Mastectomy and Axillary Web Syndrome

Mastectomy & CordingBy: Denise Stewart, founder of Breast and Shoulder Rehabilitation and Breast Cancer Occupational Therapist.

What is Axillary Web Syndrome?
Axillary Web Syndrome is known as AWS or Cording. Cording is easier to say and more accurately describes the problem.

Cording is tightness of normal tissue within the body and occurs predominantly after breast cancer surgery. It mostly develops in the first eight weeks, during the post- surgical healing phase, and sometimes during chemotherapy or after radiotherapy. Is it common? a review in 2014 of 37 studies, identified up to 84% of the women experienced cording after breast cancer surgery.

Initially, the tightness causes significant pain and can stop you from raising your arm or straighten your elbow. The tight tissue is just under the skin and can vary in thickness and presents as:

  • thin strings;
  • rope or cord like; or
  • a really thick band of tissue.

The very thick band which extends into the armpit has as yet not been recognized in the research literature as being typical of cording, however matches perfectly to the location and pain experience of the thinner cording experiences.

The tight tissue extends from the breast / chest area into the arm at varying levels:

  • to the armpit;
  • to the upper inside arm;
  • to the inside elbow;
  • to the inside wrist; and
  • at the trunk.

The tight tissue is thought to be part of the lymph system, which is normally fine, soft and very stretchy vessels, just under the skin. In this area of the body, the lymph system travels from the side of the rib cage across the armpit and then down the inside arm.

Researchers currently offer no clear understanding about how or why cording occurs and surgeons may refer to Cording as “normal”. Therapists experienced in breast cancer rehabilitation do offer an explanation – breast scar tissue that forms during healing attaches to nearby tissues. Initially scar tissue lacks length and stretch and may adhere to structures such as nearby lymph vessels. This can then result in a corresponding reduction in the amount of stretch at these structures.

Cording assessment relies solely on seeing tightness, feeling tightness and the presence of a common pain experience. I believe that this reliance on physical assessment has resulted in many difficulties faced by women experiencing cording:

  1. Cording is rarely discussed as a complication by the surgeon;
  2. Some forms of cording may be difficult to see and feel;
  3. Some women do not want to complain to their surgeon;
  4. There is no recognized comprehensive physical assessment of Cording;
  5. Cording assessment may not be a standard practice in the breast cancer clinic; and
  6. There is very limited research into treatment protocols.

Because of these factors it is important for women, to be aware of what Cording is and how to convey this in the best way to their breast cancer team member so treatment options can be sought.

If the mastectomy scar line and the mastectomy chest scar are tight and lack stretch then it may be difficult to see Cording. In this case the arm may not be able to be raised above shoulder height and the tight band you see may not be Cording, but the pectoral muscle. However Cording is characterised by a common pain experience: pain is felt down the inside arm and may extend even to the wrist, or side trunk, when reaching up high or out to the side. So although it may be difficult to see the tight tissue – the pain and the tightness is real and you should seek specialised rehab services.

Cording can also be difficult to see if there is a generous amount of stretchy skin or fat in the arm pit, trunk and upper arm. The tight band of tissue usually extends and connects to very deep tissue at the side of the breast. Very often this connection to the breast scar tissue is missed because of the depth of the tissue and the impaired feeling in this area after a mastectomy. Yet in this case the telling symptom is the woman feels upper arm tightness and stinging pain down the inside arm or at the trunk during stretches.

The aim of good Cording assessment is to be able to initiate your best recovery plan. If you need help to assess whether you could have Cording, I have published an e book, Cording: self-assessment guide. There are many more photos and steps to help you see, feel and measure the post- surgery tightness and movement restrictions secondary to Cording. More details can be seen at:

Denise Stewart Breast Cancer Occupational TherapistDenise Stewart, founder of Breast and Shoulder Rehabilitation and an Occupational Therapist trained in Australia at University of Queensland. Her career started at a major public hospital, providing rehabilitation to people with very serious and chronic illness and injuries.

Next Blog: Treatments for Cording

Mastectomy Scar – What You Need To Know

Breast Cancer RehabilitationBy: Denise Stewart, founder of Breast and Shoulder Rehabilitation and Breast Cancer Occupational Therapist.

The soft tissues of the chest, breast, shoulder, neck and arm are directly impacted by breast cancer surgery, chemotherapy and radiotherapy. Each of these treatments will have a different impact on each person; however there are some common experiences that can be better understood and managed.

Let’s focus on mastectomy surgery, the resulting mastectomy scar and some common experiences.

I have women report that they dutifully put oil or their best cream on their mastectomy scar line every day, after the wound has healed, so they can have a soft “good” scar.

What is wrong with this treatment option you may ask? The issue is twofold:

  1. The scar tissue extends much further than the mastectomy (surgical) scar line where the skin was stitched together. Scar tissue forms as a normal healing response wherever tissue is cut or damaged. So effectively with a mastectomy, scar tissue needs to form over the entire area where the breast tissue was removed from against the rib cage and where the breast tissue was removed from the skin let’s call this area the mastectomy chest scar . At the side of body, the scar may form and connect to the soft tissues that travel across into the arm, the pectoral muscle, the lymphatic structures, the serratus muscle and other muscles that connect to the shoulder-blade. So potentially, the scar tissue that forms following mastectomy can be a very large area and potentially can affect the stretch of other soft tissues in the nearby areas of the arm and shoulder-blade and the ribs (mastectomy chest scar).
  2. Oil or cream applied to a mastectomy scar line does not cause directional stretch at the deep scar tissue of the surgical scar line or the mastectomy chest scar.
    Scar tissue that forms in the healing phase often gets laid down in directions that are not in the same direction as the previous tissues. In other parts of the body when scar tissue matures (changes over time) our movement creates internal directional forces, which in turn helps to correct the direction, length and softness of the scar tissue.

Characteristics of new scar tissue at the mastectomy (surgical) scar line and the mastectomy chest scar?
Some women may have very poor feeling in this whole mastectomy chest area, it may feel dull.

The skin over the entire area may feel too connected to the rib cage and may lack stretch in the many directions that skin normally stretches.

Some women develop a significant sensitivity / pain to both light and deep touch.

In the weeks and months after surgery, the scar tissue has very limited stretch. If connections form with nearby tissue, this will cause restriction in movements in the arm. Full reach up and back behind the body may be difficult to achieve.

The mastectomy (surgical) scar line will look red or darker than your skin colour. This scar line can pucker and adhere to nearby structures (eg the pectoral muscle, the tissue covering the ribs).

Fluid may collect below the horizontal scar line because the lymphatics are not able to get passed the scar tissue.

Does scar tissue change over time?
Over time scar tissue can change, it can become stretchy, links to nearby tissue may even break away or remodel.

Pain may not be experienced when the tissue is touched and the scar line will become a lighter colour. For scar tissue to change and be remodelled it primarily requires stretch or directional force to be applied to the scar tissue, hydration (water) and a good blood supply.

It is the first requirement – stretch or directional force that poses a problem for the mastectomy scar tissue. Because of the position on the chest /rib cage, scar tissue may not actually get adequate stretch in many cases.

The usual time frame for new scar tissue to become mature, stretchy scar tissue is approximately two years. This time frame will be extended if radiotherapy is undertaken.

Can we help tight mastectomy scar tissue change and remodelling?
Because mastectomy scar tissue covers a large area and changes to scar tissue takes a long time – a supported self-management approach may need to be adopted to achieve better outcomes for women. Self-management requires:

  • Learning and using self-assessment skills to evaluate stretch in tissues over the entire chest area;
  • Learning and using a good arm and shoulder-blade movement assessment and recovery strategy;
  • Frequently use treatments that create a positive change to the tight scar tissue over the first 6-12 months after breast surgery;
  • Regularly use treatments to create a positive change to scar tissue over the 12-24 months after breast surgery;
  • Regularly use treatments to create positive change to scar tissue for 2-4 years if radiotherapy was undertaken; and
  • For some women a management program may need to be undertaken for decades.

Training, specialist treatments, monitoring and coaching are recognized support services for self-management programs for other chronic medical conditions. Support from breast cancer rehabilitation and exercise specialists must also be made available for women experiencing problematic tight mastectomy scar tissue.

The next blog will continue to discuss common experiences of mastectomy scar tissue and management options.

  • soft tissues are muscles, skin, fat, fascia, blood vessels, nerves.
  • women with severe radiotherapy damage may be an exception to this type of self-management program.

Denise Stewart Breast Cancer Occupational TherapistDenise Stewart, founder of Breast and Shoulder Rehabilitation and an Occupational Therapist trained in Australia at University of Queensland. Her career started at a major public hospital, providing rehabilitation to people with very serious and chronic illness and injuries.

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