3.5 Breast and Axilla Examination

Breast and Axilla Examination

Quick Answer: The breast and axilla examination is performed when case history reveals breast-related complaints (pain, mass, discharge, skin change) or when screening coordination is appropriate; it evaluates for masses, skin changes, and lymphadenopathy, and any dominant mass, fixed or hard node, or bloody nipple discharge triggers prompt referral for imaging or specialist evaluation rather than chiropractic management.

On NBCE Part III, the breast and axilla exam is tested at the knowledge and clinical-decision level: know when the exam is indicated, how it is performed, which findings are reassuring versus concerning, and where the referral threshold sits. Chiropractors are not expected to diagnose breast malignancy; they are expected to recognize findings that require timely referral.

When the Exam Is Indicated

Perform or arrange a breast and axilla examination when:

• The chief complaint or review of systems reveals breast pain (mastalgia), a palpable lump, nipple discharge, skin change, or axillary swelling
• Case history reveals a personal or family history of breast disease
• Screening coordination is appropriate for an asymptomatic patient of screening age, working alongside the patient's primary care provider (chiropractic screening never substitutes for mammographic screening)
• Unexplained axillary or supraclavicular lymphadenopathy is discovered incidentally during a cervical, thoracic, or upper-extremity examination

Obtain informed consent, use a chaperone, and document the indication, technique, findings, and any referral made. These procedural safeguards are themselves testable knowledge on Part III.

Examination Technique

Inspection

Inspection is performed with the patient seated, disrobed to the waist, viewed in four sequential positions that each serve a distinct diagnostic purpose:

1. Arms relaxed at the sides — establishes baseline symmetry, contour, and skin color
2. Arms raised overhead — stretches the breast tissue and accentuates retraction or dimpling as the underlying suspensory (Cooper's) ligaments and pectoral fascia pull on overlying skin
3. Hands pressed firmly on the hips with pectoral muscles contracted — isolates pectoral tethering by the same mechanism
4. Leaning forward at the waist — both breasts should hang symmetrically away from the chest wall; asymmetric fixation suggests an underlying mass tethered to deeper structures

Findings to document on inspection include asymmetry, dimpling or retraction, skin changes such as peau d'orange (orange-peel edema from dermal lymphatic obstruction, classically associated with inflammatory breast carcinoma), erythema, nipple inversion or deviation, ulceration, and spontaneous discharge.

Palpation

Palpation is performed with the patient supine and the arm on the side being examined abducted overhead, which flattens breast tissue against the chest wall. Using the pads of the fingers in a systematic pattern (vertical strip, concentric circle, or clock-face — the pattern matters less than covering the entire field), palpate from the clavicle to the inframammary fold and from the sternum to the midaxillary line, applying light, medium, and deep pressure at each point. A discrete, dominant mass that persists on repeat examination is treated with more concern than diffuse nodularity, which is common and often physiologic — fibrocystic change frequently fluctuates with the menstrual cycle and is typically bilateral and tender.

Axillary and Regional Lymph Node Palpation

Support the patient's arm in a relaxed position so the pectoral muscles are not tensed, then systematically palpate five node groups:

Supraclavicular adenopathy is never considered a normal finding and always warrants further evaluation.

Interpreting Lymphadenopathy

Not every palpable node is pathologic. Small, soft, mobile, tender nodes are common reactive findings after minor local infection. The features below help separate benign reactive adenopathy from findings that raise concern.

Men and Mastalgia Patterns

Breast complaints are not exclusive to female patients. Gynecomastia (benign glandular enlargement in males) can result from hormonal shifts, medication effects, or underlying systemic disease, and unilateral or asymmetric enlargement in a male patient should be evaluated rather than assumed benign. For mastalgia in general, distinguishing cyclical from noncyclical patterns helps direct triage: cyclical mastalgia tracks the menstrual cycle, is usually bilateral and diffuse, and is rarely associated with malignancy, while noncyclical mastalgia is constant, often unilateral or localized, and more often warrants directed evaluation, especially if a palpable mass accompanies it.

Referral Thresholds

Refer promptly, regardless of the patient's age or apparent risk profile, for:

• A discrete, dominant breast mass — a new palpable mass warrants diagnostic imaging even after a recent normal mammogram, since a mass can arise between screening intervals
• Fixed, hard, or matted axillary or supraclavicular nodes
• Unilateral, spontaneous, or bloody nipple discharge
• Skin changes including peau d'orange, new retraction, ulceration, or an enlarging, erythematous, warm breast, which can represent inflammatory carcinoma or abscess and both require urgent evaluation
• Unexplained axillary or supraclavicular lymphadenopathy without an identifiable local cause
• Unilateral or asymmetric gynecomastia in a male patient

The chiropractic role in breast and axilla findings is screening, documentation, and timely referral to the patient's primary care provider, a breast specialist, or directly to diagnostic imaging per the practice's referral pathway — not definitive diagnosis or treatment of breast pathology. On the exam, choose the answer that reflects prompt, appropriate referral over reassurance or repeat chiropractic evaluation whenever a concerning feature is present.