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Short communication
Abstract
Background and purpose Axillary web syndrome (AWS) is becoming increasingly recognised as a sequela of breast cancer treatment.
There are currently no formal guidelines on which to base therapy interventions. This case study discusses the physiotherapy management of
a patient with AWS, highlighting a soft tissue mobilisation approach.
Case description A 47-year-old hairdresser experienced sudden loss of shoulder movement and development of axillary cords 22 days after
mastectomy and axillary dissection. The management included manual therapy, mostly using soft tissue treatment techniques, combined with
education and advice.
Outcomes Pre-morbid range of movement was achieved within 11 treatments, spread over 3 weeks. The patient returned to full-time
employment after the seventh treatment by a physiotherapist, within 2 weeks of starting treatment, progressing to full range of shoulder
movement with no cords or pain by 16 weeks post surgery.
Discussion Previous theories on the pathophysiology of AWS may need to be revised. Physiotherapy intervention for these patients may
prove beneficial in limiting subsequent shoulder dysfunction. Further research is needed to develop a standardised treatment approach for
AWS.
© 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Breast cancer; Axillary web syndrome; Physiotherapy; Cording; Soft tissue techniques
Background and purpose upper limb oedema, pain, decreased shoulder mobility, and
both sensory and motor dysfunction [4–9]. Lash and Silliman
Breast cancer is the most common female malignancy in [2] concluded that ‘upper body dysfunction may arise shortly
the Western world, with a lifetime risk estimated at one in after therapy and resolve, arise, and persist for at least 21
nine in the UK [1], and yielding the largest group of cancer months, or arise at some time distant from the therapy’.
survivors in the USA [2]. Surgery is the mainstay of pri- AWS as a cause of upper limb dysfunction generally devel-
mary breast cancer treatment. Despite the adoption of more ops between 1 and 5 weeks after axillary node dissection
conservative surgical approaches, morbidity remains a clin- [10]. It has also been called ‘cording’ [11], axillary ‘strings’
ical problem [3]. One of the early contributors to pain and [12] or ‘vascular strings’ [13]. Moskovitz et al. [10] first
reduced range of movement following surgery is axillary web defined AWS as ‘a visible web of axillary skin overlying
syndrome (AWS). The aim of this case report is to describe a palpable cords of tissue that are made taut and painful by
physiotherapy management approach to a patient with AWS shoulder abduction’. Patients typically present with pain in
after surgery for breast cancer. the axilla, which can radiate down the arm, and restricted
Arm morbidity after treatment for primary breast cancer is range of shoulder movement and visible tight bands of tis-
well described in the literature with impairments that include sue, which can extend distally from the axilla to the wrist
(Fig. 1a). Although often encountered, there is little support-
∗ Corresponding author at: P.O. Box 209, Florida Hills, 1716, Roodepoort, ing literature [3,10,14–16].
South Africa. Tel.: +27 0 11 763 6990; fax: +27 0 86 618 0179. The incidence, natural history, predisposing factors and
E-mail address: willief@medi.co.za (W.J. Fourie). long-term sequelae of AWS are still poorly defined [3].
0031-9406/$ – see front matter © 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.physio.2009.05.001
W.J. Fourie, K.A. Robb / Physiotherapy 95 (2009) 314–320 315
Patient history
Observations
Passive shoulder movements
• A well-healed transverse surgical scar at the level of the
• Abduction and flexion were restricted as above.
fourth rib, from sternum to mid-axillary line.
• With the arm by the side of the body, elbow and wrist
• Arm movements away from the body produced visible
passive movement were normal and pain-free.
axillary cords extending along the medial surface of the
upper arm, across the cubital fossa and into the proximal
part of the forearm (Fig. 1a). Tissue movement and glide
Fig. 3. Progress graph showing improvement in shoulder range of movement and treatment days.
• cords were palpable but not visible on the palmar surface felt to ‘give’ or ‘pop’ with a resultant increase in abduction;
of the wrist; and and
• palpable, non-visible cords stretched around the posterior • a full explanation of possible treatment after-effects.
axillary border spreading over the scapula and posterior
chest wall (Fig. 2).
Outcomes
Passive distal skin stretching of the cords in the arm pro- The following day, Mrs. H reported increased arm and
duced pain in the head (similar to the previous headache), in neck pain, a persistent headache and discomfort in the con-
the neck above the clavicle and in the contralateral breast. tralateral breast. These symptoms resolved spontaneously
There were no outward signs of inflammation tissue swelling within 24 hours. Abduction remained improved.
or arm oedema.
Treatment
Visits 3, 4 and 5: Days 8 to 10 after onset
Based on the initial assessment of tissue restrictions, treat-
ment included:
Treatment
• gentle circular mobilisation of the identified tissue tight- Treatment was repeated over consecutive days. Different
ness on the chest wall with full hand contact and touch areas of tightness on the chest wall were addressed on dif-
grades between 2 and 3 (Appendix 3); ferent days. Stretching of the restrictive cords was repeated
• longitudinal tissue stretch to strain the tight cords with the daily. The depth and range of treatment were kept at grade 4
patient’s arm in available abduction. Several cords were tolerance levels throughout.
318 W.J. Fourie, K.A. Robb / Physiotherapy 95 (2009) 314–320
Accessory motion of soft tissues: The motion of the soft Appendix 3. Grading of techniques and depth of
tissue that occurs out of line of normal movement. touch.
When a muscle contracts, it and the connected
non-contractile soft tissues either shorten or lengthen (phys- Grades 1–3 mild and superficial touch with no discomfort.
iological movement), whereas when pressure is applied to Grades 4–6 moderate to firm touch with mild discomfort.
soft tissue, deformation of the tissue occurs (accessory move- Grades 7–8 deep, firm pressure with discomfort but toler-
ment). able.
Grades 9–10 deep, painful and potentially damaging pres-
sure.
Appendix 2. Soft tissue principles and treatment.
Indications References
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