Today I had a new patient who reminded me about how important it is to give really clear and personalized instructions for arm stretching following mastectomy surgery, especially when thick cording is present.
In this blog I’ll focus on thick cording; it’s common, but less talked about, a side effect after mastectomy and node dissection. I’ll argue with today’s case example that if people after mastectomy, with deep nodes removed, are provided with a brief arm exercise instruction, then it’s most likely they’ll get it wrong.
Firstly, recovery following mastectomy surgery to remove all breast tissue and the deep lymph nodes (ALND) is complicated. Because of the location and extensiveness of the surgery and additional cancer care medical treatments, the capacity of the primary muscles is negatively impacted. Raising the arm, supporting best posture and arm strength are affected immediately and in the long term. The quality of blood vessels, local nerves, and lymphatic vessels in the arm are likely to be affected. And on the social-emotional side of things, breast amputation does challenge a person's long-held self-image.
In Australia, most people receive very quick exercise instruction from the surgeon, a short consult with the physio about graduated arm exercises, and a PDF with arm exercises supported by the Cancer Council. This level of support has left many women (and men) experiencing chronic pain and arm movement restrictions for years after. (2015 research)
Today’s patient, Sarah, is a young woman, who is now 4 months after having mastectomy surgery and all of her deep axillary nodes removed (ALND). Her arm movement was not improving, despite being diligent at her arm stretches. So, Sarah was referred to my Oncology (Breast) Rehab practice.
What does this type of problem look like?
Sarah’s arm could only raise out the side, to just above shoulder height.
When raising the arm in front, she could reach a little higher but was still about 30 degrees short of what was possible on her non-surgery side.
At each end point of movement, her arm just could not be stretched anymore.
It was easy to see what was stopping the arm from stretching any further: a tight band extending across her armpit into the arm.
This tight band is commonly known as cording, which is usually 1-2 mm thick and can be on average 39 cm long. But in this case, the cording was about 12 mm wide, which makes it look more like a rope- pulling under the skin at the armpit.
Cording is not obvious when the arm is down at the side, but obvious when the arm is stretched out. Most women feel it as a pain in their arm when they reach out, or they just can’t physically reach out.
1-2 mm wide cording is sometimes called “fiddle strings” because there are usually a few and so it does look like the strings of a violin or fiddle. People and therapists in attendance report that arm stretches can make thin cording go away. They each say they hear a POP sound during a large arm stretch and that immediately one or more of the “strings” are no longer seen across the armpit and the arm moves more freely.
But much thicker “rope-like” cording >10mm/ 1/2inch can’t possibly respond in the same way to arm stretches. The people I’ve seen in the clinic repeat the same story: “arm stretching just hasn’t worked for me”. But there is more to this experience. I’ve noticed that when the person has tried hard; pushing their arm stretches, then there seems to be more chest stiffness and the cording stiffness doesn’t improve.
In Sarah’s case, she remembers her Surgeon instructing her to push her arm during stretches. This was interpreted as “keep pushing all arm stretches”. And this was what Sarah did every day over the last 3 months. She wanted to get her arm movement back!
In cases similar to this, I see that overstretch results in a localized point of strain, with the potential for microtears and inflammation at the chest, where the cord is attached to the mastectomy + ALND scar tissue. It’s like having a repetitive strain injury at the chest wall- strong and repeated pulling, by a long lever arm, at a small central fixed location, that just won’t budge.
It’s well known that chronic inflammation can readily lead to more scar tissue forming. This is my main hypothesis to explain persistent limited arm movement when strong arm stretches are used to stretch thick cording.
Or maybe I’m wrong- it could be the original stiffness in the chest, after mastectomy, that’s making thick cording into the arm unmanageable. There’s no clear research indicating why cording occurs – so we can only hypothesise the mechanisms at the moment.
But I am clear about the WRONG WORDS for managing thick cording and chest stiffness after mastectomy and ALND:
1. PUSH THROUGH
2. STRETCH YOUR ARM HARD
3. STRONG STRETCHES
If you’ve been using these words and instructions and your thick cording has not improved; you still can’t raise your arm fully, then read on.
The next part of today’s assessment, for Sarah, was to find where the cording was adhered to at the chest. This means that the tension and elasticity at the skin, chest muscles, and the rib cage, need to be assessed to find where the cording gets stuck. It's easy to feel the impact of scar tissue after mastectomy: some chest tissues (skin and muscle) move freely in one direction and yet can block any tissue stretch in another direction. This concept of the cording being attached at the chest is a surprise to Sarah; she wasn’t aware that it went that far.
As I’m moving my hand at Sarah’s chest, I find certain tissues are hard and have an abrupt and early barrier to stretching upwards and towards the shoulder. I drew Sarah’s attention to feel the variances in stretch and stiffness in the different layers: skin, muscle, and rib cage. She was so surprised to hear and feel these changes. No one had pointed this out to her over the 4 months; she hadn’t felt her chest area to discern the changes. Sarah went with what she was told and could see: the problem was just the cording at the armpit.
Then she said, ever so slowly: “I thought that was normal”
When no one tells you any different, then you think:
“this is it”
“this is what my new normal is, after mastectomy”.
Scar tissue is a normal response to surgery, but some people’s body delivers an extra amount of scarring at the injury site. It's this extra scar tissue that needs to be treated differently. Once scars heal, then thick scars need to be remodeled.
Currently, there are a few different ways of treating scarring and thick cording after mastectomy. The methods I choose need to be easy enough for the individual to use at home. This is based on my belief that when people take control- there’s a better sense of personal power. They need this!
The Lewit Barrier Release suits this brief: it's an easy step-by-step hands-on massage method that takes 45 seconds per treatment. It allows the body to release some of the scar-related tension and the reduced stiffness can be felt immediately.
Because managing chest stiffness and thick cording take a lot of extra work at the start, it makes sense that the person learns to do their treatment at home. This is where much longer instruction is required.
It takes time to learn about the stiff changes in the chest after mastectomy. It takes time to feel how to use your hand to stretch the tissues at the chest, to find the direction of abrupt stiffness, to find where the cording melds into the chest scar tissue. It takes guided and careful practice to apply gentle directional massage to the stiff tissues. Then at the end of the self-massage training, we take time to evaluate how the arm is moving and how this is linked to the chest softening.
It certainly is much more complicated than RICE – the common approach to strains and sprains, that we learn in First Aid training.
It takes 45 mins for the first session. Then the number of 30 min sessions needed will depend on what the person needs to feel confident about their self-care practices: learn more about how to bring more elasticity to chest stiffness after mastectomy and thick cording.
People after mastectomy and ALND need this extra level of professional support to learn about their “new normal”.
These are my thoughts about the RIGHT WORDS for managing thick cording:
· Work directly at the stiff tissues of the chest
· Your hands can bring about the changes
· Gentle holds
Normally, by now you'd want to read about the outcomes of my treatment for thick cording for this case. However in Australia, I am governed by our allied health professional registration, APRHA, who does not allow testimonials or case studies, because consumers may develop unrealistic expectations. Yet, it is acceptable by APHRA to explain medical conditions and direct people to having a personalized assessment and treatment plan developed. This is a great idea, especially if you have thick cording after mastectomy- as no one's experience is exactly the same as someone else's.
If you have thick cording and these "right" words are new to you, then this different approach is worth investigating.
I can help you if you are a Brisbane person, by seeing you at my office.
If you live too far away to visit Brisbane, then think about having an online consult. This means that I will take you and your hands through the same process that I offer here: assessment and hands-on gentle treatment.
Book an appointment at the connect button at the top of the page.