Axillary Web Syndrome (Cording)

What is Axillary Web Syndrome?

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

• Sentinel lymph node biopsy (SLNB).
• Axillary lymph node dissection (ALND).
• Surgery to stage melanoma.
• Swollen axillary (underarm) lymph nodes caused by cancer.

AWS can happen at any time after one of these procedures. It can cause pain and make it harder to move your shoulder.

It often happens in the area under your armpit and runs down the length of your arm to your elbow, and in some cases down toward your hand. It can also occur in the breast, chest, and abdominal (belly) area. There may be one large cord or many 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 them. The area may feel tight, not normal, or even painful when you move your arm. It may be hard to lift your arm above your shoulder or do overhead activities. Because of the tightness, daily activities like washing hair, getting dressed, reaching overhead, or putting on a seatbelt may be hard.

You should check regularly for AWS for the first 3-6 months after surgery. You should also continue to check every so often for up to 3 years after surgery. To check for AWS:

• Lift your arm straight out in front of you above your head and out to the side. Check if you see anything or feel any tension or discomfort.
• Pay attention to everyday tasks that use your affected arm and notice 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?

The exact cause of AWS is not known. Research suggests that it may happen 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, or cords.

What are the risk factors for AWS?

There is not enough evidence to know who is more likely to get AWS. 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 than older patients.

When and how often does it happen?

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

How is AWS treated?

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

Physical therapy can help by using:

• Exercises that help with stretching, flexibility, and strength.
• Nerve glides (stretches to improve nerve movement).
• Manual treatments like trigger point and myofascial release, scar tissue mobilization, joint mobilization, and passive stretching.
• Compression bandaging and manual lymphatic drainage may also be used to help 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.
• There are not often long-term side effects.
• AWS does not usually come back once it goes away.
• It is recommended to do self-assessment often for AWS during the first 3–6 months after surgery and continue to do them for up to 3 years.
• Physical therapy and exercise can help with pain and range of motion.