AWARENESS IS IMPORTANT
I had the misfortune of suffering twice from cording, following two operations to remove lymph nodes, the second a mastectomy. None of the GPs I met knew what cording was or which treatment to offer. Raising awareness and informing GPs about cording is an urgent task, given the large number of women affected. Cording (or as it’s sometimes known — axillary web syndrome, AWS) is a painful common side effect of lymph node removal during breast cancer surgery, yet it is often under-recognised and therefore left untreated. This is particularly relevant to GPs, who are often the first port of call for help. Recognising and understanding the symptoms could facilitate a prompt referral to physiotherapy and accelerate healing. With appropriate physiotherapy and exercises, most cases of cording are fully resolved within a few weeks or months.1
WHAT IS CORDING?
Following lymph node dissection, a woman may notice a sharp pain in her armpit (axilla). Typically, the pain occurs when the arm is stretched and raised above shoulder level.
This condition usually starts within days or weeks after surgery. A tightness develops from the site of the axillary scar, which extends along the inside of the arm, sometimes past the elbow and as far as the wrist. It can also run down the trunk and into the chest wall.
Over a period of weeks, it gradually thickens and becomes palpable and visible, looking like a tight cord under the skin. It may be a thin cord, or there can be more than one cord, creating a thick web of hardened tissue in the axilla.
CAUSES OF CORDING
Lymph nodes are removed to determine whether cancer has spread, either in sentinel lymph node biopsy, when usually only two nodes are removed, or in axillary lymph node dissection, when many nodes are cleared. The removal of axillary lymph nodes causes the lymphatic vessels connected to the removed nodes to undergo fibrosis and harden. The more lymph nodes removed, the higher the probability of AWS, but even the removal of a single lymph node can result in cording.2
CORRECTING TWO COMMON MISCONCEPTIONS
First, cording is often confused with scar tissue at the site of surgery. However, cording develops along the lymphatic vessel, extending far beyond the surgical scar.
Second, there seems to be no connection between cording and lymphoedema, and cording does not lead to lymphoedema.3,4 Lymphoedema, a condition where the removal of lymph nodes causes swelling in the body’s tissues, is regularly discussed with patients undergoing surgery and an information leaflet given, yet cording is hardly ever mentioned.
REFERRAL AND TREATMENT
The first sign of cording is tightness and pain that restricts movement in the arm, even before a cord is visible. It is important to inform and reassure the patient that it can be resolved. A referral to a specialist physiotherapist should be arranged as a priority. Failure to treat cording can result in immobility, long-term pain, and a frozen shoulder. The mainstay of treatment involves exercises and massage techniques to stretch and soften the cord.2,3
The exercises can be painful, requiring perseverance and working gradually through the pain, until arm movement improves and the pain subsides. If necessary, painkillers can be taken before physiotherapy or exercises. Swimming is very effective in restoring movement and reducing pain. In the rollercoaster of breast cancer diagnosis and treatment, cording may seem a peripheral matter. Yet, from the patient’s point of view, healing cannot fully begin while pain persists and arm movement is limited. Better awareness of cording among doctors and breast cancer patients will aid recovery and prevent chronic pain.
- © British Journal of General Practice 2019
