What is Chording (Axillary Web Syndrome) and How Can Massage Therapy Help?

I remember a patient I had years ago who presented with significant chording down her right arm after her second breast cancer surgery.  She didn’t complain about it, of course, as it was not in her nature to make a fuss over anything.  But she did mention she’s got these strange wire-like lines running down her arm to her wrist, and what there anything I could do about it…?

She looked at me slightly out of the corner of her eye, which I interpreted to mean she was uncertain if she should be bringing it up, concerned over if this was normal, and curious as to whether massage therapy could help her in any way.

I asked her to show me what was happening, so she lifted her left arm to about 90 degrees to the side (abduction) and I could clearly see 3 or 4 very thin wire-like lines raising the skin from the side of her trunk, through her axilla (armpit), through the soft part of her elbow crease (antecubital fossa) and ending at her wrist.  

She said they were uncomfortable, and were causing tightness and pain in her arm when she was trying to put on a coat, reach for a glass beside her on the counter or stretch back to hand her son a snack while in the car.  A sharp “zinging” pain often accompanied any sudden stretching/reaching movements to the side, resulting in her being more cautious than usual of moving her upper limb.

 If you or your massage therapy patients have ever faced anything like this and what to know more, this is the post for you!

What is Chording?

Chording is restrictive, potentially painful scar and fibrotic tissue that forms along lymphatic pathways in the axilla (armpit) and upper limb in distinctive “wire-like” chords running under the skin.  It is formally known as “Axillary Web Syndrome” or AWS for short.

AWS usually forms on the side that lymph nodes have been removed during surgery.  Kepics (2007) highlights that once lymph nodes are removed, the adjacent lymph vessels become non-functional, leading to fibrosis, which can lead to adhesions in axilla or chest wall via scar tissue build up.

Chording can happen in up to 86% of breast cancer patients who have had one or more lymph nodes removed during surgery (Koehler et .al . 2018)

How to Recognize Chording

It is actually quite easy to find out if you or your patient have chording.  It is simply a matter of lifting the arm to the side and slightly back (abduction and extension), with the elbow straight (Koehler et.al. 2018).  

If chording is present, the hardened lymph vessels become apparent when the arm is lifted and stretching happens to the tissues, where upon long thin chords can be visibly seen and palpated (Kepics, 2007).

How Often Does Chording Occur?

Being one of the more frequent complications after breast cancer surgery, it occurs in up to 86% of patients with lymph node removal on the same side.  Onset may be between 2 - 8 weeks postoperatively, but can also develop months or years after surgery (Koehler et.al. 2018).  

Typically, symptoms last from 1 week to 2 years (Piper et .al . 2016).  50% of people may have AWS at 18 months post-op (Koehler et .al . 2018), while 36% of patients can develop by 24 months post-op (Jacob & Bracha, 2018). 

How Can Massage Therapy Help with Chording?

I did a combination of manual therapy and home-care for my patient, and it helped matters considerably.  Within a few weeks her chords had reduced from her arm completely, the sharp “zinging’ pain cleared up and within 4-6 weeks there were no more chords in her axilla as well.  

There are a few studies outlining some massage therapy techniques that I thought I’d share, as it’s always good to see what the evidence says.

Firstly, Kepics reported:

           “Active and passive stretching, soft tissue and cord stretching techniques including myofascial release and scar releases...skin traction technique, which is found to be most beneficial. With the arm abducted to comfort level, 1 or 2 inch segments of the cord are stretched by the therapist’s thumb and index finger. This can be done along the length of the cord and onto the chest wall. Occasionally, the therapist can feel a pop or a snap in the cord where it actually breaks during the stretch. The patient usually feels no pain and gets an immediate increase in ROM. This is often felt with the thinner, piano-wire type cords that are more likely to be in the antecubital fossa and along the length of the cord rather than the thickened cords seen in the axilla. No harm seems to result from this breakage and patients are pleased with their newfound range of motion”. (Kepics, para 9, 2007) 

A case study by Lewis in 2016 mentioned Dynamic Angular Petrissage (DAP) as effective in 2 treatments to reduce chording in their patient’s upper limb.  

DAP is performed by combining Swedish massage with passive movement of the upper limb through all possible angles of movement, controlling stretch & tension on upper limb, while at same time segmentally applying petrissage to underlying soft tissue with other hand (Lewis, 2016). 

Thirdly, it has been reported that Manual Lymph Drainage (MLD) + median nerve neurodynamic glide exercises with no neural loading (Torres-Lacomba et.al. 2022) has been helpful for clearing AWS.  

MLD is a gentle manual technique designed to move fluid through the lymphatic channels more efficiently, and nerve gliding helps nerves move through the outer sheath more smoothly.

While I didn’t use MLD at the time on this particular patient, I did suggest the median nerve gliding for the sharp “zinging” pain for her home-care, and this made a significant difference to her pain levels.  Within about 2 weeks of doing it daily, she lost the sharp pain with sudden movements, and began to be able to reach to the backseat to hand her son a piece of apple without pain. 

Wrap Up

Given that chording is so common after breast cancer surgery, you may come across it in your massage therapy practice.  If you are a patient, you may experience it yourself and wonder if it’s normal.  

As we have seen, it is fairly common, and does fortunately respond well to treatment.  There are home-care exercises that can be done between massage therapy sessions to amplify the healing effects, so hope is definitely here! 

Eryn Price is a registered massage therapist and educator in British Columbia, Canada.  She has a special focus to her practice of helping women and gender-diverse people going through breast and top surgery, as well as teaching fellow massage therapists how to support this beautiful demographic.  If you would like to know more about her continuing education for professionals, or home-care support programs for patients, please visit www.mastectomyguide.com  

To learn more about how to work with post-op complications specifically using evidence-informed massage therapy, please see our Level 2: Post-op Complications for Massage Therapist program, which is offered both virtually and in-person. 

References:

Jacob T, Bracha J. Identification of signs and symptoms of axillary web syn- drome and breast seroma during a course of physical therapy 7 months after lumpectomy: a case report. Phys Ther . 2019;99:229–239 . Copyright 2018 American Physical Therapy Association . October 18, 2019 . Retrieved May 16/22 from https://pubmed .ncbi .nlm .nih .gov/30339213/ 

Kepics, Jane MS PT CLT-LANA, University of Scranton, Final Case Report. Evidence Based Medicine. December 10, 2007 . Retrieved May 3/22 from https://vodderschool .com/ treatment_of_axillary_web_syndrome 

Koehler, L. A., Haddad, T. C., Hunter, D. W., & Tuttle, T. M. (2018). Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies . Breast cancer (Dove Medical Press), 11, 13–19 . https://doi .org/10 .2147/BCTT .S146635 . Retrieved March 17/22 from https://www .ncbi .nlm .nih .gov/pmc/articles/ PMC6304256/ 

Lewis, BA, RMT, CDT, P. A., & Cunningham, PhD, J. E. (2016). Dynamic Angular Petrissage as Treatment for Axillary Web Syndrome Occurring after Surgery for Breast Cancer: a Case Report . International Journal of Therapeutic Massage & Bodywork: Research, Education, &Amp; Practice, 9(2), 28–37 . Retrieved March 17/22 from https://doi .org/10 .3822/ijtmb . v9i2 .297 

María Torres-Lacomba, PT, PhD, Virginia Prieto-Gómez, PT, PhD, Beatriz-Arranz Martín, PT, PhD, Jean Claude Ferrandez, PT, María José Yuste-Sánchez, PT, PhD, Beatriz Navarro- Brazález, PT, PhD, Helena Romay-Barrero, PT, PhD, Manual Lymph Drainage with Progressive Arm Exercises for Axillary Web Syndrome after Breast Cancer Surgery: A Randomized Controlled Trial, Physical Therapy, 2022;, pzab314 . Retrieved March 17/22 from https://doi .org/10 .1093/ptj/pzab314 

Piper M, Guajardo I, Denkler K, Sbitany H. Axillary Web Syndrome: Current Understanding and New Directions for Treatment . Ann Plast Surg . 2016 May;76 Suppl 3:S227-31 . doi: 10 .1097/SAP .0000000000000767 . PMID: 27070684 . Retrieved March 17/22 from https://pubmed .ncbi .nlm .nih . gov/27070684/