Axillary Web Syndrome (AWS), also known as lymphatic cording, refers to a condition in which a rope-like soft-tissue density develops in the axilla, which may develop as a result of breast cancer treatment.

• It usually appears in the 5 to 8 week period following breast cancer surgery and can lead to shoulder pain and restricted motion. (NCBI: PMC: Atypical presentation of axillary web syndrome)
• Cords are palpable bands of tissue which can occur in the axilla, across the antecubital fossa into the forearm and wrist, and in the breast or abdominal wall.
• The incidence of cording following breast cancer treatment ranges from 6 – 72%, and the condition can cause pain and limited range of motion in the upper extremity. (NCBI: PMC: Cording Following Treatment for Breast Cancer)

When does it happen:

• Typically 3-4 weeks post – op.
• Less often 2-4 weeks
• Less often over 4 weeks (Klose: Breast Cancer Rehabilitation)

Mondor disease is a rare condition that is characterized by scarring and inflammation of the veins located just beneath the skin of the chest.

• The affected veins are initially red and tender and subsequently become a painless, tough, fibrous band that is accompanied by tension and retraction of the nearby skin.
• In most cases, the condition is benign and resolves on its own; however, Mondor disease can rarely be associated with breast cancer.
• Although the condition most commonly affects the chest, Mondor disease of other body parts (including the penis, groin, and abdomen) has been described, as well.
• Mondor disease is thought to occur when pressure or trauma on the veins causes blood to stagnate.
• In most cases, the condition arises after recent breast surgery, but it can also be associated with physical strain and/or tight-fitting clothing (i.e. bras).
• Treatments are available to help relieve symptoms until the condition resolves. (NIH: NCATS: Mondor Disease)

The etiology of cording is not fully understood.

• The condition may be related to abnormalities in either the axillary vasculature or the lymphatics.
• Anatomic studies of resected cords reveal that these structures may represent dilated and thrombosed lymphatics and/or thrombosed superficial veins.
• The condition is considered to be a variation of Mondor’s disease, a rare thrombophlebitis of the subcutaneous veins caused by trauma such as surgery. (NCBI: PMC: Cording Following Treatment for Breast) Cancer
• AWS: may be attributed to lymph venous injury during axillary lymph node dissection due to either tissue retraction and/or patient positioning.
• Another theory is that because of the interruption in axillary flow, lymphatic vessels are dilating and scalloping to the skin. (Summit Education: Oncology Rehab Dec 12, 2019)

The incidence of cording after axillary lymph node dissection (ALND) has been reported as high as 72%, compared to 20% after sentinel lymph node biopsy (SLNB).

• Younger age, lower BMI, and being African-American have also been implicated as potential risk factors.
• While cording has been reported to cause limited range of motion, the extent to which this translates into dysfunction performing daily functional reaching activities has yet to be reported. 
• Little data exists on whether cording is associated with an increased risk of developing upper extremity lymphedema. (NCBI: PMC: Cording Following Treatment for Breast Cancer)

Body habitus:

• Pt’s that have AWS were found to be more often of lower weight with a BMI between 23-25.
• Pt’s that were obese with a BMI between 26-28.9, unlike with lymphedema, tend to have a lower incidence of cording. (Klose: Breast Cancer Rehabilitation)

Axillary web syndrome is a self-limiting and frequently overlooked cause of significant morbidity in the early post-operative period after breast cancer axillary surgery, which is characterized by axillary pain that runs down the medial arm, limited shoulder range of motion affecting mainly shoulder abduction, and cords of subcutaneous tissue extending from axilla into the medial arm, made visible or palpable and painful by shoulder abduction.

• In addition, soft tissue may give a cordlike appearance due to increased tension between the skin of the upper arm and adherence of an axillary scar to underlying fascia.
• Lymphatic cording is associated with pain and limitation of shoulder movement, and it is common to find shoulder abduction restricted to less than 90°.
• Exercise interventions should typically include supine exercises involving assisted shoulder flexion, active abduction, horizontal abduction, and a trunk rotational stretch with shoulder abduction, stretching exercises for levator scapulae, upper trapezius, pectoralis major, and medial and lateral rotators muscles of the shoulder. (Pink Ribbon Program®)

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.

• 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.
  • 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 reabsorbed by the body, but other experts say that we simply don’t yet know what happens to the cords. (Breastcancer.org Axillary Web Syndrome (Cording)