What is Cording?
Axillary Web Syndrome or Cording is a common side-effect of sentinel lymph node biopsy (SNLB) or axillary lymph node dissection (ALNB). Up to 86% of patients with one or more lymph nodes removed develop cording on surgical side. The more lymph nodes that are removed, the higher the risk for cording.
Sometimes, one or more of these cords are found in the underarm. These string-like structures are usually tender or painful to touch and can extend from armpit to the breast, arm, forearm and palm.
What causes Cording?
Although the etiology of cording is not known, some experts believe that surgery to the underarm and breast cause tissues around the lymph vessels, blood vessels and nerves to harden.
Usually, cording develops in the first few days or weeks after axillary surgery and resolves within the first 3 months post-surgery. However, some researchers have reported the appearance of persistence of cording 3 months or as late as 2 years after surgery.
How do you know if you have cording?
Most patients with cording describe pain and stiffness with arm movements, especially with overhead movements. In addition, there might be a visible cord or a bundle of cords “tenting” underneath the skin at the armpit. These cords can feel like a taut guitar string.
How can physiotherapy help?
Cording itself is not life-threatening but it can easily be treated with physiotherapy in a few sessions or in a few months. Ask your physician to refer you to a physiotherapist that specializes in oncology or breast-cancer rehabilitation.
For patients who are planning to undergo radiation therapy, it is important to resolve shoulder stiffness, pain and loss of range of motion. During radiation, patients need to be able to lift their arm above their head and hold the position for several minutes
Your physiotherapist will come up with an individualized treatment plan that may include:
1. Manual therapy: Your therapist will perform different hands-on technique to release to soft-tissues and structures that are tight. Note that the cord may snap, crackle or pop when stretched or mobilize. This usually isn’t painful and may allow you to move your arm better.
2. Arm stretching/flexibility exercises: Your therapist will work teach you exercises that can gently stretch the cord to allow your arm to move pain-free.
3. Scapular and arm strengthening exercises: Sometimes, weakness in the muscles that move the arm and scapula can cause pain. Your therapist will also provide exercises to restore strength in the arm to allow you to perform functional activities and even return to sports.
Koehler LA, Haddad TC, Hunter DW, Tuttle TM. Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies. Breast Cancer (Dove Med Press). 2018 Dec 20;11:13-19. doi: 10.2147/BCTT.S146635. PMID: 30588087; PMCID: PMC6304256.
Nevola Teixeira, L. F., Veronesi, P., Lohsiriwat, V., Luini, A., Schorr, M. C., Garusi, C., Simoncini, M. C., Sarian, L. O., Gandini, S., Sandrin, F., & Rietjens, M. (2014). Axillary web syndrome self-assessment questionnaire: Initial development and validation. Breast (Edinburgh, Scotland), 23(6), 836–843. https://doi.org/10.1016/j.breast.2014.09.001
Ryans, K., Davies, C. C., Gaw, G., Lambe, C., Henninge, M., & VanHoose, L. (2020). Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 28(12), 5881–5888. https://doi.org/10.1007/s00520-020-05424-x
Lippi, L., de Sire, A., Losco, L., Mezian, K., Folli, A., Ivanova, M., Zattoni, L., Moalli, S., Ammendolia, A., Alfano, C., Fusco, N., & Invernizzi, M. (2022). Axillary Web Syndrome in Breast Cancer Women: What Is the Optimal Rehabilitation Strategy after Surgery? A Systematic Review. Journal of clinical medicine, 11(13), 3839. https://doi.org/10.3390/jcm11133839
Harris S. R. (2018). Axillary Web Syndrome in Breast Cancer: A Prevalent But Under-Recognized Postoperative Complication. Breast care (Basel, Switzerland), 13(2), 132–135. https://doi.org/10.1159/000485023