Deep Tissue Request After Mastectomy and Axillary Node Dissection
A 55-year-old client requests a 90-minute deep-tissue massage for left shoulder and chest-wall tightness. Six months ago she had a left modified radical mastectomy with axillary lymph node dissection (14 nodes removed), followed by radiation that ended eight weeks ago. She has a 12 cm healed incision across the chest and reports 'cording' in the left axilla that restricts overhead reach. Her oncologist cleared her for 'gentle exercise' but wrote no specific massage order. She has mild lymphedema in the left forearm that is stable, and she wears a compression sleeve during the day. She wants you to 'work deep into the scar tissue and under the arm' to break up adhesions. She denies fever, new swelling, or redness. She takes tamoxifen and has no known metastases.
1. What questions and clearances are needed before working on the left shoulder and chest wall?
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Because she had axillary lymph node dissection and radiation, she is at lifetime risk for lymphedema. I need oncology or a certified lymphedema therapist to clarify whether deep tissue near the axilla, scar, and chest wall is permitted. I would ask about new heaviness, swelling, infection, or restricted range of motion, and whether the cording has been evaluated by a physical therapist. 'Gentle exercise' is not a massage order. I would request written clearance specifying areas and pressure. If clearance is unavailable, I would limit work to gentle strokes on the unaffected side and avoid the left axilla and chest wall.
2. How would you adapt the session, and what techniques are contraindicated or require extra training?
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I would avoid deep transverse friction across the axilla, sustained pressure into the scar, and any compression that could impair lymphatic drainage. I would not perform manual lymphatic drainage or compression bandaging unless certified. I would use gentle scar mobilization only if cleared and if the scar is fully healed and not recently irradiated; radiation skin can be fragile. I would work on the cervical spine, right shoulder, and postural muscles, and use light stroking on the left arm. I would coordinate with her physical therapist for cording. I would stop for new swelling, redness, or pain.
3. What signs during or after the session warrant referral?
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I would refer for new or worsening swelling in the arm or hand, heaviness, tightness, redness, warmth, fever, or restricted motion. I would also refer if the scar becomes painful or if cording worsens. I would document baseline visual asymmetry or arm circumference if trained, skin integrity, and the clearance. Aftercare would include monitoring for swelling, keeping the sleeve as prescribed, and reporting changes. I would not promise to break up adhesions.