Jodi Winicour’s “Painful Cording of the Arm” Article in the National Lymphedema Network Newsletter

The article below was published in the NLN’s May-June newsletter. References and other information regarding this article can be found on the NLN website.

Painful Cording of the Arm
by Jodi Winicour PT, CMT, CLT-LANA

If you have upper extremity lymphedema caused by breast cancer surgery or treatments, you may have experienced a painful and bothersome condition called axillary web syndrome, or AWS. [Figure 1] Unfortunately, most lymphedema certification programs do not have the time to teach the treatment of AWS, which leaves lymphedema patients well treated for their swelling conditions but inadequately cared for regarding their cording. As few as 6% [1] to as many as 72% [2] of women who have had lymph nodes removed from their armpit (axilla) will develop AWS. Considering the pain it causes along with its frequent relationship with lymphedema, knowledge of its characteristics, onset and treatment is necessary to provide safe, holistic care for breast cancer survivors.

AWS characteristics:

AWS has certainly been around since the first radical mastectomies of the early 1900s, but the phrase “Axillary Web Syndrome” was coined in 2001 by Alexander Moskovitz, MD et al. [1] He describes painful cords of tissue that originate in the axilla, run along the inside of the upper arm to the elbow, and sometimes even to the wrist or the base of the thumb. These cords are made more taught by reaching out to the side and frequently can be seen as well as felt. Painful cording typically limits overhead and forward reaching along with elbow and forearm movements which makes activities such as cooking, cleaning, exercise, reaching and dressing difficult or impossible during the more painful stages.

How and when does AWS happen?

Typical onset of cording is 2 to 4 weeks after axillary node removal. [1, 2, 4, 5] Some with AWS have so much pain that it is difficult to use their arm while others feel that stretching and massage techniques are very helpful. Studies consistently report that the AWS will resolve on its own between 3 and 4 months after onset, but therapists who treat AWS have noted it lasting up to 1 year or longer without treatment. Untreated AWS may cause problems during the planning period for radiation therapy in those not needing chemotherapy. If unresolved, the cording can make CT scanning for radiation planning a very painful procedure which can delay the start of radiation therapy. It is much less common to see AWS after chemotherapy is completed, which is typically 3 to 6 months post surgery, but it does occur.

What is the stuff called AWS?

Although there are few tissue samples of AWS that have been looked at under the microscope, we do know that AWS can be hardened and enlarged lymphatic vessels that are filled with lymphatic fluid. This fluid cannot exit the arm normally through lymphatic pathways to the axilla due to lymph node removal. [1, 5, 10] AWS may also be small veins near the skin that are clotted or hardened. [1] In some cases, the webbing is hardened and clotted lymphatic fluid that causes inflammation of the vessels and makes them stick to the fatty tissues of the arm resulting in pain when moving or stretching the arm.

What increases my risk of having AWS?

While weight gain [11,13], obesity [11,13] & higher Body Mass Index (BMI of 25-26 kg/m2 [2,12,13]) have been associated with the onset of lymphedema, a lower BMI of 23[2] and 25.1 [ 3]) have been associated with the onset of AWS. These are confusing findings especially considering that both lymphedema and AWS seem to be caused by the axillary node removal and tissue scarring. Thinner women have both the increased risk of AWS and difficulties with shoulder movement after lymph node surgeries for breast cancer, while their risk for lymphedema should be lower than heavier women. [2, 11, 13]

What can I do about AWS?

While studies written by physician researchers state that AWS will resolve on its own, therapists around the world who frequently treat AWS agree that gentle massage, manual lymphatic drainage techniques and range of motion exercise can accelerate pain relief and tissue healing. Physical therapy may shorten the natural course of AWS to 6-8 weeks. [3] In some cases, the AWS presents with a mild lymphedema of the forearm. While traditional CDT (Complete Decongestive Therapy) techniques may reduce the lymphedema, it may become a chronic condition unless the AWS is treated.

Soft tissue techniques for cording include very gentle tissue “bending” or “traction” techniques applied along the taut cord in a comfortable position of stretch. Localized thumb and whole handed MLD techniques along the cording is also useful. Do combine active stretching with massage techniques to further improvements and do not be surprised if a “pop” is heard along the cording during your gentle treatments or during stretching. This “pop” will usually ensure immediate pain relief during movement but can also lead to lymphedema on rare occasions. Please avoid being overly aggressive (causing pain) during your treatments as this can cause an inflammatory reaction that may increase the lymphedema risk of your affected arm.

Knowledge of safe and effective techniques to hasten the resolution of AWS is necessary in the treatment of those recovering from breast cancer treatments and arm lymphedema. Hopefully reading this article will help to ease you or your patients’ discomfort and increase your awareness of the treatments that are available.

Jodi Winicour PT, CMT, CLT-LANA
Longmont United Hospital, Longmont, Colorado.
Jodi is a full time clinician specializing in the treatment of lymphedema and cancer related dysfunction. She also is a Lymphedema Certification and Breast Cancer Rehabilitation Course instructor for Klose Training & Consulting.
Contact her at: Jodi@KloseTraining.com