Axillary web syndrome (AWS), also known as cording, sometimes develops as a side effect of sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). Both procedures involve removing just a few (SLNB) or many (ALND) of the axillary, or underarm, lymph nodes. Most people with breast cancer need to have at least one of these surgeries. Scar tissue from surgery to the chest area to remove the cancer itself also can contribute to cording.
If you develop axillary web syndrome, you'll often be able to see and/or feel a web of thick, ropelike structures under the skin of your inner arm. Lymphedema therapists often call these "cords." (In some cases, you may not see or feel the cords, but sensations of pain and tightness will tell you they are there.) You may first notice them when you're doing something that involves raising your arm to shoulder level or above your head. If it happens, cording typically occurs anywhere from several days to several weeks after your surgery, although there have been individual cases where it appears many months later.
With cording, it's possible to have one large cord or several distinct, smaller cords running down the arm. These cords usually start near the site of any scarring in the underarm region and extend down the inner arm to the inside of the elbow. Sometimes they can continue all the way down to the palm of your hand. In some people, cording can extend down the chest wall instead of, or in addition to, the inner arm.
The cords tend to be painful and tight, making it difficult for you to lift your arm any higher than your shoulder or extend the elbow fully. This pain and limited range of motion can have a major impact on your day-to-day life. Cording can be especially problematic if it happens before or during radiation therapy, since this therapy typically requires lifting your arm above your head.
Researchers are still studying what exactly makes cording happen. Some experts believe that the surgery to the underarm and chest area traumatizes the connective tissue that encases nearby bundles of blood vessels, lymph vessels, and nerves. This trauma leads to inflammation, scarring, and eventually hardening of the tissue. This hardening can spread down the fibers of the connective tissue, which causes the cords to form. More research is needed before we'll know for sure what the cords are made of.
We're not yet certain how many people go on to develop cording after breast cancer surgery. Very few studies have been done, and most have involved small numbers of patients. One study found that 20% of women went on to develop cording after sentinel lymph node biopsy. Studies of cording after the more extensive axillary lymph node dissection have ranged widely, finding that anywhere from 6-72% of women develop it after ALND. Still, many experts believe that cording is more likely to be a problem after ALND than SLNB, since ALND is a more extensive surgery (and more surgery tends to be more traumatic for the body).
Managing axillary web syndrome
If you have symptoms of AWS, ask your doctor to refer you to a physical therapist or other medical professional (such as a nurse or physician) who specializes in breast cancer rehabilitation. Look for someone who has seen many patients with cording. It's not a good idea to wait and see if the condition will resolve on its own. Your natural reaction to the pain of cording will be to avoid moving the arm and shoulder, which can lead to more tightness in the shoulder and chest area. Over time, this may cause more serious problems with function and mobility. Moving and stretching under the guidance of an experienced therapist are the best ways to resolve the condition and stop the pain.
Together, you and your therapist can develop a treatment plan that's right for you. Your plan may include:
- Stretching and flexibility exercises: Your therapist can work with you to help you learn exercises that gently stretch the cords and improve your pain-free range of motion. He or she can teach you exercises to do at home and advise you on how often to do them.
- Manual therapy: Your therapist also may gently massage the cord tissue. Using manual therapy, your therapist would gently pull the tissue on your outstretched arm, starting in the upper arm and moving down into the forearm. This sometimes causes the cord to snap or break, and you may even hear a popping sound when that happens. It's usually not painful, and it often brings relief by extending your arm's pain-free range of motion.
- Moist heat: Your therapist may apply warm, moist pads directly to the cords as part of therapy. However, it's important that he or she use caution when doing this. Prolonged heat can increase the production of lymph, which can lead to the fluid overload known as lymphedema. If your therapist recommends moist heat, just be sure he or she is experienced in its use for cording. You can review our page on Finding a Lymphedema Therapist for tips on how to find an experienced therapist.
- Pain medication: You may need to take some form of pain medication, such as an NSAID (non-steroidal anti-inflammatory drug, such as Motrin or aspirin), if you experience pain that prevents you from stretching the arm. But remember that the best treatment for the pain is doing the stretching exercises that help the condition get better.
- Low-level laser therapy: Some therapists use a small, hand-held device to apply low-level laser beams directly to the skin. Laser therapy can help break down the hardened scar tissue.
With the exception of pain medication, all of these treatments focus on releasing the tight scar tissue that makes up the cord(s). You may notice that releasing the cord in certain parts of the arm can magnify the tightness in other areas — not because the cording is getting worse, but because the scar tissue is still "stuck" in those other areas. For example, releasing the cord in the upper arm and elbow will reduce pain and improve range of motion, but the wrist and forearm may feel tighter at first. "I describe the cord to my patients as being like a fishing line that is stuck in several places along the fishing rod," says Nicole Stout, MPT, CLT-LANA, physical therapist and lymphedema specialist, the Breast Care Center, National Naval Medical Center. "You can release a few of the stuck spots, but it then magnifies the tightness in the other areas that are still stuck."
Fortunately, cording usually resolves for most people after a few therapy sessions, or at least within a few months. It's possible to have limited range of motion for many months or even longer, but that's not typical. For some people, cording may get better and then come back later. But usually cording is a one-time event that doesn't become a persistent problem. Experts still aren't exactly sure what happens to the cords after they break down. Some experts believe that they simply get resorbed by the body, but other experts say that we simply don't yet know what happens to the cords.
Even after cording resolves, it's a good idea to continue with stretching and flexibility exercises. These can help keep the joint and soft tissue mobile during additional treatments, such as radiation therapy, and your ongoing recovery from surgery.
We're not yet sure whether axillary web syndrome increases the risk of later developing lymphedema in the arm. Lymphedema is swelling that occurs when too much lymph fluid builds up in the arm and/or hand. This can turn into an ongoing problem that needs to be managed over time. Some experts believe that axillary web syndrome is a sign of injury to the lymphatic system, which could suggest an increased risk of lymphedema later on. A 2006 International Consensus Statement on managing lymphedema does list AWS as a risk factor for lymphedema. However, there haven't been enough research studies to say for sure whether there is a link between the two conditions. If you've had cording, it does not mean that you are considered to be at higher-than-average risk for developing lymphedema.
We do know that anyone who’s had axillary lymph node surgery is at some risk of developing lymphedema, whether or not they’ve had cording. Therefore, it’s always a good idea to follow the guidelines in the Reducing Risk of Lymphedema and Lymphedema Flare-Ups section to minimize that risk.