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You have just undergone surgery for breast cancer and as if that isn’t enough, you have now developed these painful cords in your armpit. You may even feel or see the pulling going all the way to your elbow, forearm, and wrist. They seem to be making movement and activity even more difficult than you expected. What is going on?

It is likely that you have Axillary Web Syndrome (AWS), also known as cording.

What is Axillary Web Syndrome?

Cording is a common side effect of lumpectomies or mastectomies for breast cancer. An estimated 70% of women having axillary node dissection, and 20% of women who have had sentinel node biopsy will develop cords.(1) The cords are the vessels of your lymphatic system, which is a circulatory system similar to the blood vessels spanning your entire body. These vessels are affected when the nodes they drain into have been removed.

If it occurs, axillary web syndrome usually appears within 1-8 weeks post-surgery. The cords can be very painful and limiting at onset but can be managed with the proper advice and treatment.

Why Does it Happen?

Lymphatic fluid has the ability to spontaneously thicken. When there has been trauma and inflammation to an area, an enzyme called thrombokinase is released in the tissues that have been damaged. This enzyme can accelerate coagulation and stimulate the formation of cords
AWS is more common in slimmer women with body mass index (BMI) of less than 25. It has been thought that too much or too little activity post-surgically and infection in the surgical site may influence the development of cords.

The cords may last for months or even years, with up to 15% of cording cases lasting > 6 months. (2) Axillary web syndrome will usually resolve, sometimes spontaneously but more often, with rehabilitation.

How Do I Manage It?

Post-surgically, try to return to normal activities of daily living as soon as possible, and as directed by your treatment team. Being over-protective or over-zealous can disrupt lymph fluid equilibrium, causing more lymph coagulation and possibly, cord development.

A physiotherapist experienced in treating axillary web syndrome can be very helpful in guiding and monitoring your recovery. They will prescribe and provide range of motion exercises, gentle stretching, tissue mobilization and myofascial release techniques.

The goal is to restore full, pain free function of the arm and shoulder as soon as possible. With the proper treatment, cording can usually be resolved within a few weeks.

1) Leidenus M, Leppanen E, etal. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am JSurg.2003;185(2):127-130.
2) Lauridsen MC, Christiansen P, Hessov I. The effect of physiotherapy on shoulder function in patients surgically treated for breast cancer. A randomized study. Acta Oncologica, 2005;44:449-457.

A diagnosis of cancer can be devastating for anyone. Once those words have been heard, a patient may be bombarded with information regarding diagnosis and treatment. Before long, surgery may be scheduled and you are home from the hospital awaiting further treatments. In our practice at Keary Physiotherapy we see many breast cancer patients (as well as other forms of cancer including cervical and ovarian cancer and melanoma).

Our services include:

• pre and post-operative assessments in a private setting.
• we prescribe appropriate exercise programs to begin a few days following surgery, progressing to returning to full function.
• we discuss do’s and don’ts following surgery and treatment to minimize any complications.
• we provide education on skin care and scar tissue management
• we provide instruction on scar mobilization techniques
• education and discussion on the physical side effects of breast cancer treatment and how to manage it.
• compression garment and bra fittings

Possible Physical Side Effects Following Breast Cancer Treatment:

There are several physical side effects that women may experience after breast cancer treatment:

• decreased range of motion of the affected shoulder, chestwall and thoracic spine
• decreased strength, function and endurance
• fatigue
• soft tissue fibrosis
• axillary web syndrome/cording
• pain, neuropraxia
• lymphedema

These possible side affects can be reduced significantly with guidance from a knowledgeable physiotherapist. We work closely with a garment fitter who assists with bra fittings and compression garments when needed.

Our Goal is to improve quality of life by restoring function and helping our patients get back control of their lives. We care about our patients and strive to help in any way possible.

Ten or fifteen years ago lymphedema was not a well known term in the physiotherapy world. I first wrote an article for Directions about lymphedema in 2006. Since then I have steered my practice towards cancer-related lymphedema. While my practice consists mainly of breast cancer-related lymphedema, over the last few years I have been seeing more patients with lymphedema secondary to melanoma surgery and treatment. I currently have 5 patients I am treating with lymphedema secondary to melanoma treatment, 3 have swelling in their lower extremity and 2 in their upper extremity (I currently have no face, head or neck lymphedema patients). All 5 patients had a malignant mole removed 6-9 years previously either from their leg or upper arm/shoulder area and were fine until more recently when the cancer returned and spread to the regional lymph nodes requiring either inguinal node dissection or axillary node dissection. All 5 patients noticed a painful or uncomfortable lump in their groin or axilla which turned out to be reoccurrences.

Rates of melanoma have been rising over the past 30 years and while the average age of diagnosis is 61 years, it is the most common cancer killer in young adult women and is 20 times more common in white people than African-American. Living in areas with high sun exposure and a history of severe sunburn at a young age continue to be the main risk factors for developing melanoma.

During axillary node and inguinal node dissection approximately 8-30 lymph nodes are removed depending on the individual person and the location of the tumour. The protocol for treating lymphedema secondary to melanoma is the same as for breast cancer-related lymphedema but I find melanoma patients can be very interesting. When removing inguinal lymph nodes often an incision 20-30 cm long over the groin is required. This means their scars can be much more intrusive and often more challenging, particularly when fitting for compression garments and finding pathways to redirect lymphatic fluid when using manual lymphatic drainage techniques.

Complete decongestive therapy continues to be considered the gold standard treatment for lymphedema and consists of meticulous skin care, manual lymphatic drainage, compression and remedial exercises.

Since writing my last article for Directions, British Columbia now has the addition of the BC Lymphedema Association, bclymph.org , founded in 2006, which educates, advocates and supports people living with lymphedema to take an active role in their care.

Are you feeling discomfort in your neck, upper back and shoulders and even some difficulty achieving full shoulder range of motion? Squeezing and massaging them just isn’t doing the trick? Chances are you have a muscle imbalance pattern called Upper Crossed Syndrome (UCS). It is commonly seen in people who sit at a desk or computer or have to drive long periods during the day. If you have a past history of trauma to your neck from a car accident or fall this can also lead to UCS which is really a fancy term for postural muscle imbalance. I see this also in post-mastectomy patients. Our brains tell us to protect, therefore we instinctively want to round our shoulders and protect our chestwall following surgery. Aches and pains from chemotherapy drugs and radiation may impact this. If you already have a history of working long hours in front of a computer you may be compounding an already present muscle imbalance.

The key imbalances are as follows:

Forward head posture causing weakness of the front neck (cervical) flexor muscles AND weakness of the lower trazpezius and rhomboid muscles of your upper back/shoulder blade area
PLUS
Tightness of the back neck muscles (suboccipital/upper trapezius ) AND of the front chest muscle (pectorals).

This follows a “crossed” pattern of imbalance which over time can lead to a lot of pain and dysfunction.

So what can you do about it? The goal is to correct the imbalances. First you will need to stretch the shortened (tight) muscles before you can work on strengthening the weakened ones. Think of the string at the top of your head being pulled taut to allow you to correct your posture by tucking your chin in (like making a double chin) and drawing your shoulder blades down (like putting your right shoulder blade into your left back pocket and visaversa), now adding the doorway stretch for your pectoral muscles where you stand in a doorway with your hands at shoulder height on the doorframe. Deep breathe and feel the chestwall expand. This likely feels hard to do and will take some work. Using a yoga bolster can be a great help too. Lying on the floor on top of the bolster with it lengthwise behind your back from your head to your lower spine and allowing your shoulders and arms to fall out, opening up the chestwall, feels amazing and can begin to restore flexibility in the chestwall. Add your deep breathing techniques to really expand the small chestwall muscles. Finally, add some strengthening exercises for your upper back to counterbalance the tightness of the chest muscles. If you are not sure what to do seek advice from a physiotherapist.

As a physiotherapist and a yogi I quickly realized that the two approaches to restoring health would greatly compliment each other. I find I am incorporating the principles of yoga into my physiotherapy practice more and more. Physiotherapy treatments can greatly reduce pain and inflammation to an injured area and adding some yoga principles can enhance recovery. The main yoga principles I incorporate are:

BREATHING – it is now natural for me to add breathing to all exercise programs. I know from experience that breathing into an area of pain and stiffness allows ease of movement rather than tension allowing for new optimal patterns of movement to develop. Over time the connection between breath and movement develops allowing for better body awareness. Better body awareness will minimize recurrence of injury. As well, breathing maximizes oxygen levels in the blood that allows for better healing of tissue.

POSTURES (ASANAS) – the yoga postures focus on proper body alignment to restore balance, and increase strength and flexibility of muscles and ligaments to better protect the joints. Combining postures with the breath allows for deeper movement and heightened body awareness which will minimize old habits that have caused pain and dysfunction in the past and maximize optimal movement patterns.

RELAXATION – in order for the body to heal it needs relaxation to revitalize the nervous system. In order for the body to relax the mind needs to be calm. By finding inner peace and calm you will feel refreshed and relaxed allowing better healing of tissue which will promote more positive thinking.

GOOD ARTICLE ON AXILLARY WEB SYNDROME:
Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies

LA Koehler,1,2,3 TC Haddad,4 DW Hunter,5 and TM Tuttle3,6