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AXILLARY WEB SYNDROME (AWS) “CORDING”: WHAT IS IT?

Updated: Jul 17, 2020


AUTHOR:  MATTHEW CRAIG, PINC & STEEL CANCER REHAB, PHYSIOTHERAPISTBOUNCEREHAB DIRECTOR


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.


Risk factors

  • Axillary node dissection

  • younger age

  • Low BMI


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.


Diagnostic criteria

  • 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


  1. Normal lymphatic flow

  2. Lymphatic backflow and congestion

  3. Injured lymphatic vessel attempting to reestablish lymphatic flow to existing lymph vessel (lymphangiogenesis)

  4. 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.


Skin (a), subcutaneous tissue (b), healthy lymphatic vessel (c) and injured lymphatic vessel (d)

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.