Physical Therapy Treatment of Axillary Web Syndrome
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.
REFERENCES
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.
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