Axillary Web Syndrome

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Axillary Web Syndrome

Postby patoco » Sun Sep 24, 2006 3:32 pm

Axillary Web Syndrome

Axillary Web Syndrome is a complication following a mastectomy in which the patient develops within the affected armpit a visible web of skin overlying a cord of tissue that is made tight and painful by certain shoulder motions.


A case of axillary web syndrome with subcutaneous nodules following axillary surgery.

Reedijk M, Boerner S, Ghazarian D, McCready D.

Department of Surgical Oncology, Princess Margaret Hospital, University Health Network and the University of Toronto, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9.

Axillary web syndrome (AWS) is a cause of morbidity in the early postoperative period following axillary surgery, which is characterized by cords of subcutaneous tissue extending from the axilla into the medial arm. Few reports have been published describing this entity, which results in pain and a limitation of shoulder abduction. Here, we report a case of AWS that was accompanied with sub-cutaneous nodules mimicking recurrence of breast cancer. ... t=Abstract


Axillary web syndrome after axillary dissection.

Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE.
Department of Surgery, Surgical Oncology Section, Bio-Clinical Breast Care Program, University of Washington, Box 356410, 1959 NE Pacific Street, Seattle, WA 98195, USA.

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 palpable subcutaneous cords extended from the axillary crease down the ipsilateral arm, across the antecubital space, and in severe cases down to the base of the thumb. 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.

PMID: 11448437 [PubMed - indexed for MEDLINE] ... med_docsum


Physical Therapy Treatment of Axillary Web Syndrome

Rehabilitation Oncology, 2004 by Kepics, Jane M

This article discusses the problem of axillary web syndrome, previously known as 'cording,' that may be seen after axillary node dissection. The article references a study done at the University of Washington and published in 2001 in the American Journal of Surgery, which identified the symptoms of axillary web syndrome and the mechanisms leading to this pathology. Patient evaluation procedures and physical therapy interventions are presented.

Mrs. Smith is a 52-year-old female one month status post a right lumpectomy and axillary node dissection for breast cancer. Her lymph nodes were free of metastatic disease and she will begin primary radiation therapy next week. She is referred to physical therapy for postoperative education and to screen for the need for further PT services. However, on initial examination, she complains of an inability to straighten her right elbow or to lift her arm overhead due to pain going down the right arm to the wrist. There is a visible tight 'cord' from the axilla to the elbow with tenderness to palpation of this taut tissue.

For therapists working with breast cancer patients, the above scenario is not uncommon. For many years, we talked about 'cording,' but documentation of this phenomenon was virtually nonexistent. Now, thanks to a group of researchers at the University of Washington in Seattle, we have an initial research project and a new diagnosis, namely 'Axillary Web Syndrome' (AWS).1 The researchers suggest that AWS is a result of interruption of the axillary lymphatics during axillary node dissection and is a variant of Mondor disease.2

They describe Mondor disease as a superficial thrombophlebitis of the subcutaneous veins of the chest. It is occasionally seen after local trauma, after breast procedures, as an idiopathic variant, and with undiagnosed breast cancer. The symptoms are pain, tenderness, and skin retraction over a cord-like structure on the chest wall. Research has suggested that thrombosed lymphatics rather than veins are responsible for the development of Mondor disease.

Axillary Web Syndrome is described as "a visible web of axillary skin overlying palpable cords of tissue that are made taut and painful by shoulder abduction (Figure 1). The web is always present in the axilla and extends into the medial ipsilateral arm, frequently down to the antecubital space and occasionally to the base of the thumb."

Moskovitz and colleagues' performed a retrospective study of 44 of 750 breast cancer patients (6%) treated or examined by one surgeon-Roger E. Moe, MD-at the University of Washington between 1980 and 1996. The women's ages ranged from 27 to 73 years old. They demonstrated a variety of breast cancer histology. Twenty eight received lumpectomies, and 14 patients were treated with modified radical mastectomies. One patient had no operative record available. Another patient had no surgery, but was diagnosed with Stage IV breast cancer and had extensive nodal disease. They also examined 4 more recent patients with AWS after sentinel node biopsy (SLND) without axillary lymph node dissection (ALND). Tissue sampling of the web was done in 4 patients.

Axillary Web Syndrome appeared in 3 of the 44 patients (6%) within the first postoperative week. Forty-two patients (95%) developed AWS within 8 weeks of surgery. Ten patients had their breast surgery on a date earlier than their axillary node dissection. The AWS appeared a mean 51 days after the breast surgery but only a mean 16 days after the ALND, suggesting that the etiology of AWS was most likely due to the interruption of the axillary lymphatics. Seventy-four percent (74%) of the patients demonstrated shoulder abduction of 90o or less. Eleven percent developed lymphedemam-not an unusual percentage for this population. Those patients who had SLND without ALND developed webs that were limited to the axilla and medial arm. They did not extend into the wrist.

Tissue sampling of the webs of 4 patients yielded 2 with dilated lymphatics. One of the lymphatics was filled with fibrin clot. Three of the samples demonstrated venous thrombosis.

The researchers describe AWS as self-limiting, resolving in all cases within 2 to 3 months without long-term sequelae. The researchers state that patients did not demonstrate early resolution of symptoms with nonsteroidal anti-inflammatory drugs or physical therapy (treatment not described in the paper) and range of motion (ROM) exercise.

Dr Moe speculates that the thrombosed lymphatics go through an inflammatory phase with thickening of the vessels and temporary shortening and tightening which later remits. What happens when the syndrome resolves is unknown at this time. Research is needed to determine if those lymphatics become functional again or if lymph flow is diverted to other pathways.

Following the Seattle study, Leidenius et al3 evaluated 85 patients for motion restriction and axillary web syndrome after sentinel lymph node biopsy (SLB) and axillary clearance (AC). In this prospective study from Finland, 20% of the 49 patients who underwent SLB only and 72% of the 36 patients who underwent SNB and AC developed Axillary Web Syndrome. They also describe AWS as self-limiting. Unlike the Moskovitz study, these patients were examined by a physical therapist the day before surgery as well as 2 weeks and 3 months after surgery. It may be that this proactive PT intervention led to the early resolution of symptoms.

As a physical therapist specializing in the treatment of breast cancer and lymphedema, I have treated many patients with what I now refer to as AWS. The Seattle researchers' description of the syndrome is accurate, but I do question their statement about resolution of symptoms. I often see patients months to years after surgery who have never achieved full ROM in the operative shoulder. These women complain of tightness and tenderness in the axilla, and at times, extending into the chest wall. Their shoulder posture is slightly protracted with a mild thoracic kyphosis in an effort to protect the operative site. I suggest that perhaps the syndrome didn't totally resolve. As with lymphedema, patients stop complaining to their surgeons and learn to 'live with it.'

When performing an initial examination on patients with a history of axillary node dissection, physical therapists are in a unique position to look for remnants of AWS and perform appropriate interventions. Certainly maximizing the ROM in the upper quarter will improve muscle contraction and facilitate lymph flow. Improving posture and using proper diaphragmatic breathing also are desired goals. Sometimes the cordlike structures pull tightly and deform the tissue in the upper arm, making it look edematous. Once treated, the cord and the swelling may, but not always, resolve. Combined decongestive therapy may be necessary to control the swelling and reduce pain.

Treatment for AWS takes several forms. My treatment plan has evolved over several years of practice and after many discussions with other therapists. I use various myofascial release and craniosacral techniques since the syndrome appears to be soft tissue related rather than due to muscle tightness. Unfortunately I cannot provide a research basis for the treatment but I hope to give the reader a starting point.

Patients with AWS should be treated gently in the early stages, especially if acute pain and inflammation are present. I may use local heat or ice on the painful areas. Always check sensation-including hot/cold-prior to administration of thermal modalities, as patients frequently have impairment due to loss of the intercostobrachial nerve during surgery. Use extra padding when applying heat, with a short treatment time of 8 to 10 minutes. I also visually inspect the site several times during treatment. If I am concerned about triggering lymphedema due to the heat, I will perform MLD afterwards. For home, I suggest patients use a warm shower rather than use local heat as a further precaution against burning.

Next, I will work on stretching the cord. I generally work distal to proximal. I start with the shoulder slightly abducted with the elbow as straight as possible; supinate the arm and hyperextend the wrist. The patient can flex and hyperextend the wrist slowly to provide maximum stretch and then a release, similar to nerve gliding techniques. Depending on the extent of the cord, this can be repeated with the arm in various degrees of abduction until eventually she can abduct overhead. This may take several visits depending on the acuity of the pain.

Skin traction is another beneficial technique. I gently stretch one or two inch segments of the cord with my thumb and index finger. This can be done all along the arm, in the axilla and on the chest wall. I usually include the area around the scar where the JP drainage tube was located, as I often find cords as far down as that scar. Occasionally, I can feel a pop or a snap where the cord actually breaks in the antecubital fossa or in the axilla. It is not painful and the patient usually feels an immediate increase in mobility. In a personal communication with Dr Moe, I wondered if breaking the cords was a safe practice. he questioned if we were actually breaking the cord or rather the supporting fibrous structures around them. I have not seen any ill effects of this practice and patients tend to maintain their newfound ROM without any increase in swelling.

Myofascial release techniques such as the 'arm pull' and stretching of the pectoralis major and minor, the intercostals and rib cage, the biceps and triceps, and the diaphragm release are also very helpful in stretching out the axillary web.4 Gross scar release techniques both in parallel and perpendicular to the breast and axillary scars, as well as skin rolling techniques and vertical lifts of the scars, may also be beneficial.\

I often have the patients use a reciprocal pulley and a finger ladder to encourage their participation in the treatment program and to help them define their ROM limits. Pulleys purchased for home use are quite helpful to continue daily stretching. Finally, patients are instructed in good upright posture and deep breathing exercises.

Therapists can be proactive by including AWS in preoperative and postoperative teaching along with arm mobility exercises and lymphedema precautions. Patients need to know the possible compromises to their mobility so they can seek treatment early and prevent further functional loss.


1. Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE. Axillary web syndrome after axillary dissection. Am J Surg. 2001; 181:434-439.

2. Marsch WC, Haas N, Stuttgen G. "Mondor's phlebitis" - a lymphovascular process. Dermatologica. 1986;172:133-138.

3. Leidenius M, Leppanen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185(2):127-130.

4. Manheim C. The Myofascial Release Manual. 3rd ed. Thorofare, NJ: Slack, Inc.; 2001.

Jane M. Kepics, MS, PT, CLT-LANA

Lymphedema specialist at Phoenixville Hospital of the University of Pennsylvania Health System in Phoenixville, PA. A graduate of Temple University, she has been a practicing physical therapist for 25 years. She has been certified in Dr Vodder's Manual Lymph Drainage since 1987.Thanks to Angela Tate, MS, PT for her help in reviewing this manuscript.

Copyright Rehabilitation in Oncology 2004 ... i_n9370189


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Re: Axillary Web Syndrome

Postby patoco » Fri Mar 12, 2010 8:22 am

Axillary web syndrome: nature and localization

Lymphology. 2009 Dec

Leduc O, Sichere M, Moreau A, Rigolet J, Tinlot A, Darc S, Wilputte F, Strapart J, Parijs T, Clément A, Snoeck T, Pastouret F, Leduc A.

Haute Ecole P.H. Spaak, Département de Kinésithérapie, Unité de Lympho-Phlébologie, Bruxelles, Belgique.

Axillary Web Syndrome (AWS) is a complication that can arise in patients following treatment for breast cancer. It is also known variously as syndrome of the axillary cords, syndrome of the axillary adhesion, and cording lymphedema. The exact origin, presentation, course, and treatment of AWS is still largely undefined. Because so little is known about AWS, we undertook a case series study consisting of 15 women who had undergone breast cancer surgery and presented with AWS. All subjects received a clinical examination which included body size determination and detailed measurements of the size and location of the cords.

The cords were found to originate from the axilla, continue on the medial aspect of the arm up to the epitrochlea region, then to the anteromedian aspect of the forearm, and finally reaching the base of the thumb. The cords averaged approximately 44% of the limb length. Correlation of the cord location with anatomical studies shows that in fact this path follows the specific course taken by the antero-radial pedicle which arises at the anterior aspect of the elbow from the brachial medial pedicule to anastomose in the axilla at the level of the lateral thoracic chain nodes.

Although our series is small, the correspondence between the physical findings and the anatomical studies strongly supports the notion that the cords are lymphatic in origin.

PMID: 20218085 [PubMed - in process] -
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Re: Axillary Web Syndrome

Postby Clarra » Fri Nov 12, 2010 1:42 pm

Is therapy an effective treatment or do certain circumstances require further surgery? Exactly how does stretching work in regards to AWS? Does it stretch or tear the webbing? -Clarra, Health Insurance Researcher and Advisor
Last edited by Clarra on Mon Nov 15, 2010 4:47 pm, edited 1 time in total.
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Re: Axillary Web Syndrome

Postby patoco » Mon Nov 15, 2010 12:22 pm

Hi Clara

Here's a really interesting article on Axillary web syndrome, using the non-surgical. It is a follow-up article to the one we already have listed. Yes, it does help "restretch" and should not tear it, which would be very bad.

Treatment of Axillary Web Syndrome: A case report using manual techniques.

Jane Kepics MS PT CLT-LANA
University of Scranton
Final Case Report
Evidence Based Medicine
December 10, 2007 ... b_syndrome

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Re: Axillary Web Syndrome

Postby patoco » Tue May 08, 2012 7:04 am

From Furuncle to Axillary Web Syndrome: Shedding Light on Histopathology and Pathogenesis.

April 2012

Rashtak S, Gamble GL, Gibson LE, Pittelkow MR.


Department of Dermatology, Mayo Clinic College of Medicine, Rochester, Minn., USA.


Key Words: Axillary web syndrome, Furuncle, Nodules

Axillary web syndrome (AWS) is defined as a cord-like structure extending from the axilla to the medial arm following axillary surgery in women with breast cancer. There is only limited literature on the pathogenesis of this syndrome and the etiology of the cord. A 57-year-old man presented with a band-like skin depression and tightness over the medial aspect of his arm extending from the axilla to the antecubital fossa following development of a furuncle in the ipsilateral axilla. Histopathologic examination of the 'band' revealed fibroblastic proliferation surrounding the lymphatic vessel which was identified by presence of an obvious valve as well as positive staining for D2-40, a specific marker for lymphatic endothelium. This is the first report of AWS following axillary furunculosis. This case adds to the limited data on the histopathology of AWS, further confirming the etiology of the 'cord' to be of lymphatic origin. ... /000337210

Axillary web syndrome--a variant of Mondor's disease, following excision of an accessory breast.
Dec 2011

[Article in Hebrew]

Shoham Y, Rosenberg N, Krieger Y, Silberstein E, Arnon O, Bogdanov-Berezovsky A.


Department of Plastic and Reconstructive Surgery, Soroka University, Beer Sheva, Israel.


Cording, an unusual form of superficial thrombophlebitis, is a variant of the disease first described by Fage in 1870 and subsequently characterized by Henry Mondor in 1939 as sclerosing thrombophlebitis of the subcutaneous veins of the anterior chest wall. Similar lesions have also been found in the penis, groin, abdomen, arm, and axilla and have been reported under a variety of names. In the axilla the condition is termed axillary web syndrome (AWS) and is seen after axillary lymph node dissection and sentinel lymph node biopsy. A recent report suggests that pathophysiology of AWS is lymphatic in origin rather than venous. We report a unique case of unilateral AWS after excision of an axillary accessory breast and discuss the pathophysiology.

Incidence and risk factors for axillary web syndrome after breast cancer surgery.
Feb 2012

Bergmann A, Mendes VV, de Almeida Dias R, do Amaral E Silva B, da Costa Leite Ferreira MG, Fabro EA.


Augusto Motta University Center, Av. Paris, 72 - Bonsucesso, Rio de Janeiro, RJ, 21041-020, Brazil.


The objective of the study is to estimate the incidence and risk factors of axillary web syndrome (AWS) in early postoperative period (45 days). From the prospective cohort of women undergoing breast cancer surgery, we collected the variables related to patient characteristics, treatment, tumor, and postoperative complications. We performed bivariate and logistic regression. A total of 193 patients are included with a mean age of 58.26 years, majority of which are women who are overweight or obese (72.3%). The incidence of AWS was 28.1%. The presence of pain in the ipsilateral upper-limb associated with AWS was reported in 5.4% of the patients, and the shoulder joint restriction was observed in 11.4%. When controlling for confounding between AWS and the factors that showed statistical significance in bivariate analysis, the variables that explain the occurrence of the AWS were the type of axillary surgery, where women who underwent sentinel lymph node biopsy showed 68% less risk compared with those that underwent axillary lymphadenectomy (AL) (RR = 0.32; 95% CI, 0.13-0.79; P value = 0.014) and numbness in the arm after an injury of the intercostobrachial nerve, which is 3.19 times the risk of the AWS (RR = 3.19; 95% CI, 1.40-7.29, P value = 0.006). From the above findings, we concluded that the incidence of AWS was 28.1%, and it was associated with AL and numbness in the arm after injury of the intercostobrachial nerve. ... 41/?MUD=MP
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