Physiotherapy 95 (2009) 314–320

Short communication

Physiotherapy management of axillary web syndrome following breast

cancer treatment: Discussing the use of soft tissue techniques
W.J. Fourie a,∗ , K.A. Robb b
a Private Practice, 47 Schultz Street, Roodepoort, South Africa
b St Bartholomew’s Hospital, London, UK

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
Breast cancer is the most common female malignancy in
the Western world, with a lifetime risk estimated at one in
nine in the UK [1], and yielding the largest group of cancer
survivors in the USA [2]. Surgery is the mainstay of pri-
mary breast cancer treatment. Despite the adoption of more
conservative surgical approaches, morbidity remains a clin-
ical problem [3]. One of the early contributors to pain and
reduced range of movement following surgery is axillary web
syndrome (AWS). The aim of this case report is to describe a
physiotherapy management approach to a patient with AWS
after surgery for breast cancer.
Arm morbidity after treatment for primary breast cancer is
well described in the literature with impairments that include
∗ Corresponding author at: P.O. Box 209, Florida Hills, 1716, Roodepoort,
South Africa. Tel.: +27 0 11 763 6990; fax: +27 0 86 618 0179.
E-mail address: willief@medi.co.za (W.J. Fourie).
upper limb oedema, pain, decreased shoulder mobility, and
both sensory and motor dysfunction [4–9]. Lash and Silliman
[2] concluded that ‘upper body dysfunction may arise shortly
after therapy and resolve, arise, and persist for at least 21
months, or arise at some time distant from the therapy’.
AWS as a cause of upper limb dysfunction generally devel-
ops between 1 and 5 weeks after axillary node dissection
[10]. It has also been called ‘cording’ [11], axillary ‘strings’
[12] or ‘vascular strings’ [13]. Moskovitz et al. [10] first
defined AWS as ‘a visible web of axillary skin overlying
palpable cords of tissue that are made taut and painful by
shoulder abduction’. Patients typically present with pain in
the axilla, which can radiate down the arm, and restricted
range of shoulder movement and visible tight bands of tis-
sue, which can extend distally from the axilla to the wrist
(Fig. 1a). Although often encountered, there is little support-
ing literature [3,10,14–16].
The incidence, natural history, predisposing factors and
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
Fig. 1. (a) Visible cording and tightness in the axilla and upper arm upon
referral. (b) The left axilla with complete resolution of all the cords.
Moskovitz et al. [10] hypothesised that interrupted axillary
lymphatics appear to play an important role in the devel-
opment of this syndrome, proposing a ‘lymphovenous injury
with stasis’ as aetiology. Their histological findings of throm-
bosed and dilated lymphatics, plus the distribution of the web
cords matching the distribution of the superficial lymphatic
drainage, further led them to believe this to be an angio-
lymphatic event. Damage to veins due to thrombophlebitis
[13] and damage to lymphatic ducts due to aseptic lymphan-
gitis [12] have also been mentioned as possible causative
factors.
Given that AWS mainly occurs as a result of axillary
surgery and not breast surgery [10,14], axillary scarring may
also need consideration as possible contributing aetiology.
Loose areolar connective tissue binds the numerous axillary
structures together, while simultaneously allowing abundant
movement by virtue of its extensibility and elasticity [17].
Fat further protects the vital neurovascular structures in this
space [18]. Surgical removal or sampling of lymph nodes
involves careful dissection of varying numbers of axillary
nodes, together with their supporting fat and areolar connec-
tive tissue [19]. If this protective axillary connective tissue
315
is damaged, resultant adhesions or scarring can contribute to
limited arm/shoulder movement.
Additional factors contributing to the development of
early shoulder morbidity may include: decreased or delayed
activity due to pain; inadequate explanation of, or poor under-
standing of, rehabilitation exercises; or an overly vigorous
approach to early rehabilitation [20,21]. This could give new
scar tissue time to organise and form adhesions [20], or may
put patients at risk of stimulating over-production of fibrosis
by prolonging the inflammatory response [22,23].
Articles from the surgical literature [10,14] agree that
AWS is self-limiting and should resolve spontaneously within
3 months. Neither non-steroidal anti-inflammatory drugs nor
physiotherapy treatment and range-of-motion exercises were
reported to be effective in achieving early resolution of symp-
toms [10,14]. A consistent feature of these studies is the lack
of reporting on physiotherapy regimens. In other studies,
active range-of-motion exercises [11–13], stretching of the
involved region using soft tissue stretching techniques [16]
and manual myofascial soft tissue interventions [15] have
been reported to be beneficial.
Although Johansson et al. [13] only documented two cases
of vascular strings, representing less than 5% of their sam-
ple population, some evidence suggests that the condition
is not self-limiting. In three studies, cords, identified as an
early limiting factor [11–13], were still present as restricted
shoulder movement in some patients at 12-month follow-up
visits [13]. Wyrick et al. [16] mentioned the presence of cords
up to 3 years post surgery. However, a problem in reporting
may be due to the possibility that the presentation of axillary
cords and tissue scarring from surgical procedures share sev-
eral co-existing similarities and one may be mistaken for the
other.
AWS is a distressing and often debilitating condition for
many cancer patients. It poses a challenge for physiothera-
pists as there are no guidelines on which to base treatment
plans. Often, patients with restriction of shoulder movement
only come to medical attention at the time of radiation sim-
ulation [3], when future cancer treatment may be delayed by
an inability to achieve and maintain 90 degrees of abduction
with external rotation for radiotherapy planning and treat-
ment [24].
This case report presents a patient who developed AWS
and restricted shoulder movements following surgery for
breast cancer. By providing a detailed description of the
management of this case, it is hoped to contribute to the
understanding and development of treatment guidelines for
this syndrome.
Case description
The patient was a 47-year-old hairdresser (Mrs. H)
referred for treatment by a physiotherapist to address a loss
of shoulder elevation following surgery for breast cancer.
316 W.J. Fourie, K.A. Robb / Physiotherapy 95 (2009) 314–320

Patient history

Mrs. H underwent a left modified radical mastectomy with

removal of six axillary lymph nodes on the non-dominant
side. Postoperatively, she was shown an active-assisted shoul-
der exercise for arm elevation by the surgeon, and given a
pamphlet describing general home shoulder mobility exer-
cises by a local women’s cancer support group. She appeared
to be compliant and made good progress, achieving 80%
pain-free shoulder elevation post surgery. There were no
immediate postoperative complications and no relevant past
medical history or previous musculoskeletal problems.
On Day 22 post surgery, 2 days before visiting the physio-
therapist for the first time, she developed a severe headache
and nausea. This was associated with the simultaneous devel-
opment of tight, painful subcutaneous cords in the axilla and
medial upper arm, extending over the cubital fossa to the Fig. 2. Arrows showing direction of skin and superficial fascia tightness on
left wrist. Progressive loss of shoulder elevation developed chest wall and arm from surgical scarring, drain sites and tight cords in the
over 24 hours. She was unable to continue with exercises and, axilla, Visible and palpable cords drawn in red on patient’s skin.
although the headache and nausea settled, the cords remained.
This resulted in pain down the arm as well as marked restric- – attempts to elevate the arm or to reach out were limited by
tions in all attempted shoulder movements. painful pulling in the axillary and upper arm cords. Pain
prevented elbow extension with the shoulder abducted; and
– scapulohumeral rhythm was severely distorted during
Physical examination: Day 3 after onset of cording attempted arm elevation.

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

Soft tissues around the shoulder girdle, chest wall and

Active shoulder movements
Shoulder range of motion was measured and recorded
using an International Standard Goniometer (Zimmer
Orthopaedics Ltd., Cat. No. 337 supplied by Zimmer South
Africa (Pty) Ltd.) with the patient seated. This method has
shown good intrapractitioner reliability with absolute differ-
ences of 4.0 ± 3.6 degrees (abduction) and 4.4 ± 2.1 degrees
(flexion) [13]. This method was used throughout.
• Movements on the non-operated right arm were full and
pain-free.
• On the operated side:
– abduction was restricted to 40 degrees;
– flexion was restricted to 60 degrees with the elbow
extended;
– elbow flexion allowed a further 20 degrees of abduction
and flexion;
– internal and external rotation were only mildly restricted
in relation to the non-affected arm;
neck were evaluated for restricted physiological and acces-
sory tissue glide (Appendix 1). Although this approach is
commonly used to evaluate soft tissue integrity, there is lit-
tle published information on the psychometric properties of
these techniques.
Several areas and directions of tightness between tissue
layers were identified (Fig. 2):
• the dermis and superficial fascia surrounding the surgical
scar were tight in all directions;
• drain scars were adherent to underlying deep structures
and immobile;
• scarring, adhesions and cording rendered the floor of the
axilla tight and immobile;
• restrictive palpable cords extended from within the axilla,
along the medial upper arm and across the cubital fossa
into the forearm (Fig. 1a);
• the superficial fascia in the upper arm was mobile with tight
cords, originating from the axilla, restricting full distal
tissue glide;
 W.J. Fourie, K.A. Robb / Physiotherapy 95 (2009) 314–320
Fig. 3. Progress graph showing improvement in shoulder range of movement and treatment days.
• cords were palpable but not visible on the palmar surface
of the wrist; and
• palpable, non-visible cords stretched around the posterior
axillary border spreading over the scapula and posterior
chest wall (Fig. 2).
Passive distal skin stretching of the cords in the arm pro-
duced pain in the head (similar to the previous headache), in
the neck above the clavicle and in the contralateral breast.
There were no outward signs of inflammation tissue swelling
or arm oedema.
Treatment and outcomes (Fig. 3)
Sessions lasted between 30 and 45 minutes. Manual soft
tissue techniques (Appendix 2) were used throughout. A
home programme of gentle stretching and self-mobilisation
was taught and modified at each treatment session. Treatment
goals were to increase and restore tissue mobility and reduce
restrictions in soft tissue glide. Feedback, re-assessment of
range of motion and tissue glide were incorporated into all
sessions.
First visit: Day 3 after onset
Treatment
Based on the initial assessment of tissue restrictions, treat-
ment included:
• gentle circular mobilisation of the identified tissue tight-
ness on the chest wall with full hand contact and touch
grades between 2 and 3 (Appendix 3);
• longitudinal tissue stretch to strain the tight cords with the
patient’s arm in available abduction. Several cords were
317
felt to ‘give’ or ‘pop’ with a resultant increase in abduction;
and
• a full explanation of possible treatment after-effects.
Outcomes
The following day, Mrs. H reported increased arm and
neck pain, a persistent headache and discomfort in the con-
tralateral breast. These symptoms resolved spontaneously
within 24 hours. Abduction remained improved.
Second visit: Day 7 after onset
Feedback
Residual discomfort from the first treatment.
Treatment
Further mobilisation and stretching of restricted tissue.
Touch grades between 2 and 4.
Outcomes
Shoulder stiffness and discomfort increased initially but
settled again.
Visits 3, 4 and 5: Days 8 to 10 after onset
Treatment
Treatment was repeated over consecutive days. Different
areas of tightness on the chest wall were addressed on dif-
ferent days. Stretching of the restrictive cords was repeated
daily. The depth and range of treatment were kept at grade 4
tolerance levels throughout.
318 W.J. Fourie, K.A. Robb / Physiotherapy 95 (2009) 314–320
Outcomes
Shoulder abduction had only improved by 10 to
15 degrees. However, subjective patient feedback reported
markedly improved pain, discomfort, general scapular and
thoracic mobility, freedom in tissue glide and wellbeing. This
improvement allowed Mrs. H limited return to work 14 days
after starting physiotherapy treatment.
Visits 6 to 11: Days 11 to 26 after onset
Treatment
Visits were reduced to every second or third day, while
treatment time, depth of touch (up to grade 6) and firmness
of stretch were steadily increased over all areas of residual
tightness.
Outcomes
Continued improvement in shoulder mobility, regaining
150 degrees of elevation with no discomfort. The improved
wellbeing allowed Mrs H to return to full-time work 26 days
after onset of cording.
Physiotherapy treatment was discontinued after the 11th
visit with encouragement to continue self-mobilising and
graded exercises. Mrs. H continued to improve, regaining
full range of movement with no visible or palpable cording
(Fig. 1b).
Discussion
The authors frequently see patients with cording, often
in association with restrictions due to surgical scarring in
early postoperative clinics, or when referred for rehabilitation
in preparation for radiotherapy. The treating physiotherapist
may therefore be the first to see, diagnose or suspect AWS.
Experiential evidence in the authors’ departments and the
broader professional field [24] suggests that cording may
be more common than the incidence of 6% reported by
Moskovitz et al. [10].
This case report describes the onset, presentation, treat-
ment and outcomes of a patient with AWS referred for
treatment by a physiotherapist. It may help to shed further
light on a frequently encountered but under-reported con-
tributor to early shoulder morbidity after surgery for breast
cancer. Although the onset and presentation of this case is
consistent with published findings [10,12–16], some symp-
toms at the time of onset have not been reported previously.
These include the acuteness of the onset, the associated
headache and nausea, and the extent of the palpable cords.
The aetiology and nature of AWS remain poorly under-
stood, making it difficult to interpret the palpable restrictions
in the soft tissues. These restrictions may be secondary to the
pathology described in the literature [10,12–14], or may be an
integral part thereof. The reported time of onset within 2 to 6
weeks post surgery [10,12–16] suggests that cording may be
associated with early stages of wound healing. The authors
hypothesise that newly-formed adhesions around lymphatic
vessels in the axilla may be responsible for the cords and
thrombosed vessels. However, to date, there is little evidence
to support this.
During evaluation and treatment, the cords had a simi-
lar consistency and feel to restrictive scar tissue over the
anterior chest wall. These restrictions were felt as tissue
movement and glide reaching a premature end to its nor-
mal anticipated range. When the tight tissue cords were put
under strain, several cords were felt to ‘give’ or ‘pop’. This
popping was not painful and often resulted in an immedi-
ate increase in the range of abduction of the arm. In the
absence of any other explanation of this observation in the
literature, it is reasonable to conclude that the popping of
the cords may be consistent with adhesions releasing under
strain.
An impairment-based treatment approach was used
throughout. Technique selection, direction and depth of
treatment were based on impairments revealed during the
assessment of tissue glide and areas of fibrosis. This approach
has the advantage of giving the therapist the flexibility to
adapt treatment to the patient, rather than treating the diagno-
sis. Additionally, the therapist’s intervention can be modified
in line with the patient’s improvement [25].
As the patient’s condition and mobility improved, fewer
soft tissue restrictions were palpable, whilst cords became
fewer and less pronounced. At the same time, active shoulder
range of motion improved. Therefore, a relationship appears
to exist between a treatment approach using soft tissue mobil-
ising techniques and improvement in the active range of
shoulder movement.
Conclusion
The treatment of AWS is currently fragmented, and insuf-
ficient information is available about the nature of this
condition. Without a clear explanation of its pathophysiol-
ogy, one can only speculate about the cause and outcome of
this case, and why some patients develop AWS while others
do not. There is a definite need for clinical guidance to assist
healthcare professionals on what constitutes best practice for
the management of AWS. More research is now needed to
investigate the pathophysiology of AWS and to investigate
potential therapeutic options.
Ethical approval: None Obtained.
Funding: None.
Conflict of interest: None declared.
Appendix 1. Motion of soft tissue.
Physiological motion of soft tissues: The motion of the
soft tissues that occurs in line with movement due to muscle
contraction.
 W.J. Fourie, K.A. Robb / Physiotherapy 95 (2009) 314–320
Accessory motion of soft tissues: The motion of the soft
tissue that occurs out of line of normal movement.
When a muscle contracts, it and the connected
non-contractile soft tissues either shorten or lengthen (phys-
iological movement), whereas when pressure is applied to
soft tissue, deformation of the tissue occurs (accessory move-
ment).
Appendix 2. Soft tissue principles and treatment.
Indications
• Decreased fascial glide.
• Compromised connective tissue or fascial mobility.
• Soft tissue tension patterns.
• Dynamic and passive limitations in ranges of tissue move-
ment.
• Joint hypomobility in primary as well as accessory move-
ment patterns.
Aims of treatment
• Correcting patho-anatomy, pathophysiology and pathome-
chanics.
• Increasing reduced tissue mobility and flexibility.
• Restoring tissue glide.
Assessment of tissue glide
Using gentle but firm hand on body contact (limbs and
trunk):
• glide the soft tissue longitudinally superiorly and then infe-
riorly;
• glide the soft tissue transversely medially and laterally;
and
• glide the tissue clockwise and counterclockwise.
Treatment techniques
• The therapist’s hand and patient’s tissue move as a unit,
allowing no hand-on-skin sliding or friction.
• Full hand contact is used over larger areas like the trunk.
• Palm- or finger-only contact is used over extremities or
where concentrated tissue mobilisation is required.
• Modified massage techniques are used:
– modified effleurage, gliding skin and superficial fascia;
– modified kneading and tissue wringing for the deep fascia
and myofascial interfaces; and
– modified skin rolling for deep muscle and myofascia-on-
bone interfaces.
Techniques are applied longitudinally, transversely and
rotationally, and performed at inner-range, mid-range and
end-range of available tissue movement.
319
Appendix 3. Grading of techniques and depth of
touch.
Grades 1–3 mild and superficial touch with no discomfort.
Grades 4–6 moderate to firm touch with mild discomfort.
Grades 7–8 deep, firm pressure with discomfort but toler-
able.
Grades 9–10 deep, painful and potentially damaging pres-
sure.
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