Axillary Web Syndrome (Cording)

What is it?

Axillary Web Syndrome (AWS), also known as cording, is when a fibrotic band or rope/cord-like texture develops under the skin. It can be caused by:

• Sentinel lymph node biopsy (SLNB).
• Axillary lymph node dissection (ALND).
• Surgery to stage melanoma.
• Cancer causing swollen axillary (underarm) lymph nodes.

AWS can happen at any time after these surgeries. It can cause pain and affect your ability to move your shoulder.

It often occurs in the area under the armpit and runs down the length of the arm to the elbow and in some cases down towards the hand. It can also occur in the breast, chest, and abdominal region. There may be one large cord or several smaller cords.

What are the signs of AWS?

You can usually feel these rope/cord-like areas under your arm, but you may not be able to see it. The area may feel tight, not normal, or even painful when moving your arm. It doesn’t usually cause redness, swelling, numbness, or tingling. You may have difficulty raising your arm above your shoulder or when doing overhead activities. Because of the tightness, daily activities like washing hair, getting dressed, reaching overhead, or putting on a seatbelt may be difficult

You should check regularly for AWS during the first 3-6 months after surgery. It is recommended to continue to check periodically for up to 3 years after surgery. To check for AWS:

• Lift your arm above your head forward and out to the side. Check if you see anything or feel any tension or discomfort.
• Pay attention to everyday tasks that involve using your affected arm and note if it is getting harder to do them.
• Lift your arm and with your opposite hand feel along your armpit down to your elbow to feel for any changes.

If there is any new tension, loss of strength, or you feel any cording, webbing, or string-like ropes contact your provider.

What causes AWS?

Currently, the exact cause of AWS is not known. Research suggests that it may occur after surgery to remove lymph node(s) or for melanoma staging. These procedures may cause trauma to the tissue that surrounds nearby blood vessels, lymph vessels, and nerves. As a result, there is inflammation (swelling), scarring, and hardening of tissue in that area. This scarring and hardening results in fibrotic bands also called cords.

What puts a person at risk for AWS?

There is not enough evidence to tell who would be more likely to get AWS compared to another person. However, AWS is more commonly seen after more invasive and extensive axillary surgery. Lean patients (mean body mass index of ≤ 23) are more likely to develop AWS than obese patients (mean body mass index of ≥ 26). It is more common in younger patients compared to older patients.

When does it happen and what is the incidence?

Cording can occur within days or weeks of the surgery, and sometimes even years later. It most often occurs within 2 and 8 weeks postoperatively and occurs in anywhere from 6- 86% of patients.

How is AWS treated?

Cording may get better over time on its own. Medications such as over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDS) and other pain relievers can be used to manage pain. These medications don’t treat the AWS, they only manage the pain. You should continue to use the affected arm as much as possible. If you stop using your arm because of pain, it can lead to more impairments over time. Physical therapy is often recommended to help you regain function.

Physical therapy can help by using:

• Stretching and flexibility exercises.
• Strengthening exercises.
• Nerve glides (stretches to improve nerve movement).
• Manual treatments such as trigger point and myofascial release, scar tissue mobilization, joint mobilization, and passive stretching of affected body regions.
• Compression bandaging and manual lymphatic drainage may also be used to assist with recovery.

Takeaways

• If you notice cording/webbing under your arm or have trouble using your arm, contact your provider right away.
• In most cases, with proper self-care and exercise, it will resolve.
• It is not often associated with long-term side effects.
• AWS does not usually come back again.
• It is recommended to perform frequent self-assessment for AWS during the first 3–6 months after surgery and continue to perform self-assessments up to 3 years.
• Physical therapy and exercise can reduce pain and increase range of motion.