ORIGINAL RESEARCH| Volume 103, ISSUE 9, P1798-1806, September 2022

Download started.


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

  • Linda Koehler
    Corresponding author Linda Koehler, PhD, PT, Division of Physical Therapy, Division of Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota Medical School, 420 Delaware St SE, Mayo Mail Code 388, Minneapolis, MN 55455.
    Division of Physical Therapy, Department of Rehabilitation Medicine, University of Minnesota Medical School, Minneapolis, Minnesota

    Division of Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota Medical School, Minneapolis, Minnesota

    Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
    Search for articles by this author
  • Amanda Day
    Division of Physical Medicine and Rehabilitation, Department of Rehabilitation Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
    Search for articles by this author
  • David Hunter
    Radiology, University of Minnesota, Minneapolis, Minnesota
    Search for articles by this author
  • Anne Blaes
    Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota

    Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota
    Search for articles by this author
  • Tufia Haddad
    Department of Oncology, Mayo Clinic, Rochester, Minnesota
    Search for articles by this author
  • Ryan Shanley
    Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota

    Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, United States
    Search for articles by this author
Published:April 05, 2022DOI:



      To determine the cumulative incidence and natural history of axillary web syndrome (AWS) and its related postoperative risk for physical impairments in a cohort of women followed for 5 years post breast cancer surgery.


      Prospective, longitudinal study.


      Academic health center.


      Women (N=36) with and without AWS after breast cancer surgery with sentinel node biopsy or axillary lymph node dissection.


      Not applicable.

      Main Outcome Measures

      Participants were assessed for AWS, shoulder goniometric flexion and abduction range of motion, function (Disability of the Arm, Shoulder, and Hand), lymphedema (bioimpedance spectroscopy, girth measures, tissue dielectric constant), and pain (visual analog scale) at 2, 4, 12, and 78 weeks and 5 years after breast cancer surgery. Analysis of variance compared range of motion, function, lymphedema, and pain in women identified with AWS with those without AWS across visits. Univariate logistic regression assessed if AWS was a risk factor for physical impairment at 5 years.


      The cumulative incidence of AWS was 57%. Fifty percent (14/28) of the women who completed all study visits had signs of AWS at 5 years. Abduction active range of motion was significantly lower in women with AWS at 2 and 4 weeks post surgery. AWS was identified as a risk factor for reduced shoulder motion at 5 years. Regardless of AWS, 75% of the women experienced 1 or more upper extremity physical impairments at 5 years, which is an increase from 66% at 78 weeks in the same cohort.


      AWS is associated with reduced shoulder range of motion in the early postoperative time period, can persist for 5 years after breast cancer surgery, and increases the risk of long-term reduced shoulder range of motion. Long-term physical issues are apparent after breast cancer surgery regardless of AWS.


      List of abbreviations:

      AROM (active range of motion), AWS (axillary web syndrome), DASH (Disabilities of Arm, Shoulder, and Hand), MCID (minimal clinically important difference), PI (primary investigator), PROM (passive range of motion), VAS (visual analog scale), TDC (tissue dielectric constant)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • DeSantis CE
        • Ma J
        • Gaudet MM
        • et al.
        Breast cancer statistics.
        CA Cancer J Clin. 2019; 69: 438-451
        • Recchia TL
        • Prim AC
        • Luz CM.
        Upper limb functionality and quality of life in women with five-year survival after breast cancer surgery.
        Rev Bras Ginecol Obstet. 2017; 39: 115-122
        • Armer JM
        • Stewart BR.
        A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population.
        Lymphat Res Biol. 2005; 3: 208-217
        • Chrischilles EA
        • Riley D
        • Letuchy E
        • et al.
        Upper extremity disability and quality of life after breast cancer treatment in the Greater Plains Collaborative clinical research network.
        Breast Cancer Res Treat. 2019; 175: 675-689
        • Moskovitz AH
        • Anderson BO
        • Yeung RS
        • Byrd DR
        • Lawton TJ
        • Moe RE.
        Axillary web syndrome after axillary dissection.
        Am J Surg. 2001; 181: 434-439
        • Koehler L.
        Axillary web syndrome and lymphedema, a new perspective.
        Lymph Link. 2006; 18: 9-10
        • Thompson Buum HA
        • Koehler L
        • Tuttle TM.
        Venturing out on a limb: axillary web syndrome.
        Am J Med. 2017; 130: e209-e210
        • Koehler LA
        • Haddad TC
        • Hunter DW
        • Tuttle TM.
        Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies.
        Breast Cancer Targets Ther. 2019; 11: 13-19
        • Koehler LA
        • Hunter DW.
        The axillary web and its lymphatic origin.
        Lymphology. 2016; 49: 185-191
        • Koehler LA
        • Hunter DW
        • Haddad TC
        • Blaes AH
        • Hirsch AT
        • Ludewig PM.
        Characterizing axillary web syndrome: ultrasonographic efficacy.
        Lymphology. 2014; 47: 156-163
        • Johansson K
        • Chong H
        • Ciornei CD
        • Brorson H
        • Mortimer P.
        Axillary web syndrome: evidence for lymphatic origin with thrombosis.
        Lymphat Res Biol. 2020; 18: 329-332
        • Bernas MJ.
        Axillary web syndrome, the lost cord, and lingering questions.
        Lymphology. 2014; 47: 153-155
        • Leidenius M
        • Leppanen E
        • Krogerus L
        • von Smitten K.
        Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer.
        Am J Surg. 2003; 185: 127-130
        • Koehler LA
        • Blaes AH
        • Haddad TC
        • Hunter DW
        • Hirsch AT
        • Ludewig PM.
        Movement, function, pain, and postoperative edema in axillary web syndrome.
        Phys Ther. 2015; 95: 1345-1353
        • Koehler LA
        • Hunter DW
        • Blaes AH
        • Haddad TC.
        Function, shoulder motion, pain, and lymphedema in breast cancer with and without axillary web syndrome: an 18-month follow-up.
        Phys Ther. 2018; 98: 518-527
        • O'Toole J
        • Miller CL
        • Specht MC
        • et al.
        Cording following treatment for breast cancer.
        Breast Cancer Res Treat. 2013; 140: 105-111
        • Brunelle CL
        • Roberts SA
        • Shui AM
        • et al.
        Patients who report cording after breast cancer surgery are at higher risk of lymphedema: results from a large prospective screening cohort.
        J Surg Oncol. 2020; 122: 155-163
        • Ryans K
        • Davies CC
        • Gaw G
        • Lambe C
        • Henninge M
        • VanHoose L.
        Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study.
        Support Care Cancer. 2020; 28: 5881-5888
        • de Sire A
        • Losco L
        • Cisari C
        • Gennari A
        • Boldorini R
        • Fusco N
        • Cigna E
        • Invernizzi M
        Axillary web syndrome in women after breast cancer surgery referred to an Oncological Rehabilitation Unit: which are the main risk factors? A retrospective case-control study.
        Eur Rev Med Pharmacol Sci. 2020; 24: 8028--8035
        • Baggi F
        • Nevola Teixeira LF
        • Gandini S
        • et al.
        Axillary web syndrome assessment using a self-assessment questionnaire: a prospective cohort study.
        Support Care Cancer. 2018; 26: 2801-2807
        • Norkin C
        • White J.
        Measurement of joint motion: a guide to goniometry.
        F.A. Davis Company, Philadelphia, PA2009 (Vol 4)
        • Riddle DL
        • Rothstein JM
        • Lamb RL.
        Goniometric reliability in a clinical setting. Shoulder measurements.
        Phys Ther. 1987; 67: 668-673
        • Hunsaker FG
        • Cioffi DA
        • Amadio PC
        • Wright JG
        • Caughlin B.
        The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population.
        J Bone Joint Surg Am. 2002; 84: 208-215
        • Harrington S
        • Michener LA
        • Kendig T
        • Miale S
        • George SZ.
        Patient-reported upper extremity outcome measures used in breast cancer survivors: a systematic review.
        Arch Phys Med Rehabil. 2014; 95: 153-162
        • Miale S
        • Harrington S
        • Kendig T.
        Oncology Section Task Force on Breast Cancer Outcomes: clinical measures of upper extremity function.
        Rehab Oncol. 2013; 30: 27-34
        • Franchignoni F
        • Vercelli S
        • Giordano A
        • Sartorio F
        • Bravini E
        • Ferriero G.
        Minimal clinically important difference of the Disabilities of the Arm, Shoulder and Hand outcome measure (DASH) and its shortened version (QuickDASH).
        J Orthop Sports Phys Ther. 2014; 44: 30-39
        • Price DD
        • McGrath PA
        • Rafii A
        • Buckingham B.
        The validation of visual analogue scales as ratio scale measures for chronic and experimental pain.
        Pain. 1983; 17: 45-56
        • Myles P
        • Myles D
        • Galagher W
        • et al.
        Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state.
        Br J Anaesth. 2017; 118: 424-429
        • Casley-Smith JR
        • Casley-Smith JR
        Modern treatment of lymphoedema. I. Complex physical therapy: the first 200 Australian limbs.
        Australas J Dermatol. 1992; 33: 61-68
        • Armer JM
        • Stewart BR.
        Post-breast cancer lymphedema: incidence increases from 12 to 30 to 60 months.
        Lymphology. 2010; 43: 118-127
        • Ward LC
        • Czerniec S
        • Kilbreath SL.
        Quantitative bioimpedance spectroscopy for the assessment of lymphoedema.
        Breast Cancer Res Treat. 2009; 117: 541-547
        • Mayrovitz HN
        • Davey S
        • Shapiro E.
        Suitability of single tissue dielectric constant measurements to assess local tissue water in normal and lymphedematous skin.
        Clin Physiol Funct Imaging. 2009; 29: 123-127
        • Koehler LA
        • Mayrovitz HN.
        Spatial and temporal variability of upper extremity edema measures after breast cancer surgery.
        Lymphat Res Biol. 2019; 17: 308-315
        • Verbelen H
        • Gebruers N
        • Eeckhout FM
        • Verlinden K
        • Tjalma W.
        Shoulder and arm morbidity in sentinel node-negative breast cancer patients: a systematic review.
        Breast Cancer Res Treat. 2014; 144: 21-31
        • Kuehn T
        • Klauss W
        • Darsow M
        • et al.
        Long-term morbidity following axillary dissection in breast cancer patients–clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors.
        Breast Cancer Res Treat. 2000; 64: 275-286
        • Aerts PD
        • De Vries J
        • Van der Steeg AF
        • Roukema JA.
        The relationship between morbidity after axillary surgery and long-term quality of life in breast cancer patients: the role of anxiety.
        Eur J Surg Oncol. 2011; 37: 344-349
        • Harrington S
        • Padua D
        • Battaglini C
        • et al.
        Comparison of shoulder flexibility, strength, and function between breast cancer survivors and healthy participants.
        J Cancer Surviv. 2011; 5: 167-174
        • Janz NK
        • Mujahid M
        • Chung LK
        • et al.
        Symptom experience and quality of life of women following breast cancer treatment.
        J Womens Health (Larchmt). 2007; 16: 1348-1361
        • Tengrup I
        • Tennvall-Nittby L
        • Christiansson I
        • Laurin M.
        Arm morbidity after breast-conserving therapy for breast cancer.
        Acta Oncol. 2000; 39: 393-397
        • Koehler LA
        • Mayrovitz HN.
        Tissue dielectric constant measures in breast cancer surgery : a 78-week longitudinal study.
        Phys Ther. 2020; 100: 1384-1392
        • Simovitch R
        • Flurin P
        • Wright T
        • Zuckerman J
        • Roche C.
        Quantifying success after total shoulder arthroplasty: the minimal clinically important difference.
        J Shoulder Elbow Surg. 2018; 27: 298-305
        • Harrington S
        • Padua D
        • Battaglini C
        • Michener LA.
        Upper extremity strength and range of motion and their relationship to function in breast cancer survivors.
        Physiother Theory Pract. 2013; 29: 513-520
        • Marazzi F
        • Masiello V
        • Marchesano D
        • et al.
        Shoulder girdle impairment in breast cancer survivors: the role of range of motion as predictive factor for dose distribution and clinical outcome.
        Tumori. 2019; 105: 319-330
        • Smoot B
        • Paul SM
        • Aouizerat BE
        • et al.
        Predictors of altered upper extremity function during the first year after breast cancer treatment.
        Am J Phys Med Rehabil. 2016; 95: 639-655
        • Runowicz CD
        • Leach CR
        • Henry NL
        • et al.
        American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline.
        CA Cancer J Clin. 2016; 66: 43-73
        • Hauerslev KR
        • Madsen AH
        • Overgaard J
        • Damsgaard TE
        • Christiansen P.
        Long-term follow-up on shoulder and arm morbidity in patients treated for early breast cancer.
        Acta Oncol. 2020; 59: 851-858
        • Verbelen H
        • Tjalma W
        • Meirte J
        • Gebruers N.
        Long-term morbidity after a negative sentinel node in breast cancer patients.
        Eur J Cancer Care. 2019; 5: e13077
        • Sagen A
        • Karesen R
        • Sandvik L
        • Risberg M.
        Changes in arm morbidities and health-related quality of life after breast cancer surgery - a five-year follow-up study.
        Acta Oncol. 2009; 48: 1111-1118
        • Levangie PK
        • Drouin J.
        Magnitude of late effects of breast cancer treatments on shoulder function: a systematic review.
        Breast Cancer Res Treat. 2009; 116: 1-15
        • Stout Gergich NL
        • Pfalzer LA
        • McGarvey C
        • Springer B
        • Gerber LH
        • Soballe P.
        Preoperative assessment enables the early diagnosis and successful treatment of lymphedema.
        Cancer. 2008; 112: 2809-2819
        • Stout NL
        • Andrews K
        • Binkley JM
        • Schmitz KH
        • Smith RA.
        Stakeholder perspectives on dissemination and implementation of a prospective surveillance model of rehabilitation for breast cancer treatment.
        Cancer. 2012; 118: 2331-2334
        • Stout NL
        • Pfalzer LA
        • Springer B
        • et al.
        Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care.
        Phys Ther. 2012; 92: 152-163