Axillary web syndrome (AWS), aka cording, may develop after breast cancer surgery, especially after axillary lymph node procedures. The exact cause remains uncertain, but research increasingly supports involvement of the superficial lymphatic system. Inflammation, vascular changes, and connective tissue fibrosis may also contribute to cord formation. It presents as palpable and sometimes visible, cords extending from the axilla into the arm, often causing pain and restricted shoulder mobility. I would describe it as feeling like guitar strings.
It clinical practice, some therapists (myself included) have sometimes used manual therapy techniques to deliberately snap or break these cords to help release restrictions. Sometimes, it also just happens without intention while performing soft tissue mobilization and range of motion work. I wanted to check the current evidence to see if there were any updates on treatment for AWS and this is what I found.
The evidence does not prove snapping is harmful, however, it also does not prove it is beneficial. A 2023 randomized controlled trial involving 60 patients compared stretching exercises alone with stretching combined with a manual snapping maneuver. At one month, there was no statistically significant difference in shoulder range of motion between groups.
At the three-year follow-up, there was also no significant difference in breast cancer-related lymphedema incidence.
Persistent cording does not always mean persistent disability as long as full range of motion (ROM) is achieved with manual therapy and stretching. Cording does not always disappear when shoulder function improves. A 2025 study involving 25 women found palpable AWS in 64% at three to six years, without significant differences in pain, ROM, or lymphedema. A five-year prospective study found that 50% of the 28 participants assessed at five years continued to demonstrate AWS. However, persistence of a palpable cord did not necessarily mean continued pain or functional impairment.
Given these findings, what do I think treatment should focus on?
Full pain free range of motion is always the goal. As there is no established evidence that intentionally breaking persistent cords prevents future complications with ROM or decreases risk of lymphedema, if progressive stretching and appropriately graded manual therapy can address these limitations without deliberately rupturing the cord, it may not be beneficial to work more aggressively to snap the cords especially if underlying structures may include lymphatic or vascular tissue, and the long-term effects of mechanical cord disruption remain uncertain.
References
Johansson K, et al. (2020). Axillary Web Syndrome: Evidence for Lymphatic Origin with Thrombosis. Lymphatic Research and Biology, 18(4), 329–332. https://doi.org/10.1089/lrb.2019.0074
Sandrin F, et al. (2023).
The efficacy in shoulder range of motion of a snapping manual maneuver added to a standardized exercise protocol in axillary web syndrome: A randomized controlled trial. Acta Oncologica, 62(8), 969–976. https://doi.org/10.1080/0284186X.2023.2241995
Five-Year Cumulative Incidence of Axillary Web Syndrome and Comparison in Upper Extremity Movement, Function, Pain, and Lymphedema in Survivors of Breast Cancer With and Without Axillary Web Syndrome (2022).
Archives of Physical Medicine and Rehabilitation. https://www.sciencedirect.com/science/article/abs/pii/S000399932200291X
González-Rubino JB, Vinolo-Gil MJ, Martín-Valero R. (2023).
Effectiveness of physical therapy in axillary web syndrome after breast cancer: A systematic review and meta-analysis.
Supportive Care in Cancer, 31, 257. https://doi.org/10.1007/s00520-023-07666-x
Long term outcomes of axillary web syndrome and its association with lymphedema and functional impairments in breast cancer survivors (2025). Discover Medicine. https://doi.org/10.1007/s44337-025-00401-x
