Lymphedema– Causes, Symptoms, Diagnosis, Treatment and Ongoing care



  • Swelling of a body part due to an abnormality in regional lymphatic drainage
  • Results in increased interstitial volume secondary to the accumulation of tissue (lymphatic) fluid
  • Most common in the lower limb (80%) but also can occur in the arms, face, trunk, and external genitalia



  • Predominant sex: Female > Male.
  • Predominant age: Any age
  • 13% of breast cancer patients treated with surgery; 42% of those treated with surgery and radiation therapy
  • Estimated to be between 1/6,000 and 1/300 live births; Milroy disease presents at birth.
  • Meige disease develops during puberty.


  • 120 million people worldwide are affected with filariasis.
  • 3 million–5 million people are affected by secondary lymphedema in the US.

Risk Factors

  • Filariasis: Most common cause worldwide
  • Mastectomy
  • Prior trauma
  • Infection of affected limb
  • History of prior surgical or radiation therapy for malignancy
  • Long history of venous insufficiency
  • Obesity


  • Milroy disease: Autosomal dominant; diagnosed either at birth or the 1st year of life
  • Lymphedema praecox has onset between the ages of 1 and 35 years.
  • Lymphedema tarda occurs >35 years.

General Prevention

Treatment of congestive heart failure (CHF), venous insufficiency


  • Postoperative: Gradual failure of distal lymphatics, which have to “pump” lymph at a greater pressure through damaged proximal ducts
  • Risk is higher with postoperative radiation because radiation reduces regrowth of ducts owing to fibrous scarring.


Secondary lymphedema:

  • Trauma; recurrent infection; malignancy, including metastatic disease
  • Developing countries: Most common cause is filariasis (Wucheria bancrofti).

Commonly Associated Conditions

Venous disease

Pressure, Lymphatic system, congestive heart failure, lymphatic drainage, recurrent infection, breast cancer, malignancy,



Recent surgery: Vein stripping can significantly exacerbate mild lymphedema (1)[B].

  • 1st symptom: Painless swelling
  • Feeling of heaviness in the limb, especially at the end of the day and in hot weather

Physical Exam

  • Initial: Pitting edema, can spread proximally
  • Later: Nonpitting; after 1st year, does not spread proximally/distally but spreads radially
  • Hyperkeratosis (thicker skin)
  • Papillomatosis (rough skin)
  • Increase in skin turgor
  • Positive Stemmer sign (inability to pinch the skin of the dorsum of the second toe between the thumb and forefinger): Exclude heart failure.

Diagnostic Tests & Interpretation

  • Lack of response to elevation or diuretic therapy may indicate a lymphatic insufficiency (2)[B].
  • Diuretics increase excretion of salt and water thereby decreasing plasma volume, venous capillary pressure, and filtration. Diuretics improve filtration edema but don’t improve lymph drainage over the long-term.


Initial lab tests

  • Comprehensive chemistry panel: Evaluate for hepatic or renal impairment.
  • Urinalysis: Protein-losing nephropathy


Initial approach

  • Ultrasound: Evaluate for acute/chronic deep vein thrombosis (DVT). Gives information about soft-tissue changes but does not tell about truncal anatomy of the lymphatics (1)[B].
  • Duplex ultrasound: Lymphedema causes gradual impedance of venous return that aggravates the edema; 82% of patients with unexplained limb edema were diagnosed using a combination of duplex ultrasound and lymphoscintigram (3)[A].

Follow-Up & Special Considerations

  • Lymphangiogram: Direct cannulation of lymphatics through the skin; risk for infection, local inflammation; not used commonly (3)[C]
  • Lymphoscintigram: Radiolabeled protein technetium-99m-labeled colloid:
    • Measures lymphatic function, lymph movement, lymph drainage, and response to treatment
    • Sensitivity 73–97%; specificity 100%
    • Best to use 1-h and delayed images together (3)[A]
  • CT scan: Calf skin thickening, thickening of the subcutaneous compartment, increased fat density, thickened perimuscular aponeurosis; typical honeycomb appearance (3)[B]
  • MRI: Circumferential edema, increased volume of subcutaneous tissue, honeycomb pattern above the fascia between the muscle and subcutis; cannot differentiate primary from secondary lymphedema (3)[B]

Differential Diagnosis

CHF, renal failure, hypoalbuminemia, protein-losing nephropathy, lipidemia, DVT, chronic venous disease, postoperative complications following ipsilateral surgery, cellulitis, Baker cyst, idiopathic edema



  • Micronized purified flavonoid fraction [Daflon 500 mg] is effective in decreasing venous stasis and idiopathic cyclic edema, chronic venous insufficiency, and postmastectomy lymphedema. It also reduces capillary permeability and the inflammatory component (4)[C].
  • Benzopyrenes (coumarin): Reduces edema fluid by increasing the number of macrophages and enhancing proteolysis resulting in the removal of protein, increasing softness in the limbs, and decreasing elevated skin temperature.
    • Decreases symptoms and signs and decreases instances of secondary infection
    • Some reports of hepatotoxicity (4)[C]

Additional Treatment

General Measures

  • Elevation of affected limb: May be difficult for some patients to comply
  • Prevent disease progression.
  • Achieve mechanical reduction and maintenance of limb size.
  • Alleviate symptoms.
  • Prevent skin infection.

Issues for Referral

  • Refer to physical therapist with lymphedema training for manual decongestive therapy.
  • Provide education for patient/family for self-administration of therapy in future.
  • Education for family about bandaging
  • Fitting for compression garments

Additional Therapies

Support's development and hosting
  • Exercise: Lymph flow occurs as a result of inspiratory reduction in the intrathoracic pressure associated with inspiration. Best results are achieved with combination of flexibility, strength, and aerobic training (3)[B].
  • Compression with custom-made elastic stocking (minimum pressure 40 mm Hg):
    • Protection against external incidental trauma
    • Decreases the intrinsic trauma on the skin owing to chronically increased interstitial pressures, which cause stretch of the skin and subcutaneous tissues
    • No data on preference of custom made versus prefabricated
    • Replace every 3–6 months or when starting to lose elasticity (1)[B].
  • Multilayer bandaging: Inner layer of tubular stockinette followed by foam and padding to protect the joint flexures and to even out the contours of the limb so that pressure is distributed evenly; outer layer of at least 2 short-stretch extensible bandages; more effective than hosiery alone (1)[B]
  • Pneumatic pumps: Development of high pressure up to 150 mm Hg; can reduce limb girth by 37–68.6%; wear a compression stocking when not using pump; high risk of genital edema; no metastasis in limb owing to risk of spread (1)[B]

Complementary and Alternative Medicine

Heat therapy: Hot water immersion, microwave, and electromagnetic irradiation may be helpful (1)[C].

Surgery/Other Procedures

  • Debulking procedures (Charles procedure): Radical excision of subcutaneous tissue with primary or staged skin grafting:
    • Men had less improvement than women.
    • Main risk is infection and necrosis of the skin graft.
  • Bypass procedures: Creation of lymphatic–venous anastomosis: Reserved for highly refractory cases only

In-Patient Considerations

Initial Stabilization

  • May admit to specialized rehabilitation unit for combination treatment in patients with heart failure or severe pulmonary disease
  • IV antibiotics for infection

Admission Criteria

Systemic signs of infection

IV Fluids

Not used unless needed for sepsis


  • Leg elevation
  • Encourage patient mobilization/exercise.
  • Patient education for bandaging/wound care

Discharge Criteria

  • Resolution of signs/symptoms of infection (e.g., elevated white blood cell count, fever, abnormal vital signs)
  • Clinical improvement in wound appearance

Ongoing Care

Follow-Up Recommendations

Lymphedema will return in several days if patient stops wearing compression garments during the day and bandaging at night.

Patient Monitoring

  • Daily visit to therapist for acute treatment
  • Monthly visits for maintenance care


Low sodium

Patient Education

  • Use compression garments, especially when exercising.
  • Avoid affected limb(s) being dependant for long period of time: Patient should perform daily skin examination.


Good with daily care


  • Infection (local versus systemic): Common
  • Risk of wound formation (venous wounds/abrasions) that are difficult to heal: Common
  • Lymphangiosarcoma: Found in lymphedematous arms of patients following radical mastectomy; also in patients with Milroy disease; treatment is radiotherapy with surgery, reserved for patients with discrete nonmetastatic disease.


1. Warren A, et al. Lymphedema: A comprehensive review. Ann Plastic Surg. 2007;59(4):464–72.

2. Mortimer P. “implications of the Lymphatic System in CVI-Associated Edema.” Angiology. The Journal of Vascular Diseases 2000;51(1):3–7.

3. Brennan MJ, Miller LT. Overview of treatment options and review of the current role and use of compression garments, intermittent pumps, and exercise in the management of lymphedema. Cancer.1998;83:2821–7.

4. Tiwari A, Cheng KS, Button M, et al. Differential diagnosis, investigation, and current treatment of lower limb lymphedema. Arch Surg. 2003;138:152–61.



457.1 Other lymphedema


234097001 lymphedema (disorder)

Clinical Pearls

  • Use short-stretch bandages for wrapping (not ACE wraps).
  • Heat/whirlpool typically makes the wounds/lymphedema worse, not better.
  • Patients with lymphedema are at much higher risk for infection than patients with only venous insufficiency


About the author

Many tips are based on recent research, while others were known in ancient times. But they have all been proven to be effective. So keep this website close at hand and make the advice it offers a part of your daily life.