Cording (axillary web syndrome) after breast surgery: symptoms and what helps

Cording is a band of tight tissue that can form under the skin of the arm after surgery that removes lymph nodes from the armpit. Macmillan Cancer Support describes it as a cord-like structure on the inner arm, and says it is also called axillary web syndrome. Cancer Research UK adds that the cord starts in the armpit and may stay there, or travel down to the elbow or even the wrist or thumb.

It is sometimes described as feeling like a guitar string. Cancer Research UK says the cord is not always visible but can usually be felt, and calls cording harmless though it can be painful and may limit arm movement. Macmillan says you may see or feel the cords when you lift the arm to shoulder height or above.

The first sign is often not a visible cord but pain and tightness. A reader's letter in the British Journal of General Practice describes a sharp pain in the armpit that comes when the arm is stretched and raised above shoulder level, then a tightness that extends along the inside of the arm and over weeks becomes thicker and easier to feel.

• A tight, pulling sensation from the armpit down the inner arm.

• Pain when you stretch the arm and raise it above shoulder level.

• A feeling of a cord, or several cords, under the skin that you can see or feel when you lift the arm.

• Reduced range of movement of the arm and shoulder, which Macmillan says can affect many daily activities.

Macmillan says cording may develop a few days after surgery, or a few weeks after, and sometimes appears many months later. It usually gets better slowly over a few months but can take longer, and it can come back, although this is rare. If cording continues, Macmillan says you may be able to have surgery to improve symptoms.

Cancer Research UK also notes that it can appear even months after surgery under the arm and that it usually gets better within a few months. That is why raising it with your breast care team is worthwhile whenever it appears, not only in the first weeks.

Doctors do not know exactly why cording happens. Macmillan says it is thought to be caused by inflammation and scarring of the tissues that surround the lymph vessels, blood vessels and nerves. Cancer Research UK describes it as possibly happening when lymph vessels, which carry fluid from the arm, become hardened.

Risk rises with the amount of surgery under the arm. Macmillan says cording is more common after most of the lymph nodes are removed, called axillary lymph node dissection or clearance, and less likely if only 1 or 2 nodes are removed in a sentinel lymph node biopsy. The BJGP letter suggests that even one node removed can result in cording, so it is not limited to people who had a full clearance.

It is different from scar tissue at the wound itself. The same letter says cording develops along the lymphatic vessel and extends well beyond the surgical scar, and that research it cites found no connection between cording and lymphoedema. This is one clinician's summary, so ask your own team about any link to arm swelling.

Macmillan stresses keeping the arm and shoulder moving, because this helps prevent further tightness that can lead to more serious movement problems. Its suggestions are practical and are the same in outline as those given by Cancer Research UK.

• Ask your cancer doctor, breast care nurse or specialist nurse to refer you to a physiotherapist, who can teach exercises to gently stretch the cords and improve movement.

• Gentle massage of the area, which a physiotherapist or nurse can show you how to do yourself.

• A warm, moist heat pad, used briefly. Macmillan says it is important not to use heat for too long each time, as heat can increase the risk of lymphoedema.

• Painkillers if pain stops you moving the arm and shoulder. Macmillan mentions an anti-inflammatory painkiller such as ibuprofen, and Cancer Research UK also says anti-inflammatory painkillers may help; ask your nurse or doctor which is right for you.

Tell your breast care nurse or GP if you notice tightness or a cord, if your reach is shrinking, or if the pain stops you doing everyday tasks. The BJGP letter warns that untreated cording can lead to immobility, long-term pain and a frozen shoulder, which is a further reason not to put up with it.

Separate problems can arise after surgery, so do not assume every new symptom is cording. Breast Cancer Now lists a wound that feels tender, swollen or warm, redness, discharge, or feeling generally unwell with a raised temperature as possible signs of infection, and says to contact your GP, breast care nurse or specialist straight away. New swelling of the arm or hand is also worth reporting promptly.

Within the NHS, Cancer Research UK and Macmillan both point to the breast care nurse or specialist nurse as the person to tell, and say they can refer you to a physiotherapist.

The same applies if your surgery was private: the team that did the operation is the natural first contact. If you arrange physiotherapy independently, it is sensible to tell your surgical team and to choose someone familiar with recovery after breast or armpit surgery.