AUTHOR: MATTHEW CRAIG, PINC & STEEL CANCER REHAB, PHYSIOTHERAPIST& BOUNCEREHAB 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
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.
TREATMENT
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
Manual therapy
Active and passive home exercises
Education
Skin traction
Instruction in soft tissue stretching techniques
Heat (must be approved by your health professional)
Cord stretching
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
SUMMARY
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
REFERENCES
Buum, H. A. T., Koehler, L., & Tuttle, T. M. (2017). Venturing Out on a Limb: Axillary Web Syndrome. The American Journal of Medicine, 130(5), e209-e210.
Sarri, A. J., Dias, R., Laurienzo, C. E., Gonçalves, M. C. P., Dias, D. S., & Moriguchi, S. M. (2017). arm lymphoscintigraphy after axillary lymph node dissection or sentinel lymph node biopsy in breast cancer. OncoTargets and therapy, 10, 1451.
Demir, Y., Güzelküçük, Ü., Keskburun, S., Yaşar, E., & Tan, A. K. (2017). A rare cause of shoulder pain: axillary web syndrome.
Wariss, B. R., Costa, R. M., Pereira, A. C. P. R., Koifman, R. J., & Bergmann, A. (2017). Axillary web syndrome is not a risk factor for lymphoedema after 10 years of follow-up. Supportive Care in Cancer, 25(2), 465-470.
Lewis, P. A., & Cunningham, J. E. (2016). Dynamic Angular Petrissage as Treatment for Axillary Web Syndrome Occurring after Surgery for Breast Cancer: a Case Report. International journal of therapeutic massage & bodywork, 9(2), 28.
Cho, Y., Do, J., Jung, S., Kwon, O., & Jeon, J. Y. (2016). Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection. Supportive Care in Cancer, 24(5), 2047-2057.
Bergmann, A., Mendes, V. V., de Almeida Dias, R., e Silva, B. D. A., Ferreira, M. G. D. C. L., & Fabro, E. A. N. (2012). Incidence and risk factors for axillary web syndrome after breast cancer surgery. Breast cancer research and treatment, 131(3), 987-992.
Leidenius, M., Leppänen, E., Krogerus, L., & von Smitten, K. (2003). Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. The American journal of surgery, 185(2), 127-130.
Koehler, L. A. (2009). Axillary web syndrome. Lymphedema Management: The Comprehensive Guide for Patients and Practitioners, 2nd edn. Thieme Medical Scientific Publishers, New York, NY, 70-72.
Moskovitz, A. H., Anderson, B. O., Yeung, R. S., Byrd, D. R., Lawton, T. J., & Moe, R. E. (2001). Axillary web syndrome after axillary dissection. The American journal of surgery, 181(5), 434-439.
Lacomba, M. T., Del Moral, O. M., Zazo, J. L. C., Sánchez, M. J. Y., Ferrandez, J. C., & Goni, A. Z. (2009). Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast cancer research and treatment, 117(3), 625-630.
Reedijk, M., Boerner, S., Ghazarian, D., & McCready, D. (2006). A case of axillary web syndrome with subcutaneous nodules following axillary surgery. The Breast, 15(3), 410-412.
Fourie, W. J., & Robb, K. A. (2009). Physiotherapy management of axillary web syndrome following breast cancer treatment: discussing the use of soft tissue techniques. Physiotherapy, 95(4), 314-320.
Leduc, O., Sichere, M., Moreau, A., Rigolet, J., Tinlot, A., Darc, S., … & Snoeck, T. (2009). Axillary web syndrome: nature and localization. Lymphology, 42(4), 176.
Tilley, A., Thomas-MacLean, R., & Kwan, W. (2009). Lymphatic cording or axillary web syndrome after breast cancer surgery. Canadian Journal of Surgery, 52(4), E105.
Kepics, J. M. (2004). Physical Therapy Treatment of Axillary Web Syndrome. Rehabilitation Oncology, 22(1), 21-22.
Piper, M., Guajardo, I., Denkler, K., & Sbitany, H. (2016). Axillary Web Syndrome: Current Understanding and New Directions for Treatment. Annals of plastic surgery, 76, S227-S231.