What are the expectations from a physical exam for breast pain and swelling?

Physical Examination Expectations for Breast Pain and Swelling

A thorough clinical breast examination should systematically evaluate for focal versus diffuse findings, skin changes, palpable masses, and lymphadenopathy to determine whether imaging is indicated and to exclude malignancy. 1, 2

Key Components of the Physical Examination

Inspection

• Assess for skin changes including erythema, warmth, edema, dimpling, or peau d'orange appearance, as these may suggest inflammatory processes or rarely inflammatory breast cancer 3, 4
• Evaluate for asymmetry in breast size, contour, or visible masses, which can indicate underlying pathology 2
• Examine the nipple for inversion, distortion, or discharge, as these findings warrant further investigation 4
• Look for skin thickening or fixation, which when present may suggest infection or malignancy 3

Palpation

• Systematically palpate all breast quadrants to distinguish between focal tenderness (localized to one area) versus diffuse tenderness (throughout the breast), as this fundamentally changes management 1, 2
• Document any palpable masses with precise location, size, consistency, and mobility—the presence of a palpable mass with pain changes cancer risk assessment and mandates imaging workup 1, 5
• Assess for nodularity, though breast pain can be associated with diffuse palpable nodularity, there is no relationship between extent of nodularity and severity of pain 6
• Evaluate the chest wall by having the patient place hands on hips and contract pectoral muscles to distinguish breast pain from musculoskeletal causes like costochondritis 2, 7

Lymph Node Examination

• Palpate axillary, supraclavicular, and infraclavicular lymph nodes bilaterally, as abnormally enlarged or dense lymph nodes may suggest malignancy or infection 3, 4

Critical Decision Points Based on Examination Findings

Normal Examination with Diffuse Pain

• If the clinical breast exam is completely normal with diffuse, non-focal pain, reassurance and symptomatic management are appropriate without imaging, regardless of whether pain is cyclical or non-cyclical 1, 8
• Reassurance alone resolves symptoms in 86% of women with mild pain and 52% with severe pain 8

Focal Tenderness or Palpable Findings

• The combination of focal pain plus a palpable area fundamentally changes management—this requires mandatory imaging workup as up to 10-15% of breast cancers can be mammographically occult 1
• Never dismiss a palpable clinical finding based solely on negative imaging, as ultrasound may detect lesions not visible on mammography 1
• For women ≥40 years with focal findings, diagnostic mammography is appropriate (rating 4-5/9), and ultrasound is usually appropriate (rating 9/9) when mammography is negative but clinical findings persist 6, 1

Signs Suggesting Infection

• Clinical presentation of palpable mass (95%), pain (52%), erythema (52%), warmth (33%), and skin thickening (19%) are typical findings in breast infection 3
• Periductal inflammation presents with exquisite continuous burning pain behind the nipple and hypersensitive breast, often associated with heavy smoking 6

Common Pitfalls to Avoid

• Do not be falsely reassured by the absence of a mass—while cancer risk with pain alone is only 1.2-6.7%, any focal palpable finding requires imaging regardless of pain characteristics 1, 8
• Avoid attributing all breast pain to hormonal causes without proper examination—extramammary causes like costochondritis, muscle strains, and nerve entrapment must be considered when breast exam is normal 9
• Do not overlook large breast size as a cause of non-cyclical pain, which may be associated with neck, shoulder, and back pain 6