Beyond the Cord: Understanding Axillary Web Syndrome After Breast Cancer Surgery

1. Axillary web syndrome is more than a visible cord.

AWS, or cording, typically presents following breast cancer surgery and may involve tight, rope-like cords extending through the axilla, upper arm and sometimes beyond the elbow or along the chest wall. 

For some people the cords are visible. For others they may only become apparent with appropriate positioning and palpation. Pain, a pulling or pinching sensation and restricted movement may be the first indications that AWS is present. 

2. AWS appears to involve injury to lymphatic and/or venous vessels.

Biopsy studies discussed in the episode have identified affected cords as thrombosed or inflamed lymphatic or venous vessels. Evidence of recanalisation has also been observed, providing a possible explanation for why AWS frequently improves as postoperative healing progresses. 

The precise pathophysiology continues to be investigated. 

3. AWS is not uncommon following breast cancer surgery.

In the early postoperative AMBER cohort, 17.3% of participants presented with axillary web syndrome. 

While AWS was more common following more extensive axillary surgery, it was not limited to these patients. Clinicians therefore need to remain alert to AWS even after more conservative surgical procedures. 

4. Axillary lymph node dissection is an important risk factor.

Participants undergoing axillary lymph node dissection had approximately four times the odds of developing AWS compared with those undergoing sentinel lymph node biopsy. 

Mastectomy was also associated with higher odds of AWS compared with breast-conserving surgery. 

The group at greatest risk was those who underwent both mastectomy and axillary lymph node dissection, with 47.4% developing AWS in the early postoperative period. 

5. Do not overlook patients who have undergone sentinel lymph node biopsy.

Although risk was higher following axillary lymph node dissection, approximately 80% of the AMBER cohort underwent sentinel lymph node biopsy and AWS was still identified among these patients. 

Postoperative education about cording should therefore not be restricted to people undergoing axillary clearance. Patients should know what symptoms to look for and when and where to seek support. 

6. AWS can have a measurable impact on pain and function.

Compared with participants without AWS, those with AWS reported a higher frequency and severity of pain and poorer upper-limb function. 

They were also more likely to have shoulder range of motion below the threshold required for normal everyday function. 

Shoulder abduction, or lifting the arm out to the side and overhead, was the movement most commonly affected. 

7. Assessment may require more than asking the patient to lift their arm.

Not every cord is immediately visible. 

When symptoms suggest AWS, assessment may involve positioning the patient supine and progressively moving the arm into abduction and elevation to expose the axillary region. Visual assessment can be combined with careful palpation for cords. 

Functional clues may include difficulty reaching overhead, straightening the elbow, washing or brushing the hair, or a characteristic pulling or pinching sensation during movement. 

8. Developing AWS does not mean the patient has done something wrong.

Patients may worry that they exercised too much, exercised too little or somehow caused the condition. 

The discussion emphasises that AWS appears to form part of the postoperative healing response following lymphatic and vascular injury. Patient education can help reduce unnecessary concern while providing guidance about appropriate movement and rehabilitation. 

9. Rehabilitation should reflect the stage of healing.

During approximately the first 12 weeks, when cords may still be inflamed and tender, the approach described in the episode favours appropriate range-of-motion exercise and stretching while avoiding unnecessarily aggressive manual techniques. 

When cording persists beyond this early healing period, rehabilitation may be progressed according to the individual presentation, including more prolonged stretching and manual therapy where clinically appropriate. 

The priority is not simply to eliminate a palpable cord, but to restore comfortable, functional shoulder movement. 

10. Restricted movement can have consequences if it is not addressed.

Pain may cause some people to stop moving the affected arm and hold it close to the body. 

Over time, this may contribute to secondary shoulder stiffness and, in some cases, a frozen-shoulder-type presentation. Restoring shoulder range of motion is therefore important for both immediate function and longer-term shoulder health. 

AWS may also create practical challenges when a patient needs to position the arm overhead for radiotherapy. Early rehabilitation and collaboration with the radiation therapy team may help the patient achieve a comfortable and appropriate treatment position. 

11. AWS was not associated with early arm swelling in this analysis.

The early postoperative AMBER analysis did not find a statistically significant difference in the proportion of participants with an arm-volume difference greater than 200 mL, an indicator of potential lymphoedema, between those with and without AWS. 

AWS and lymphoedema should therefore be considered related to lymphatic injury but distinct clinical conditions. 

Current evidence does not establish AWS itself as an independent risk factor for lymphoedema. Longer-term AMBER analyses will help researchers understand this relationship more clearly. 

12. Prospective surveillance provides a useful framework for care.

Identifying individual risk before or soon after surgery, educating patients about potential impairments and reassessing them during recovery may allow AWS and other cancer-related impairments to be detected earlier. 

People at greater risk, particularly those undergoing axillary lymph node dissection and mastectomy, may warrant closer follow-up. However, education about signs and symptoms remains important for people undergoing less extensive surgery as well. 

13. Early referral can support recovery and self-management.

When AWS develops, early access to a physiotherapist or appropriately skilled rehabilitation clinician can help patients understand what is happening, identify appropriate exercises and movement strategies, and recognise what should be avoided during the early healing period. 

Early assessment is particularly important when pain or restricted movement is interfering with everyday activity or upcoming cancer treatment. 

Axillary web syndrome may resolve as tissues heal, but that does not mean its impact on recovery should be overlooked. Pain, restricted shoulder movement and reduced upper-limb function are clinically important and warrant appropriate assessment and rehabilitation.