Axillary web syndrome (AWS) can happen after breast cancer surgery that involves removing lymph nodes from the armpits.
AWS is also called “cording.” It refers to the development of scarring or connective tissue under the arm. This can be painful and limit the arm’s range of motion.
In this article, we look at the causes, symptoms, and treatment options for AWS.
AWS, or cording, can happen after a biopsy or surgery on the lymph nodes under the arm.
The area is called the axillary region and the lymph nodes there are called axillary lymph nodes. During surgery for breast cancer, the surgeon may remove either a few or many of these lymph nodes. As a result, AWS can develop.
A person with AWS may be able to feel a web of thick, rope-like structures under their arm. Or, the only symptom may be a feeling of pain or tightness when raising the arm above the head or straightening the elbow, for example. The symptoms may appear several days to several weeks or months after surgery.
While experts are uncertain about common it is, AWS may affect 20% of people who have had a few nodes removed and up to 72% of people who have had many nodes removed.
Research from 2019 reports that it may affect
Physical therapy, home care strategies, and pain relief medications are some ways of treating AWS, and many people see an improvement over time.
The nonprofit organization Breastcancer.org urges people to pursue treatment for AWS. Without treatment, it can limit the range of motion, leading to stiffness elsewhere in the body.
Physical therapy can help reduce the symptoms of AWS, or cording.
A doctor or physical therapist may recommend specific stretches. People may be able to do some at home, while others require medical supervision.
The best stretches and number of repetitions vary from person to person, depending on the extent of scar tissue.
The Canadian Cancer Society recommends the following:
This can help expand the chest and boost lymph circulation.
- Sit up straight on a chair, keeping the neck and shoulders relaxed.
- Breathe in deeply and slowly through the nose and feel the chest expand.
- Breathe out completely.
- Repeat 4–5 times.
Shoulder blade squeeze
- Sit or stand up straight.
- Keep the arms down by the sides, the elbows straight, and the palms facing in.
- Open the chest and squeeze the shoulder blades together and downward while turning the palms forward.
- Hold this position for 10 seconds while breathing deeply, then return to the starting position.
- Repeat this 5–10 times or as often as a physical therapist advises.
- Lie on the back with the knees up and the feet flat on the floor.
- Start with the arms down by the sides and the palms facing up.
- Gently squeezing the shoulder blades together, slowly raise the arms to the sides until the fingers meet above the head, and hold the position for 2–3 breaths.
- Slide the arms back to the starting position, as if making snow angels.
- Repeat this 5–10 times or as often as a physical therapist advises.
If using both arms is painful, try moving one at a time.
The Ohio State University Wexner Medical Center also recommends:
- Sit on a chair with the feet flat on the floor, the head up, and the neck straight.
- Place both hands behind the neck with the elbows pointing forward.
- Gently bring the elbows out to the sides and hold this position.
- Gently return the elbows to point forward.
- Repeat this as often as a physical therapist advises.
AWS most commonly occurs after a surgical procedure for breast cancer:
People may experience it after:
- a mastectomy, in which a surgeon removes one or both breasts
- a lumpectomy, in which they remove a lump within a breast
- a sentinel node biopsy, in which they remove a few lymph nodes from under the arm
- an axillary lymph node dissection, in which they remove several lymph nodes from under the arm
Doctors are not completely sure why AWS happens. One theory is that breast surgery may traumatize the blood vessels and connective tissue under the arm. This causes inflammation, which eventually hardens nearby soft tissue.
- the type of surgery
- the length of follow-up treatment
- whether postoperative checkups looked for signs and symptoms of AWS
AWS is also called “cording” because the characteristic tissue under the skin resembles cord or rope. A person may be able to see or feel it, and this might be the first indication of AWS.
Or, a person may first experience tightness and pain in the area, or a doctor may identify it during an exam after surgery.
The signs and symptoms of AWS are as follows, and they can be mild to severe:
The scar tissue that characterizes AWS forms under the arm, at the site where lymph nodes were removed. The tissue can vary in thickness, and it may be visible or palpable.
For some people, the scarring extends from the armpit down to the elbow, wrist, or thumb. One long cord of scar tissue may develop, or several smaller cords may run down the inner arm. In some cases, the cording can extend down into the torso.
AWS can cause pain, and the skin may feel stretched and tight.
A person’s natural reaction may be to limit movement in the affected arm, such as by avoiding lifting the arm above the head. However, limiting movement can worsen the symptoms because it can cause the tissue to tighten.
Decreased range of motion
AWS can significantly reduce the range of motion, which can interfere with a person’s daily activities. It can make simple tasks, such as putting on clothes, difficult.
AWS is not a life threatening complication of surgery, but it can affect a person’s quality of life and their range of activities.
If the symptoms are mild, physical therapy alone may release the scar tissue, improving the range of motion and reducing discomfort.
However, depending on the extent of the scar tissue, physical therapy may only reduce the tightness in one area. For example, if scar tissue runs from under the armpit to the wrist, exercises may improve the tissue under the arm, but the area near the elbow may still feel tight.
Some additional treatment approaches include:
A doctor may recommend various massage techniques, such as nerve gliding and scar tissue release.
The process involves a healthcare professional manipulating the connective tissue to break it down. This improves the person’s range of motion.
Doctors are not exactly sure what happens to scar tissue after it breaks down, but the body likely reabsorbs it.
People should only receive this massage from a practitioner who specializes in therapy after breast surgery. They have the expertise to perform the techniques correctly while preventing further tissue damage.
A physical therapist may use a low-level laser to treat AWS. Laser therapy involves directing powerful beams of focused light at hardened scar tissue to break it up.
Laser therapy may not be effective in all cases. For example, the effectiveness may depend on the thickness of the scar tissue, and some people require multiple laser sessions.
Laser therapy can also cause side effects. Discuss the potential risks and benefits with a doctor before opting for this treatment.
Beyond the exercises above, some additional home care techniques include:
- Nonsteroidal anti-inflammatory drugs: These medications are sometimes called NSAIDs, and one example is ibuprofen (Advil, Motrin). They will not reduce the scarring, but they can help manage pain and discomfort.
- Moist heat: Applying moist heat to the area may reduce discomfort. However, consult a healthcare professional about the best way to do this, as heat can stimulate the production of lymph fluid, which may make symptoms worse. Make sure that any application is warm, not hot, to avoid burning.
- Other exercises: A physical therapist can recommend a tailored routine.
Following a doctor’s instructions after surgery, including any stretches or exercises that they suggest, may help reduce the risk of developing AWS.
If AWS develops, the doctor can recommend treatment options and ways to adapt the overall treatment plan.
AWS involves scar tissue developing under the arm, and this cord-like tissue may extend down the torso or down the arm to the hand. It results from damage to the connective tissue during a biopsy or surgery.
Exercises, pain medication, and massage can help release this tissue, manage discomfort, and improve the range of motion. A physical therapist and a doctor can help develop a suitable exercise plan.