it was more difficult because it would be the most 'natural' looking, feeling, and maintaining reconstruction.

After the successful surgery I was referred to a "Supportive Care" physician within the cancer center. He was very helpful and immediately suggested PT as well as some other testing for Thoracic Outlet Syndrome. It has been 9 months of PT (both with a therapist & at home) as well as a 1st rib resection to alleviate the circulatory problems.

At this point, the nerves in my left arm will probably need at least 3 years before I know whether the damage done to them is permanent or just temporary. However, the pain in my chest wall and sternum is debilitating. Is this Tietzes Syndrome on top of my TOS?

Gosh, Erika, you've had a tough time.

Firstly, Tietze's syndrome is not uncommon after breast reconstruction. Do you have tenderness if you have press on the joints between the ribs and the sternum? Is there visible swelling of any one of these joints?

Tietze's sometimes affects the sternal-clavicular SC joint, in which case a Thoracic Outlet Syndrome TOS may occur. Pain and tingling in the arm, characterised by worsening when you lift the arms, as when in hanging washing. Or, perhaps you had a cervical rib, or both.

Obviously I cannot examine you, so all is speculation. I gather chiropractic help has given some relief, so the obvious is to continue. My experience is that heavy PA adjustments may aggravate the condition, but "anterior thoracics" will relieve. Perhaps discuss this with your chiro.

You've had a rough time. I would recommend moving over to a part time less stressful job, smell the roses, and keep active. I wish I were nearer!

I hope this has contributed.

Dr B

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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Interesting questions from visitors

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Greetings, Dr B.
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