Axillary Web Syndrome

By Elizabeth Morin SPT, American International Co"ege

What is Axillary Web Syndrome?

Axillary web syndrome (AWS) is a painful and functionally limiting complication after lymph node resection most likely due to lymphatic thrombosis. It is described as a visible web of axillary skin overlying palpable cords of tissue that are made taut and painful by shoulder abduction.

Symptoms:
Decreased shoulder ROM (usually in exion and abduction) Pain with shoulder movement Cord formation Scar adhesions

Causes:
Interruption of axillary lymphatics due to: Sentinel lymph node biopsy (SLNB) Axillary lymph node dissection (ALND) Also observed in patients following axillary staging for melanoma and patients with breast cancer and axillary metastases who developed AWS without ever having surgery.

Cording
The cause of cording is unknown but many hypotheses have been made. Some speculate that the thrombosed lymphatics go through an inammatory phase with thickening of the vessels and temporary shortening and tightening which later remits. The underlying pathology is lymphatic thrombosis.
Disruption of normal lymph drainage channels leads to lymph stasis. Lymph stasis can either lead to lymphedema or axillary cording

Cording
One study found that the cord was a lymph vessel that had undergone brosis, surrounded by fat and granulation tissue. The lymph vessel then attaches to the axilla or chest via scar tissue.

Cord Formations & Locations:

Single cord in axilla Divided cord in axilla Cord visible beyond elbow Cord palpable in chest

Axillary Web Syndrome

AWS can occur weeks, months, and even years after surgery. Due to lack of research, the percentage of AWS cases after surgery is unknown, but is estimated to range anywhere from 5-20%.

Axillary Web Syndrome

The majority of AWS cases resolve within a couple months. Most people with AWS only develop it once, but in rare instances, some people may have AWS reoccur years later.

Physical Therapy
For many years, doctors believed that manual therapy may increase patients chances of developing lymphedema and discouraged physical therapy and manual techniques. However, recent research suggests that Physical Therapy treatments relieve symptoms of AWS and quicken recovery.

PT Treatments include:
Release Manipulations Scar Massage Scar Mobilization Manipulations Scar Stretching Myofascial Release Muscle Stretching (biceps, pecs, trap, subscap, latiss) Manual Treatment of Shoulder Joint PNF Patterns Low Level Laser Therapy Kinesiotaping

Release Manipulations
Make up 2/3 of the treatment session Applied at cord attachment and follows course of the cord along the arm as far a necessary Cord is stretched and mobilized by means of hooking manipulations Arm is in abducted position and raised higher during treatment 20-40 degrees of shoulder ABD can be achieved in 1 treatment

Release Manipulations
Not uncommon to hear an audible tear during treatment Painless Usually results in increased mobility

PT Treatment:
Precautions:
Lymphedema Radiation

Contraindications:
Reddening of the scar Metastasis

PT Treatment:
2-3x a week for 1-2 months, or until AWS resolves HEP included: AROM exercises for exion PROM exercises for exion

AROM

PROM

Axillary web syndrome after axillary dissection.

Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE.
Am J Surg. 2001 May;181(5):434-9.

Background: Some patients undergoing axillary lymph node dissection (ALND) experience postoperative pain and limited range of motion associated with a palpable web of tissue extending from the axilla into the ipsilateral arm. The purpose of this study is to characterize the previously undescribed axillary web syndrome (AWS). Methods: To identify patients with AWS, a retrospective review was performed of all invasive breast cancer patients treated by a single surgeon (REM) between 1980 and 1996. Records were also reviewed of 4 more recent patients who developed AWS after undergoing sentinel node lymph node dissection (SLND) without ALND. Results: Among 750 sequentially treated patients, 44 (6%) developed AWS between 1 and 8 weeks after their axillary procedure. The web was associated with pain and limited shoulder abduction (< or = 90 degrees in 74% of patients). AWS resolved in all cases within 2 to 3 months. AWS also occurred after SLND. Tissue sampling of webs in 4 patients showed occlusion in lymphatic and venous channels. Conclusions: AWS is a self-limiting cause of morbidity in the early postoperative period. More limited axillary surgery, with less lymphovenous disruption, might reduce the severity and incidence of this syndrome, although SLND does not eliminate its occurrence.

Physiotherapy management of axillary web syndrome following breast cancer treatment: Discussing the use of soft tissue techniques
W.J. Fouriea, K.A. Robb
(2009)Physiotherapy,95(4),pp.314-320.

Background and purpose: Axillary web syndrome (AWS) is becoming increasingly recognized as a sequela of breast cancer treatment. There are currently no formal guidelines on which to base therapy interventions. This case study discusses the physiotherapy management of a patient with AWS, highlighting a soft tissue mobilization approach. Case description: A 47-year-old hairdresser experienced sudden loss of shoulder movement and development of axillary cords 22 days after mastectomy and axillary dissection. The management included manual therapy, mostly using soft tissue treatment techniques, combined with education and advice. Outcomes: Pre-morbid range of movement was achieved within 11 treatments, spread over 3 weeks. The patient returned to full-time employment after the seventh treatment by a physiotherapist, within 2 weeks of starting treatment, progressing to full range of shoulder movement with no cords or pain by 16 weeks post surgery. Discussion: Previous theories on the pathophysiology of AWS may need to be revised. Physiotherapy intervention for these patients may prove beneficial in limiting subsequent shoulder dysfunction. Further research is needed to develop a standardized treatment approach for AWS

Physiotherapeutic treatment for axillary cord formation following breast cancersurgery.

Josenhans E.
Pt_Zeitschrift fr Physiotherapeuten. 2007; 59 (9): 868 - 878.

Background and purpose: The general recommendation with patients who have AWS has been to avoid any manual manipulation of the cords because of concern about causing lymphedema. The purpose of this study was to try a physical therapy approach to AWS since the syndrome was essentially unstudied. Case description: 123 patients who had axillary cord formation after breast cancer surgery were studied and treated. Treatment consisted of discovering the anchoring of the cord at its origin and then carefully manipulating the point of fixation. Stretches and manual techniques were also performed. One patient also had the cord surgically removed and found that it was a fibrotic lymph vessel. Outcomes: PT treatment resulted in increased shoulder mobility in 90% of the patients, and cord elimination in 94% of patients. No patient developed lymphedema due to treatment. Discussion: The treatment carried out in this study resulted in increased shoulder mobility and decreased pain. Further research should be performed to determine whether the cord disappears by itself, to see the percentage of patients who benefit from only therapeutic exercise, and to see the percentage of patients who benefit from only manual techniques.