Axillary web syndrome (AWS) is a side effect of breast cancer surgery. It can develop after the removal of the lymph nodes from the armpits.

The condition involves the development of scarring or connected tissue under the arm. AWS, or cording, can be painful and limit the range of motion in the affected arm.

In this article, we look at the causes, symptoms, and treatment options for AWS.

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Axillary web syndrome can restrict movement in the arms. Several types of treatment are available to help restore function.

AWS most commonly occurs due to breast cancer surgery.

When a doctor recommends surgery for breast cancer, it usually takes the form of a mastectomy or lumpectomy. These surgeries involve removing the breast or a lump within the breast.

A healthcare provider might need to conduct a sentinel node biopsy or an axillary lymph node dissection. The difference between a sentinel node biopsy and an axillary lymph node dissection is the number of lymph nodes they remove.

Breast cancer cells are most likely to spread to the lymph nodes in the armpit, which is why a surgeon will remove them.

The sentinel node is often the first, or first few, lymph node(s) into which a tumor drains. In a sentinel node biopsy, the surgeon only removes a few nodes.

An axillary node dissection involves removing a larger number of nodes from the armpits, although the exact number may vary.

AWS can take anywhere between a few days and several weeks to develop after surgery. Some people have developed AWS months after surgery.

Doctors are not completely sure why some people develop it. 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.

Figures are unclear on how common AWS is. A 2019 journal article estimates that anywhere between 6% and 86% of people develop AWS after breast cancer surgery.

Its authors put the wide range down to different types of surgery, varying lengths of follow-up treatment, and whether postoperative checkups looked for AWS symptoms.

People often receive a diagnosis upon noticing the characteristic web- or cord-like scar tissue under their arm. A doctor might also identify it during a follow-up exam after surgery.

Some people may feel tightness or pain in the affected arm, even though the scar tissue may not be visible.

AWS is also known as cording because the visible tissue under the skin resembles cord or rope.

The symptoms of AWS range from mild to severe and may include the following:

Scar tissue

Scar tissue forms under the arm at the site of node removal. Although it can vary in thickness, a person can often easily see and feel the band of scar tissue under the skin.

For some people, the scarring extends from the armpit all the way 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, cording can extend down into the torso.

Pain

AWS can be painful. The skin can feel stretched and tight.

If pain and tightness occur, a person's natural reaction may be to limit movement in the affected arm. For example, they may avoid movements such as lifting their arms overhead.

However, limiting movement to avoid pain can make the condition worse, as avoiding movement in the affected arm can actually tighten the tissue.

Decreased range of motion

The condition can significantly reduce range of motion, which can interfere with a person's daily activities.

A person's range of motion may be so limited that they cannot raise their arms overhead. Even simple tasks, such as putting on clothes, can be more difficult.

Here, learn more about recognizing and treating breast cancer.

Although AWS is not a life threatening complication of surgery, it can interfere with a person's quality of life.

If the condition is mild and does not cause pain or affect range of motion, a person may not require surgery. In most cases, a doctor may recommend physical therapy to release the scar tissue. Doing so should improve a person's range of motion and reduce discomfort.

Depending on the extent of the scar tissue, treatment may only decrease tightness on one part of the cording. For example, if scar tissue runs from under the armpit to the wrist, treatment may improve the tissue under the arm, but the area near the elbow may still feel tight.

Treatment may include the following options:

Guided stretches

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Some stretches can help reduce the impact of AWS. A person may be able to perform these at home without supervision.

A doctor or physical therapist may recommend certain stretches. People may be able to do some of these at home, but it may be necessary to do others under medical supervision only.

The specific stretches may vary depending on the extent of scar tissue. One stretch usually involves the following:

    1. Lift the arms out to the sides and straighten the elbows.
    2. Raise the hands until feeling a stretch.
    3. Hold the stretch for about 30 seconds.
    4. Repeat the stretch a few times, raising the arms a little higher each time.

          Holding the stretches for the prescribed amount of time is vital. If the stretches are too brief, they may not be effective in improving a person's range of motion.

          Massage

          A doctor may recommend various massage techniques to treat AWS, such as nerve gliding and scar tissue release.

          The different massage methods involve a healthcare professional manipulating the connective tissue with their hands. This helps break up scar tissue and improve a person's range of motion.

          Doctors are not exactly sure what happens to the scar tissue after it breaks down. They suggest that the body reabsorbs it.

          People should only receive this type of treatment from a practitioner who specializes in therapy after breast surgery. They will have the expertise to perform the procedure correctly while avoiding further tissue damage.

          Laser therapy

          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. For this reason, some people may require multiple laser sessions.

          Laser therapy may also have side effects. A person should always weigh the potential risks and benefits with a doctor before choosing the procedure.

          Home care

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          Nonsteroidal pain medication can help reduce discomfort from AWS.

          A healthcare professional who specializes in breast cancer rehabilitation might recommend home treatment. For example, they may suggest that the person performs the stretches a few times per day at home.

          Additional home treatment may include:

          • Nonsteroidal pain medication: Although pain medication will not reduce scarring or treat the underlying problem, it can reduce the pain and discomfort associated with it. Over-the-counter pain medication such as acetaminophen can be effective.
          • Moist heat: Applying moist heat to the area may reduce discomfort. People should always follow a doctor's advice and exercise caution when using heat, as it can stimulate the production of lymph fluid, which may make symptoms worse.

          Following a doctor's instructions after surgery, including performing the suggested stretches, may help reduce the risk of developing AWS.

          People who develop the AWS should ask their doctor if they need to continue performing the stretches after the symptoms improve to prevent it from reoccurring.

          Q:

          Does lymph node removal have any other adverse effects?

          A:

          Lymph node removal comes with the risk of some adverse effects in addition to AWS. Sometimes, the procedure can damage the nerves, which can result in temporary or permanent loss of some sensation in the armpit or back of the arm.

          Another possible risk is stiffness or weakness in the arm, which physical therapy may improve. Lymphedema, or swelling, in the arm or torso may also occur after lymph node removal.

          There is also a risk of infection in the surgical area.

          Yamini Ranchod, PhD, MS Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.