CO-AUTHOR: JACK RAYMENT, BOUNCEREHAB PINC CANCER REHAB PHYSIOTHERAPIST
ACKNOWLEDGEMENT: LOU JAMES, FOUNDER AND TRUSTEE PINC & STEEL CANCER REHABILITATION
WHAT IS IT?
Axillary Web Syndrome (AWS), also referred to as “Cording” in Australia, is a common pathology following lymphadenectomy (breast surgery) and can result in the need for early post-operative and long-term rehabilitation.
Cording refers to a rope-like structure that develops mainly under the armpit but can extend to into the arm. It usually appears after axillary dissection (surgical cutting around the armpit area) and can develop from 9 weeks post procedure. Due to its late presentation, cording may appear after a patient has had their final surgical follow up. As a result, patients often end up seeing a physiotherapist months after the surgery.
Axillary node dissection
WHAT DOES IT LOOK AND FEEL LIKE?
Cording can been seen as a palpable cord of tissue that is made taut and painful with certain shoulder movements (mainly abduction). A pull or stinging feeling is experienced under or down the arm as pain limits full movement. The pain can be described as making you feel like you can’t reach the full distancewhen using your shoulder and arm. Because of its location, cording can significantly limit shoulder, scapular and elbow movements due to pain and tissue adherence. These limitations cause significant impairments with overhead and forward reaching activities of daily living.
Presence of palpable and visible cords of tissue in the axilla in maximal shoulder abduction
+/- associated pain
+/- shoulder range-of-motion limitation
HOW DOES IT FORM?
Scar tissue formation is part of the normal post operative healing process. A mechanism where the new scar tissue must attach to some of the tissue that goes down your arm. The surgery involves the removal of lymphatic vessels which are surrounded by a fine mesh called fascia. It’s this fascia which gets attached to the scar and so as the wound undergoes the healing process the scar tissue forms, tightly grabbing onto the fascia.
The problem is at the scar tissue within the breast, however, the problem feels like it’s in the arm. Although it interferes with reach, the origin of the pathology really does come from the scar tissue within the breast. Inflexibility to the lymph vessels leads to pain and avoidance of movement. As a result of the pain restricting movement, adaptive loss of range of motion may become progressively worse.
AN IN-DEPTH LOOK INTO THE PATHOPHYSIOLOGY OF CORDING
Follow the numbers on the image below:
A – Abnormal Flow
Normal lymphatic flow
Lymphatic backflow and congestion
Injured lymphatic vessel attempting to reestablish lymphatic flow to existing lymph vessel (lymphangiogenesis)
Congested lymphatic vessel attempting to establish lymphatic flow through a collateral pathway. It does this by exiting the damaging vessel via smaller pathways closer to the skin where it then finds its way into a large healthy flowing vessel.
B – Cord Formation
5) The end of an injured lymph vessel attached to interstitial tissue (“in between tissue”) while attempting to regenerate
6) Newly forming lymphatic vessels become adhered to surrounding tissue while attempting to find collateral pathways to healthy lymphatics
7) Lymphatic vessel adhered in two areas causes tethering of the lymphatic vessel which appears as a “cord” of tissue under the surface of the skin.
The physiotherapists at bounceREHAB are trained in the assessment, diagnosis and treatment of cording and can facilitate an appropriate management plan. The clinic offers specific services through PINC Cancer Rehabilitation, STEEL Cancer Rehabilitation and Pain Management.
Treatment may include:
Myofascial release techniques
Active and passive home exercises
Instruction in soft tissue stretching techniques
Heat (must be approved by your health professional)
Pulley and gentle passive and active ROM
Deep breathing and postural exercises
Hooking manipulationsScar management
Lightweight compression garments
Manual lymphatic drainage
A 2017 research paper by Wariss and colleges found the occurrence of cording was not a risk factor for lymphoedema after 10 years of follow-up
Cording is a poorly understood but common cause of significant morbidity after axillary lymph node dissection for breast cancer. It evolves from the disruption of superficial lymphatics and vessels and results in inflexible lymph vessels which leads to pain and avoidance of movements. These adaptations lead to the loss of range of motion and functional disability. Physiotherapy intervention has been shown to improve the severity and duration of symptoms, helping patients return to full function. For more treatment or more information visit bounceREHAB
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