Monday 7 October 2013

Treatment of Axillary Web Syndrome

by Swapnil Rege, MSc PT
Clinic Director & Physiotherapist - LifeMark Health Brampton

Technique Improves Shoulder Range of Motion While Decreasing Axillary Cording

Several years ago, while on a shadowing placement, I had a chance to visit a non-profit cancer treatment clinic. We were shown a very simple technique to treat axillary web syndrome that significantly improves range of motion of the shoulder and decreases the axillary cording. I have used that technique successfully for every axillary web syndrome client I have seen since. Over time, I have established my own routine for treating these individuals.

What Causes Axillary Web Syndrome?

Axillary web syndrome is thought to be caused by a disruption of the lymphatic network following sentinel axillary node biopsy or axillary lymph node dissection [1]which in lay terms means the removal of nodes of the lymphatic system that are most likely to contain cancer cells. This type of biopsy can be used to help determine the stage of cancer or extent of cancer in the body.

Traditional treatment methods, which are still effective, include assisted range of motion exercises of the shoulder with pulleys, and passive range of motion performed by the therapist and scar tissue massage.

The presentation of axillary web syndrome includes:

  • Reduced abduction of the affected shoulder, worse than limitation in flexion. Pain will be reported with both movements (worse with abduction)
  • Palpable and/or visible axillary cord in the affected side. The cord generally runs from the axilla and can extend medially all the way to the wrist. In many cases, the cord may not be visible. Do not discount the presence of axillary web syndrome if you do not see the cord. If your client has had breast cancer surgery and has limited shoulder range of motion, I would pursue the treatment as a trial
  • Subjective complaints of pulling in the axilla and medical aspect of the arm
  • Significant difference in median nerve glide tension between the affected and unaffected arm
Swapnil Rege, MSc PT, demonstrates treatment of Axillary Web Syndrome

Treatment of Axillary Web Syndrome Includes the Median Nerve Glide

The treatment includes:

  1. Moist heat to the cord 8-10 minutes with extra padding and frequent visual inspection of the site to avoid burns due to sensory impairment. Make a clinical judgment on whether you want to use heat. It will depend on time since surgery, skin integrity, inflammation present, etc.
  2. Client perform AAROM exercises of the affected shoulder, 10 repetitions in flexion and abduction with a 5 second hold at a comfortable level
  3. Manual median nerve glide on the unaffected side - 1 repetition, followed by median nerve glide on the affected side - 1 repetition. Do this sequence until you have completed 5 median nerve glides on each side
  4. AAROM of the affected shoulder as described previously
  5. Patient-directed median nerve glide on the wall. Start with unaffected side - 1 repetition, followed by nerve glide on affected side - 1 repetition. As with the therapist-directed medial nerve glide, continue this procedure until the client has completed 5 repetitions on each side.
  6. Ice post-treatment if required. As with the application of heat, precautions need to be taken prior to applying ice.
  7. Education on home program:
  • AAROM exercises of the affected shoulder: provide pulleys for home or alternatively can do wall-walking exercise
  • Patient-directed median nerve glide, 5 repetitions each side, 2-3 times per day
  • Heat and ice application as appropriate
You may choose to complete the protocol differently than what is presented above. However, the key is to complete the median nerve glide. There are no research studies to date about the efficacy of median nerve glide with treatment of axillary web syndrome and hence this is considered anecdotal evidence.

This treatment, if done correctly, resolves the axillary web and significantly improves shoulder range of motion within one to two treatments. Do not be discouraged if you see significant improvements on one day and significant regression the following day. In my experience, this is common and within 2-3 weeks, resolves completely. I encourage patients to complete the exercises for one additional month after complete resolution to ensure no reoccurrences.

View the video of Swapnil Rege, MSc PT demonstrating the treatment of Axillary Web Syndrome at !

To find a Cancer Rehab Canada near you, visit the list of British ColumbiaSaskatchewanOntario, or Nova Scotia locations.

[1] Moskovitz AH, Anderson BO, Yeung RS, et al. Axillary web syndrome after axillary dissection. Am J Surg. 2001;181:434–9.

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