Most breast cancer patients are told that the chest-wall and underarm pain after mastectomy will fade with time. For roughly 25–60 percent of patients, depending on the surgical extent and the published series cited (Andersen & Kehlet, 2011; Gärtner et al., 2009), it does not. That residual pain — burning, electric, sometimes triggered by light touch, often confined to a specific band from armpit to inner elbow — is called post-mastectomy pain syndrome (PMPS), and it is one of the best-characterized and most under-treated iatrogenic neuropathies in oncology medicine.
The pain is not in the patient’s head. It is not “scar tissue tightness.” In about two thirds of people with persistent pain after breast surgery, the pain has a neuropathic component (Haroutiunian et al., 2013), most often from injury to the intercostobrachial nerve at the axilla. Nerve injury during surgery is probably the most important cause of long-term pain after an operation (Kehlet et al., 2006), and it can be identified, tested with a diagnostic block, and treated. The job at our consultation is to map the pain pattern to the responsible nerve, test it with an ultrasound-guided block, and walk through a procedural ladder that escalates only as needed.
Modal Pain Management NYC is at 369 Lexington Avenue Floor 25 in Midtown Manhattan, two blocks south of Grand Central. Dr. Alex Movshis is dual board-certified in Anesthesiology and Pain Medicine, fellowship-trained at the Icahn School of Medicine at Mount Sinai, and sees every patient personally at every visit. Same-week new-patient consultations are routine.
What PMPS actually is
Post-mastectomy pain syndrome is neuropathic chest-wall, axillary, or upper-arm pain that persists after breast surgery. Definitions differ on timing. The general definition of chronic post-surgical pain uses three months (Schug et al., 2019), and a 2016 consensus review proposed at least six months (Waltho & Rockwell, 2016). Multiple peripheral nerves can be involved, but the pattern usually maps to one or a small combination of specific nerves.
Intercostobrachial neuralgia. The intercostobrachial nerve is the lateral cutaneous branch of T2, often joined by fibers from T1 or T3, and supplies sensation to the axilla, the upper-medial arm, and the upper-medial chest wall. Axillary lymph node dissection (ALND) and to a lesser extent sentinel lymph node biopsy (SLNB) routinely transect or stretch this nerve. The resulting neuropathy produces a band of burning, electric, or hypersensitive skin from armpit to inner elbow. Wearing a bra, deodorant application, and overhead reaching all aggravate it. This is the most common single mechanism behind PMPS and the most under-recognized.
Intercostal neuralgia (T3–T6). Surgical disruption of the intercostal nerves at their distal cutaneous branches — by the mastectomy incision itself, by tissue expanders, or by implant pocket dissection — produces a band of neuropathic pain across the chest wall in one or several dermatomal distributions.
Neuroma at the mastectomy scar. Small painful neuromas form along the incision in a subset of patients. Each neuroma typically produces a discrete Tinel-positive point — gentle tapping at a specific spot reproduces a sharp, radiating pain.
Long thoracic nerve and thoracodorsal nerve injury. Less commonly, traction or transection of the long thoracic nerve (causing winged scapula and serratus anterior weakness) or the thoracodorsal nerve (causing latissimus dorsi weakness) produces a motor-deficit picture plus referred pain.
Persistent post-radiation chest-wall pain. Adjuvant radiation therapy can cause a distinct form of neuropathic pain that overlaps clinically with PMPS but has a different mechanism (radiation-induced fibrosis and nerve injury). Treatment paths overlap but differ, especially on the medication side.
What you should expect us to ask and find at the visit
The new-patient consultation takes 45–60 minutes, may include an ultrasound exam, and focuses on three things — the pattern, the operative report, and a careful sensory map.
The pattern. When did the pain start? What is its quality (burning, electric, aching, sharp)? What is its distribution — and can you trace it with one finger? What sets it off? What relieves it? What is its impact on sleep, on bra and clothing tolerance, on reaching overhead, on intimacy? Has it gotten better, worse, or stayed the same over the past 6 months?
The operative report. We ask for the operative report from the index surgery. Knowing whether the procedure was lumpectomy, simple mastectomy, modified radical mastectomy, or skin-sparing/nipple-sparing mastectomy; whether it involved sentinel lymph node biopsy or axillary node dissection; whether reconstruction (tissue expander, direct implant, autologous flap) was performed; and whether intra-operative regional anesthesia (paravertebral block, serratus plane block, PECS block) was used — every one of those data points changes the differential. Operative reports are usually available through the surgical practice’s patient portal in under ten minutes.
The focused physical examination. A sensory map of the affected territory using brush, cold metal, and pinprick — we draw the affected area on a paper template that becomes part of the chart. Tinel testing along the lateral chest wall, the axilla, and any palpable nodules at the incision. Strength testing of serratus anterior (long thoracic nerve), latissimus dorsi (thoracodorsal nerve), and pectoralis (medial and lateral pectoral nerves). Range-of-motion testing of the shoulder — adhesive capsulitis is a common silent comorbidity after axillary intervention.
The deliverable at the end of the visit is a working diagnosis (typically: dominant intercostobrachial neuralgia, or dominant intercostal neuralgia at specific dermatomes, or dominant neuroma at a defined point) and a recommended diagnostic block.
The procedural ladder for PMPS
Step 1 — neuropathic-pain medication. Most patients reach Modal because medication has failed, but for a fraction of newly referred PMPS cases, a structured medication trial is the right first move. Gabapentin titrated to 1800–3600 mg/day in divided doses, or pregabalin 150–600 mg/day. Tricyclic antidepressant (nortriptyline) or SNRI (duloxetine) for patients with mood comorbidity or gabapentinoid intolerance. Topical 5% lidocaine patch (Lidoderm) over the affected band helps some patients with the focal skin component and is often underused.
Step 2 — ultrasound-guided intercostobrachial nerve block. The single most informative procedure. Performed in our procedure suite under ultrasound guidance, the block delivers a small volume of local anesthetic into the axillary fascia at the intercostobrachial nerve target. The diagnostic answer usually arrives within 15 minutes. If the band of burning pain goes away while the anesthetic works, intercostobrachial neuralgia becomes the likely diagnosis. When the diagnostic block clearly relieves the usual pain, the next step is referral to a surgeon who focuses exclusively on peripheral nerve entrapment (Step 6).
Step 3 — ultrasound-guided intercostal nerve blocks. For patients with a more medial chest-wall pain distribution or with pain across multiple dermatomes, sequential intercostal blocks at T3, T4, T5, and T6, each a small volume of local anesthetic, separate the affected levels and document the diagnostic response.
Step 4 — ultrasound-guided neuroma test injection. For palpable or sonographically identified neuromas at the scar, a trial injection of a small volume of local anesthetic at the neuroma tests whether it is the pain source. When it clearly relieves the usual pain, the next step is surgical referral (Step 6).
Step 5 — stellate ganglion block for sympathetically-maintained components. A subset of PMPS patients have a sympathetically-maintained pain component — typically marked by allodynia, color or temperature change, or sweating in the affected territory. Stellate ganglion block under ultrasound guidance can be both diagnostic and therapeutic for this subset, though the published studies are small (Wijayasinghe et al., 2014).
Step 6 — surgical referral, and referral for peripheral nerve stimulation (PNS). When a diagnostic block clearly relieves the usual pain, Dr. Movshis refers to a surgeon who focuses exclusively on peripheral nerve entrapment, for neurectomy or selective neurolysis. Modal Pain does not implant stimulators. Referral to an implanting specialist for peripheral nerve stimulation of the intercostobrachial or intercostal nerve is another option, with growing published evidence (Deer et al., 2016).
Pulsed radiofrequency after mastectomy has been studied mainly at the nerve roots next to the spine: in a 64-patient randomized trial, 76% of patients treated at the dorsal root ganglion had at least half their pain gone at six months, against 24% treated further out at the paravertebral nerve, although both groups did equally well at one month (Hetta et al., 2020). Because treating the root next to the spine is technically harder and carries more risk, the authors suggested trying the paravertebral approach first. Modal Pain does not perform pulsed radiofrequency at either site, so it is an option only by referral.
What insurance covers, and how we handle it
Most commercial PPO insurance plans cover image-guided peripheral nerve blocks for chronic post-surgical neuropathic pain, typically with prior authorization. The diagnostic block is usually approved as part of a structured workup.
Modal Pain Management NYC checks your benefits and goes over what your plan covers and any expected cost by phone before your visit, so there are no surprise bills, and handles prior authorization on your behalf. Most commercial PPO plans are accepted, including Aetna, Anthem Blue Cross Blue Shield, Cigna, Empire Blue Cross Blue Shield, the Empire Plan, Oscar, Oxford, UMR and UnitedHealthcare. The practice does not accept Medicare, Medicaid, HMO plans, or workers’ compensation. Check your plan or call (646) 290-6660.
Coordination with your oncology team
PMPS care does not replace oncology care — it complements it. We send notes to your medical oncologist, radiation oncologist, and breast surgeon as requested or as needed and welcome direct referrals from oncology teams across NYC. For patients still on active surveillance, on anti-hormonal therapy (tamoxifen, aromatase inhibitors), or undergoing reconstructive surgery, treatment timing is coordinated with the oncology team.
When to come in
The right cadence is same-week consultation for any of the following: chest-wall, axillary, or upper-arm pain persisting more than three months after breast surgery; pain that limits sleep, work, or daily function; pain that is worsening rather than improving over time; failure of a structured trial of gabapentinoid plus topical lidocaine; or recurrent pain after a prior block elsewhere that briefly worked.
To schedule, book online or call (646) 290-6660.
For the broader post-surgical nerve pain framework — including post-thoracotomy, post-hernia, and post-arthroplasty patterns — see the post-surgical and scar-tissue nerve pain overview.
References
- Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302(18):1985–92. doi:10.1001/jama.2009.1568 · PubMed
- Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention. J Pain. 2011;12(7):725–46. doi:10.1016/j.jpain.2010.12.005 · PubMed
- Waltho D, Rockwell G. Post-breast surgery pain syndrome: establishing a consensus for the definition of post-mastectomy pain syndrome to provide a standardized clinical and research approach - a review of the literature and discussion. Can J Surg. 2016;59(5):342–50. doi:10.1503/cjs.000716 · PubMed
- Haroutiunian S, Nikolajsen L, Finnerup NB, Jensen TS. The neuropathic component in persistent postsurgical pain: a systematic literature review. Pain. 2013;154(1):95–102. doi:10.1016/j.pain.2012.09.010 · PubMed
- Hetta DF, Mohamed SAB, Mohamed KH, Mahmoud TAE, Eltyb HA. Pulsed Radiofrequency on Thoracic Dorsal Root Ganglion Versus Thoracic Paravertebral Nerve for Chronic Postmastectomy Pain, A Randomized Trial: 6-Month Results. Pain Physician. 2020;23(1):23–35. PubMed
- Wijayasinghe N, Andersen KG, Kehlet H. Neural blockade for persistent pain after breast cancer surgery. Reg Anesth Pain Med. 2014;39(4):272–8. doi:10.1097/AAP.0000000000000101 · PubMed
- Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618–25. doi:10.1016/S0140-6736(06)68700-X · PubMed
- Schug SA, Lavand’homme P, Barke A, et al. The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain. Pain. 2019;160(1):45–52. doi:10.1097/j.pain.0000000000001413 · PubMed
- Deer T, Pope J, Benyamin R, et al. Prospective, Multicenter, Randomized, Double-Blinded, Partial Crossover Study to Assess the Safety and Efficacy of the Novel Neuromodulation System in the Treatment of Patients With Chronic Pain of Peripheral Nerve Origin. Neuromodulation. 2016;19(1):91–100. doi:10.1111/ner.12381 · PubMed
- Mejdahl MK, Andersen KG, Gärtner R, Kroman N, Kehlet H. Persistent pain and sensory disturbances after treatment for breast cancer: six year nationwide follow-up study. BMJ. 2013;346:f1865. doi:10.1136/bmj.f1865 · PubMed
- Kannan P, Lam HY, Ma TK, Lo CN, Mui TY, Tang WY. Efficacy of physical therapy interventions on quality of life and upper quadrant pain severity in women with post-mastectomy pain syndrome: a systematic review and meta-analysis. Qual Life Res. 2022;31(4):951–973. doi:10.1007/s11136-021-02926-x · PubMed
- Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162–73. doi:10.1016/S1474-4422(14)70251-0 · PubMed
- Wijayasinghe N, Duriaud HM, Kehlet H, Andersen KG. Ultrasound guided intercostobrachial nerve blockade in patients with persistent pain after breast cancer surgery: a pilot study. Pain Physician. 2016;19(2):E309–18. PubMed
