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Leg Lymphedema

Traditionally, leg lymphedema has been thought of as a primary and or hereditary lymphedema condition. However, with cancer treatment become much more effective and with so many more cancer patients not only surviving cancer but literally achieving a cure, more and more incidents of leg lymphedema are coming to the forefront. We have long understood breast cancer as a leading cause of secondary lymphedema, but the frightening truth is that as statistics are kept we are finding similar ratios among cancers survivors of all types.

In conjunction with this the medical community is slowly coming to a clearer understanding of other conditions that could trigger lymphedema as well.

I hope this page will provide leg “lymphers” with information that is both helpful and that can enable them to have a better quality of life and lifestyle. Our page Your Emotions and Self Image with Lymphedema give helpful tips and insights on facing the emotional challenge of lymphedema.

For information on leg see our page on lymphedema in children

Risk Factors for Leg Lymphedema

1.) Lymph node removal for biopsies

2.) Serious infections that include lymphangitis, cellulitis or erysipelas.

3.) Deep invasive wounds that might tear, cut or damage the lymphatics.

4.) Radiation treatments, especially ones that are focused in areas that might contain “clusters” of lymph nodes

5.) Morbid obesity can cause secondary lymphedema by “crushing” the lymphatics

6.) Serious burns, even intense sunburn

7.) Infection of the microscopic parasite filarial larvae, though this is more common in tropical countries

8.) For primary lymphedema any person who has a family history of unknown swelling of a limb

9.) Radiation and chemotherapy for cancer

10.) Insect bites

11.) Bone fractures and breaks

SECONDARY LEG LYMPHEDEMA

Related terms: leg swelling, leg edema, leg lymphoedema

Introduction

If you ask most people that are familiar with lymphedema the question, “Are you aware of secondary lymphedema,” most would reply that “yes, it is where the arm swells after the lymph system has been damaged by breast cancer biopsy and treatment.” This is called arm lymphedema.

Even if they are aware that such a condition as secondary leg lymphedema exists, their response might well be that it is a small group of afflicted men who have prostate cancer.

Thus shows how little awareness there is about this particular form of lymphedema. Even in the lymphedema world it is a poor step-child.

However, if the membership of Lymphedema People and the posts in the online lymphedema support groups are an indication, this condition is increasing dramatically.

The reasons for this increase are multiple. They include:

1. increased survival rates of cancer 2. improved treatment of trauma injuries that previously would have been terminal 3. increase in antibiotics for infections and treatment for other conditions that previously might have resulted in death.

It is also important to note that secondary leg lymphedema does not necessarily start immediately after the injury or trauma. It may not start for years.

What is secondary leg lymphedema?

Secondary lymphedema is a condition where the lymphatic system has been damaged. The main job of this system is to move excess through and out of our bodies. When it becomes damaged or impaired, it is no longer able to accomplish this function and these fluids (lymph fluids) collect in the interstitial tissues of our legs. This causes leg swelling.

Another important function of the lymph system is to help our bodies fight infections. With lymphedema, this ability is also weakened and the patient becomes more susceptible to infections.

What causes secondary leg lymphedema?

Secondary leg lymphedema (also referred to as acquired lymphedema) is caused by or can develop as a results of:

1.) Surgeries involving the abdomen or legs where the lymph system has been damaged. This includes any intrusive surgery.

Examples are

vein stripping surgery for peripheral vascular disease hip replacement knee replaement insertion of bolts, screws and other devices in orthopaedic repair lipectomy

2.) Removal of lymph nodes for cancer biopsy. These cancers include, but are not limited to

prostate cancer testicular cancer ovarian cancer uteran cancer vulva cancer bladder lymphoma - both hodgkins and non hodgkins melanoma colon Kaposi Sarcoma

3.) Radiation treatment of these cancers that scars the lymph system and lymph nodes

4. Some types of chemo therapy. For example, tamoxifen has been linked to secondary lymphedema and blood clots.

5.) Severe infections/sepsis. Generally referred to as lymphangitis, this is a serious life-threatening infection of the lymph system/nodes.

6.) Trauma injuries such as those experienced in an automobile accident that severly injures the leg and the lymph system.

7.) Burns - this even includes severe sunburn. We have a member that acquired secondary leg lymphedema from this.

8.) Bone breaks and fractures.

9.) Morbid obesity - the lymphatics are eventually crushed by the excessive weight. When that occurs, the damage is permanent and chronic secondary leg lymphedema begins.

10.)Insect bites

11.)Parasitic infections

What are some of the symptoms of secondary leg lymphedema?

These symptoms may include:

1.) Unexplained swelling of either part of or the entire leg. In early stage lymphedema, this swelling will actually do down during the night and/or periods of rest, causing the patient to think it is just a passing thing and ignore it.

2.) A feeling of heaviness or tightness in the leg

3.) Increaseing restriction on the range of motion for the leg.

4.) Unsual or unexplained aching or discomfort in the leg.

5.) Any change involving hardening and/or thicking of the skin or areas of skin on the leg.

STAGES OF LEG LYMPHEDEMA

There are three basic stages active of lymphedema. The earlier lymphedema is recognized and diagnosed, the easier it is to successful treat it and to avoid many of the complications.

It is important as well to be aware that when you have lymphedema, even in one limb there is always the possibility of another limb being affected at some later time. This “inactive” period referred to as the latency stage. It is associated with hereditary forms of lymphedema.

LATENCY STAGE

Lymphatic transport capacity is reduced No visible/palpable edema Subjective complaints are possible

STAGE I

(Reversible Lymphedema) Accumulation of protein rich edema fluid Pitting edema Reduces with elevation (no fibrosis)

STAGE II

(Spontaneously Irreversible Lymphedema) Accumulation of protein rich edema fluid Pitting becomes progressively more difficult Connective tissue proliferation (fibrosis)

STAGE III

(Lymphostatic Elephantiasis) Accumulation of protein rich edema fluid Non pitting Fibrosis and sclerosis (severe induration) Skin changes (papillomas, hyperkeratosis, etc.)

Treatment of Leg Lymphedema

The treatment for arm lymphedema is much the same as treatment for leg lymphedema. The preferred treatment is decongestive therapy.

Complications of leg lymphedema

1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immunodeficient and the proein rich fluid provides an excellent nurturing invironment for bacteria.

2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids. See Lymphedema and Pain Management.

4. Loss of Function due to the swelling and limb changes.

5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections. See also Thrombophlebitis

7. Sepsis, Gangrene are possibilities as a result of the infections.

8. Possible amputation of the limb.

9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as dry skin, splitting, plaques and nodules, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations.

12. Pain ranging from mild in early lymphedema to severe in late stage lymphedema.

13. Lymphatic cancers which can include angiosarcoma, lymphoma; Kaposi's Sarcoma; lymphangiosarcoma (Stewart_treves Syndrome); Cutaneous T-Cell lymphoma; Cutaneous B-Cell lymphoma; Pseudolymphomatous Cutaneous Angiosarcoma. See also: Primary Lymphedema and Cancer for a discussion and Lymphatic Cancers Secondary to Lymphedema.

Note: These cancers are rare and are usually associated with long term, untreated or improperply treated lymphedema. Typically occuring in stage three or four; quite rare in stage two.

14. Skin complications possible in stages 3 and 4 include papillomatosis; placques including “cobblestone” appearing placque; dermatofibroma; Skin Tags; Warts and Verrucas; Mycetoma skin fungus; dermatitis and many lymphedema patients report increased problems with psoriasis; eczema and shingles. I would suspect this may be due to again, the immunocompromised condition of the arm or leg afflicted with lymphedema.

15. Documented but rare complications in late stage also can include Lymphomatoid Papulosis; Cutis Marmorata; Acroangiodermatitis; Dermatolymphangioadenitis (DLA); Papillomatosis cutis carcinoides

16. Debilitating joint problems. This is caused by a combination of the excess fluid weight and the constant inflammatory process that accompanies lymphedema. As we have gotten older, many lymphedemapatients are having total knee replacement, total hip replacement, or total shoulder replacement while others are experiencing carpal tunnel syndrome and are having carpal tunnel surgery or experiencing shoulder problems associated with lymphedema and must haverotator cuff surgery

Stages of leg lymphedema

There are three basic stages active of lymphedema. The earlier lymphedema is recognized and diagnosed, the easier it is to successful treat it and to avoid many of the complications.

It is important as well to be aware that when you have lymphedema, even in one limb there is always the possibility of another limb being affected at some later time. This “inactive” period referred to as the latency stage. It is associated with hereditary forms of lymphedema.

LATENCY STAGE

Lymphatic transport capacity is reduced No visible/palpable edema Subjective complaints are possible

STAGE I

(Reversible Lymphedema) Accumulation of protein rich edema fluid Pitting edema Reduces with elevation (no fibrosis)

STAGE II

(Spontaneously Irreversible Lymphedema) Accumulation of protein rich edema fluid Pitting becomes progressively more difficult Connective tissue proliferation (fibrosis)

STAGE III

(Lymphostatic Elephantiasis) Accumulation of protein rich edema fluid Non pitting Fibrosis and sclerosis (severe induration) Skin changes (papillomas, hyperkeratosis, etc.)

Treatment of leg Lymphedema

The treatment for leg lymphedema is much the same as treatment for arm lymphedema. The preferred treatment is decongestive therapy. See also manual lymphatic drainage mld complex decongestive therapy cdt.

However, there is an important exception and that is pneumatic compression pumps should not be used in leg lymphedema.

During the course of treatment, the leg will be wrapped in compression bandages after the treatment session. Upon completion of the treatment, compression sleeves and leg garments will be prescribed.

There is one final and critical area pertaining to the treatment, control and management of lymphedema, and that is exercise. Not only is it vital for our over all health, it helps in weight control and is important for the movement of lymph fluid through our body. No matter the stage of lymphedema, underlying medical conditions or age, everyone of us should have a plan for exercises for lymphedema.

Sometimes too, the process we must go through to get our treatment covered is maddening to say the least. You made need to learn how_to_file_a_health_insurance_appeal to reverse a coverage or treatment denial and you may even have to learn the process how to file a complaint against your insurance company with your state commissioner.

Self Leg Massage

All the Lymphatic Drainage strokes are based on one principle motion.

Research has found that the initial lymphatics open up and the lymph angions are stimulated by a straight stretch, but even more so with a little lateral motion. After these 2 motions, we need to release completely to allow the initial lymphatics to close and the lymph to be sucked down the channels. In this zero pressure phase don’t completely disconnect from the skin, just return your pressure to nothing. Also don’t pull the skin back with you as you return, let it spring back by itself.

This basic motion may resemble a circle, and is called stationary circles. All motions are based on this principle.

In orienting this motion, we always want to push the lymph towards the correct nodes, so the last, lateral stretch motion should be going towards the nodes.

Think about moving water. Visualize those initial lymphatics just in the skin, stretch, opening them up, then release and wait for the lymph angions to pump the lymph down the vessel. Remember how superficial this is. If you are feeling muscle, or other tissue under the skin, you are pushing too hard.

Here are four points remember when performing Lymphatic Massage-

1. Correct pressure is deep enough so that you do not slide over the skin, but light enough so that you don’t feel anything below the skin. This is about 1-4 ounces. It is very common for massage therapists trained in Swedish or deep tissue to apply too much pressure with lymphatic drainage massage. Sometimes it is hard to believe that something so light could be effective. Always remember- you are working on skin. How much pressure does it take to deform the skin? Almost nothing. Remember- if you push too hard you collapse the initial lymphatic.

2. Direction of your stroke is of great importance, because we always want to push the lymph towards the correct nodes. If you push the lymph the wrong way, your work will not be effective.

3. Rhythm is very important because with the correct rhythm and speed, the initial lymphatics are opened, and then allowed to shut and then there is a little time that is given for that lymph to get sucked down along the vessel. An appropriate rhythm will also stimulate the parasympathetic nervous system, causing the client to relax.

4. Sequence means the order of the strokes. When we want to drain an area, we always start near the node that we are draining to. Always push the lymph toward the node. Then as we work, we move further and further away from the node, but always pushing the fluid back in the direction of the node. In this way we clear a path for the lymph to move, as well as create a suctioning effect that draws the lymph to the node.

Self Manual Lymph Drainage for the Lower Extremity

v Rules for MLD:

o The strokes should be made with arcing motions or half circle motions.

o Do not slide over your skin, but rather, keep your fingers in contact with your skin and stretch it gently over the underlying tissues.

o You should have NO PAIN.

o Each stroke should be done 10-15 times SLOWLY, taking about 2 seconds for each stroke.

o If redness occurs, you are pressing too hard.

o For lymphedema of BOTH legs, perform all moves on both sides.

o The best position to be in for this is seated reclined, or lying down and propped up slightly.

o Make sure you can make skin-to-skin contact for all of these strokes. They won't work when done over clothing.


1. Neck: Place the flats of your fingers on your opposite shoulder, in the triangular part just above the collarbone and next to your neck. Move your hand in an arcing motion stretching the skin forward and down towards your chest. Repeat this on the other side.

2. Armpit: Raise your arm (on the same side as the leg in which you have lymphedema), bend you elbow, and place the hand behind your head. Place the flat of your opposite hand in your armpit. Stretch the skin in an arcing motion up towards the neck.

3. Above the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) below the breast, but above the waist. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.

4. Below the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) on or just below the waist, but above your hip. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.

5. Deep (diaphragmatic) breathing: Place both open palms on top of each other below the belly button. Take a slow breath in and feel your belly rise up into your hands as it expands to take in the air. Then breath out and feel your belly sink in as the breath leaves you. As you get better at this you can use your hands to resist your stomach slightly as you breath in, and press in slightly with your hands as you breath out. Don’t get dizzy. Start with only 2 or 3 breaths and work up to 10 as you get stronger.

6. Groin: Place the flat of your hand on the front of your groin, right where your underwear falls. Make a scooping motion in the groin, rolling your hand from the thumb to the little finger. Imagine that your hands are the bottom of a water wheel.

7. Back of knee: Place the flat fingers of both hands behind your knee. Perform a scooping motion up towards the body.

8. Repeat steps 3, 4 and 6 (waist and groin areas)

A very special Thanks to Katy from

LymphedemaTherapists · Lymphedema Therapists

Tips on Wrapping a Lymphedema Leg

One of the best posts on how to wrap a leg…from LLLymphedema2@yahoo.com

Since you have the swelling in the feet (and toes), it is probably lymphedema, perhaps compounded with lipedema. The traditional bandaging technique is with a stockinet, then some artiflex (cotton padding), and lastly, the bandages. I bandage directly over the skin. The padding is supposed to even out if you should constrict some part of the bandaging, causing the lymph not to flow, but the bandages are really not like rubber bands – properly spaced and overlapped, they will not cause constriction – and the artiflex is a pain. The stockinet is just another thing to wash and dry. I went to www.bandages.com and found that they have new bandages that are thick enough to be used without layering (e.g. the stockinet and padding). Perhaps this is the way to go, or perhaps you want to bother with stockinets and padding. If you were seeing a therapist, they would also use foam instead of artiflex (just cotton padding). Some pictures of bandaging look absolutely monstrous. My so called therapist used some foam, etc., but I soon discovered that the leg went down more without it. The pad is supposed to “spread” the compression so there is no binding – but what really happens is all the elasticity of the bandages goes to compressing the FOAM – not compressing your leg. A little compression trickles down to the actual leg, but my experience was that the swelling went down better without the extra stuff. However, since this is against tradition, you should at least be aware if any part of your leg feels too tight, and, if so redo the bandages (which is at least an hour for two legs – and bandages that were OK while you were up and around can suddenly become too tight in the middle of the night – which means you have to get up and do it again.) Anyway, with or without stockinet and padding, here is one technique for bandaging:

materials (1 large leg not grossly larger than normal (I am 5'9” and the calf measure is 21” and I have wide, swollen feet - if you are substantially larger, you may need more)

optional: stockinet, artiflex, foam

required:

1 roll 1” professional strength masking tape. 1 ea 3” strip of heavy padding around the ankles 1 ea 1” x 5m medi-rip 2 ea 8 cm. x 5 m short stretch bandages 1 ea 10 cm x 10 m short stretch bandages 1 ea 6 cm x 5 m short stretch bandages.

Double for 2 legs, if you are very much larger than me, add another 1 ea 10 cm. x 5 m short stretch bandage for each leg.

I sit on my bed and have a low table I can rest my foot on, but two chairs will work also (one to sit on and one to put your foot on).

Wrap the 3” strip of heavy padding (or chock pads) around the ankles. The figure 8's you are making around your foot and from the foot onto the leg will tend to bind right at the intersection of the foot and leg (where the 90” turn is made. This is the only place padding is essential. Secure it with masking tape. Secure all the bandages after they have been wrapped with masking tape. Cut a lot of 5” strips of masking tape and have them ready. Stick them on the edge of the table, or a windowsill, or something.

First hold all the bandages so that you are drawing from the bottom of the bandage cylinder (the bandages rolled up are a cylinder), not the top. A little experimentation will show you that this is much easier.

Start with the 1” medi-rip (it is a self cohesive bandage, but looses some of the self cohesion with laundering). Use this tiny bandage to bandage along the toe line. That is, make the same arc that the joints of the toes to the feet make. Do not bind the toes. If you can, wrap each toe with it, but I find that this binds the toes and hurts, so I leave my toes unwrapped, even though they swell, but if you start with the larger short stretch bandages, there will be a half moon that swells even more (Since if you make a straight circle from just below the little toe to just below the big toe, this will leave some area of foot not bandaged and the lymph will be pushed into this area, and it will be worse than before. The little 1” medirip can be wrapped in a curved path that covers all of the foot. Overlap this 1” medirep by 1/2 and continue winding it around your foot until you get to the end of the arch, then take it up diagonally over the top of the foot, and you will still have enough bandage to wrap again just under the toe line again for a few wraps. The medi wrap has strands of elastic in an otherwise cotton strip, so pull the medirip tight (that is the elastic is extended, but not to the point of discomfort).

When you wrap the bandages, pull a bit at the end of each circle, but do not stretch them too hard, or with constant tension as far as they will stretch. You want them to exert a little spring, but don't strangle your legs. If you get them too tight, it will hurt, and you must undo your wrapping and redo it (a big pain). If you don't stretch them a little, they won't have much compression. Of course, it's always the bottom bandages on the feet that hurt, so you have to unwrap the whole deal to get to them.

Next,step 2 take a 8 cm. x 5 m short stretch bandage, and start at the tip of the foot, but do not bind any toes, and since you already have the medi-rip, allow a little breathing space to make sure you don't bind toes. Then wind around your foot overlapping the bandages by about 1/2 to 2/3 (I probably overlap 2/3) until you have gotten almost to the leg (your foot should be at a 90 degree angle to the leg, and for me this is 2 or 3 wraps), then go around the heel itself, and, as you come off the other side of the heel, take the bandage diagonally up on the top of the foot to just below the top of the first wrap (just under the bottom of the big toe), go around the bottom of the foot, and then bring the bandage back around the ankle just above the heel, then around the ankle, and back up diagonally across the top of the foot just like before, overlapping 1/2 to 2/3 of the previous path. This will make large figure 8s. Continue with the figure 8's each layer a little higher around the ankle, until you again are wrapping just in front of the leg (no more space to do another figure 8) and use the rest of the bandages going in straight circles (not figure 8's) around the ankles.

Next,step 3 take the second 8 cm x 5 meter short stretch bandage, and start at the base of the leg (around the ankles), go around once or twice, to anchor the bandage, then on the next turn go down around the bottom of the foot close to the heel, and then around the bottom of the foot and then over and up around the leg, then continue making figure 8's up the leg overlapping by about 2/3. To make a figure 8 around the leg, on one side of the front of the leg, the bandage is going uphill (or towards your knee), then it goes more or less straight around the back of the leg at the high end of the 8, then goes downhill (or towards the foot), as you come across the front of the leg again, then more or less straight across the back of the leg at the low end of the 8 and then up again for the next figure 8. On me, this bandage is finished just about at the beginning of the calf (a little above the bottom of the muscle – it would be ideal if this bandage ended just before the muscle begins, but it will be a bit different for everyone depending of how much they overlap and how large their leg is.

Next,step 4 do figure 8's with the 10 cm x 10 m bandage. Begin at the bottom of the leg with the beginning of the bandage facing upward, so the first direction is in a downward direction, (the end pointing up) coming around and then going up again. The 10 cm x 10 m bandage should take you up to just below the knee, but if the legs are very large, you may need another 10 cm. bandage. Each course of the figure 8 should overlap a little less or evenly, but not more than the previous course. The more you overlap the greater the compression, and you must always have less compression proximally (towards your heart) than distally (towards your toes).

Finally,step 5 take the last 6 cm. x 5 meter short stretch bandage and start at about mid calf or a little higher, and wind in straight circles until just below and as close as possible to the knee. This last bandage gives compression over the tops of the top 8's where there is not as much overlap, and sort of holds it all up, as the circumference of the leg is actually smaller at the knee than at the mid calf (doesn't slide down because a smaller circle would have to slide over a larger circumference of the leg).

I have been complemented on my ability to wrap, but It is hard to know if a novice can make much sense of my directions – but I tried. Look at some photographs of the bandaging while you are at www.bandages.com. You don't see to many photographs of the figure 8's, but they give more compression and stay up better, and bind less. You will get the general idea of winding up the leg, and overlap by looking at the photographs, however. It may seem complicated to follow my directions (I tried to be clear), but the real technique is not very hard at all.

The new thick bandages that do not need padding (padding is included) are : KomprimED. They are located on the bandagesplus web site under bandages, then under two way stretch bandages. I think you should start with these, as the padding may be more important for someone who is just beginning bandages. This is much simpler than all those stupid layers.

*Soft and comfortable directly on patient's skin *Thicker texture avoids application of foam and padding in many cases *Suitable for lymphedema and venous ulcers *Patient-friendly application requires less layers *All bandages are short-stretch/low stretch KomprimED 4cmx5m

Other wise, the standard short stretch bandages are rosidal or comprilan. I use rosidal. The medi-rip is under the section cohesive bandages on page 2 under the more general category bandages.

Lymphedema Of The Legs And Ankles

By Linda Fisher

The obstruction of the flow of lymph from a given area results in the accumulation of abnormally large amounts of tissue fluid in that area. Such an accumulation is called lymphedema. Lymphadema is not only uncomfortable, it may cause such problems as pain, infection and recurrent infection, difficulty in movement, clothing restrictions, and air travel restrictions.

Remembering that the lymph moves upward in the body toward the heart, from the finger tips in toward the heart, and from the top of the head down toward the heart, we can see that the fluid moving furthest in the body is from the lower extremities. Some causes of lymphedema of the lower extremities is congestive heart failure, trauma to the back or lower abdominal area, blockage in the groin (inguinal nodes), or blockage behind the knee (popliteal nodes).

I often use the analogy of a traffic accident on the freeway to explain movement of lymph. At the point of the accident, all traffic either stops or slows to a near halt, until the accident is cleared away, thus allowing the traffic to again flow naturally. Anatomically, at the point of blockage, everything slows down and begins to accumulate backward along the path of flow. If the feet and ankles are swollen, it generally means that there is a blockage “up ahead.”

Even in slender young people, we sometimes see signs of lymphedema in the legs. This appears as “heavy ankles” or as a little pouch of fat on the inside curve of the knee area. When present in this portion of the population, we usually find that the individual is not getting the right exercise and eating largely of the wrong foods, or just the opposite. Many joggers, tennis players, and aerobic exercise enthusiasts exercise and eat properly, but they get this problem because repeated hard impact will slow lymph movement.

In the middle age and senior group, we may see a different, but very common, problem - shuffling the feet instead of walking comfortably. When you cannot lift your feet to step properly, you may just accept that you probably have an “arthritic problem.” Many times, you may have a large mass of lymph fluid behind your knee that has pooled, and then hardened. Imagine the pain this would cause. It would be like strapping a tennis ball behind your knee and then attempting to walk!

There is more than one cause of lymphedema in the lower extremities. The ones mentioned above are just some of the more common ones.

Tips to Avoid Blockage:

Do not wear tight jeans or tight under garments. Do not cross the knees when sitting; cross feet at the ankles instead. For the exercise enthusiast, integrate some form of slow, rhythmic exercise - yoga and pilates are excellent, as is walking. Bouncing on a trampoline is excellent - no need to jump. Bend your knees and get a gentle bounce going for a minimum of 12-15 minutes a day. If balance is a concern, hold onto a stationary item or purchase a balance bar that attaches to your trampoline. Also, if wheel chair bound, place your feet on the trampoline and have someone else bounce it for you - you will receive a positive benefit from this. Lie on a slant board. And, as always, drink plenty of clean water, practice deep belly-breathing, and eat plenty of fresh, unprocessed foods. Caution: In the case of congestive heart failure, be absolutely sure to check with your health care practitioner before attempting any form of exercise and, of course, no slant-boarding! “Creating free lymphatic movement through the body is a vital part of any healing process.”

Linda Fisher owns the Lympathic Wellness Center in Santa Maria.

Lymphedema of the Leg

What can cause lymphedema of the leg? Can lymphedema of the leg become worse?

Lymphedema are classified on the basis of their origins. Two form of lymph-edema of the leg that occur frequently are described below.

A) PRIMARY LYMPHEDEMA OF THE LEG

The cause is a congenital malfunction of the lymphatic system which results in lymphedema of the leg that often begins with peripheral edema. There is swelling of the foot and lower high. If this goes untreated, the entire leg may become endematous. Since the patient discovers the condition only after the foot begins to swell, it is difficult to take the preventive measures.

Primary Lymphedema can be present at birth, but it may also develop later on. The swelling usually starts during puberty. Diagnosing congenital lymphatic vessel malformation without the presence of lymphedema is very difficult.

B) SECONDARY LYMPHEDEMA OF THE LEG

The causes:

- surgical severing of lymphatic vessels

- removal of lymph nodes in the groin and/or in the true pelvis

- accidental trauma to the lymph passages of the legs, e.g.g when a bone is broken as the result of a strong blow to the upper thigh, etc.

- radiotherapy of the groin area, the lower abdomen, or the lower lumbar vertebrae

- inflammation of the lymphatic vessels or the blood vessels of the leg or thepelvic region.

The result is lymphedema of the leg which frequently begins centrally. Lymphedema then spreads relatively rapidly to the entire leg.

If there is no actual edema and “only” the preconditions for lymphedema of the leg are present, the condition is termed “predisposition to edema.” At this stage it is important to take preventive measures.

Although lymphedema of the leg and/or the trunk after an abdominal operation does not constitute a threat to the life of the patient, it can according to Stillwell”….. often be the source of considerable physical and mental suffering and occasionally even cause disability.”

Untreated, lymphedema will get progressively worse, and a case of mild edema can degenerate with hardening of the tissues as a result of fibrosis or scleroses. Morever, long-term untreated lymphedema may lead to a form of cancer.

Wittlinger

Lower limb and leg lymphedema

Just as lymphedema of the upper extremities can become a complication after post surgical removal of breast cancer, lymphedema of the lower extremities can be a debilitating condition with several cancers. Prostate, lung, liver, lymphomas, ovarian, and abdominal cancers can cause swelling of the legs. The swelling can come from any compression or surgical removal of the lymph nodes in the lower body. It can also come secondarily to production of fluid into the abdomen (ascites) which spreads into the legs. When under treatment for any cancer, if your protein levels fall into lower levels, fluid will leak into your whole body including legs

When you first notice swelling in your legs, you need to act to reverse it. Once you let the legs blow up to large size, it is harder to reverse the process. This must be discussed with your doctor. The use of elastic stockings with at least 30 mm hg pressure is the first step. If the edema is only at the ankles and feet, then you only need stocking to the knee. Any medical supply store can help fit the stockings. You should read the package and measure your ankle,calf and the length from the knee to the heel so that you are sure that they fit you correctly. These measurements are usually listed on the box. If the edema goes up to the knee or past, you will need thigh high stockings. You must keep pulling these up as the stocking fall down with wear during the day. The stockings are all hard to apply. You need someone with strong hands. Sometimes it helps to wear rubber gloves to get a better grip on the stockings. There are also leotards for edema that goes above the thigh. When you apply these stockings, they should be perfectly smooth. If you leave wrinkles, it will become painful underneath or you can cut the circulation in that spot. The stockings should be worn through the day from when you first get up. You do not sleep with them on. At night you remove the elastic hose and elevate your legs on pillows in the bed. Try to get them above your heart. You can wrap legs with elastic wraps.

This is difficult to do correctly. The wraps should be on a diagonal. If you go in straight circles, you could end up with a turnicate like constriction of the leg and make the edema worse. If you develop numbness in your toes or coldness, that means that you have wrapped it too tightly. You should totally remove it and apply it again.

For men, often the edema will go up into the scrotum. You should also elevate your penis at night to try to empty the water back in to the abdomen. Wearing a jock strap helps support the heavy and often painful scrotal sack when you are up and about.

When the edema is not responding, you can use the external pump devices if so desired. These devices can be rented from a medical supply house. They are usually covered by insurances. After pumping you must then wear the elastic stockings until bed time. You pump daily for 2-3 weeks to get the severe edema under control. You can also go to outpatient physical therapy or edema clinics for treatments.

When you are sitting you need to elevate your legs during the day or lie down at intervals with the legs elevated on pillows. Do not wear tight shoes as any kind of constriction only adds to the edema above or below the constriction. You must also be very careful not to cut yourself or open the skin. You must immediately see an MD if you have a weeping sore. It will take careful treatment to heal it without infection developing. Sometimes antibiotics are necessary.

Exercises like pumping your feet up and down, leg kicks, going up and down on your toes in standing will help decrease edema. A regular exercise program of walking, exercise with light weights or any kind of movement activity is also helpful. In some instances, decreasing your salt intake becomes necessary.

Other precautions are to be careful with heat or ice on severely swollen legs. That includes your shower or bath water. Bathe legs with regular soaps and rinse well. If you develop athlete's foot, be sure to treat it with one of the common sprays or powders. Be careful cutting your toenail. Get treatment for ingrown toe nails. The problems are more complex when severe edema is involved.

Cancer Supportive Care

PREVENTATIVE STEPS FOR LEG LYMPHEDEMA

For the patient who is at risk of developing Lymphedema, and for the patient who has developed Lymphedema.

WHO IS AT RISK? At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, Lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity Lymphedema, see What is Lymphedema?) The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.

1. Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).

2. Never allow an injection or a blood drawing in the affected leg(s). Wear a LYMPHEDEMA ALERT Necklace.

3. Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.

4. Avoid vigorous, repetitive movements against resistance with the affected legs.

5. Do not wear socks, stockings or undergarments with tight elastic bands.

6. Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.

7. Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)

8. When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).

9. Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.

10. When travelling by air, patients with Lymphedema and those at-risk should wear a well-fitted compression stocking. For those with Lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.

11. Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.

12. Patients who have Lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.

13. Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of Lymphedema.

14. Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.

15. Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot. Dry feet carefully after swimming.

16. See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).

17. Wear clean socks & hosiery at all times.

18. Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings. Powder behind the knee often helps, preventing rubbing and irritation.

Unfortunately, prevention is not a cure. But, as a cancer and/or Lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your Lymphedema.

Revised © January 2001 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259.

Foot care for Lower Extremity Lymphedema

Foot care for Lower Extremity Lymphedema

Keith Smiley

The National lymphedema network NLN has been flooded with questions regarding foot and ankle care for patients with lower extremity lymphedema. Dr. Joseph Hewitson, a San Francisco Podiatrist, who has worked with many lymphedema patients, provided NLN a list of guidelines and suggestions for proper foot care for people suffering from lower extremity lymphedema. These guidlelines are excerpted from The July NLN newsletter.

Nail Care

Be sure to trim your toenails, but not necessarily straight across. If the corners have grown into the skin, trim the offending border.

If you get an infection, you should remove that side of the nail to resolve the infection. Antibiotics often will not work because an abscess (walled off infection) has occurred. Soaking may only provide temporary relief.

A lymphedema patient should never undergo a chemical matrisectomy (destroying root growth matrix with a chemical to permanently remove nail).

Fungal nails are common in lymphedema patients and should be soaked in 1:1 vinegar/water solution for 20 minutes, with antifungal solution applied afterwards.

Routine foot care every three months with a podiatrist if possible or your physician.

Meticulous nail care decreases the chance for inflammation and infection.

Taking Care of Your Toes

The inner spaces between your toes need to be kept clean and dry.

Soaking in a 1:1 vinegar/water solution for 20 minutes at least once a week and running a piece of gauze between your toes to remove any debris will help keep your web spaces clean.

Using a drying agent/antifungal solution like Castelani's Paint decrease chances of irritation and infection.

Applying lambs wool (see your pharmacist) between the toes allows the web greater breathability.

Open toed compression garments will also allow greater breathability, as will breathable footwear that is fitted correctly.

Dr. Hewitson says that proper footwear is very important. He says always buy your shoes at the time of day when your foot is most swollen (usually the end of the day). If you wear a compression garment, make sure you fit your shoes to accommodate this. Good athletic shoes are excellent to wear because they are more supportive, and more breathable. For very large feet, a Velcro strap shoe is usually more accommodating.

If you have painful corns and calluses, they should be routinely trimmed by a podiatrist or practitioner. Never use any callous removal pads, because they can cause burns and infections.

Dr. Hewitson also says to always work with reputable practitioners who are willing to further educate themselves on lymphedema. He adds, you may be their best and only teacher.

Suite 101

…………..

Related article with more foot care tips:

Skin Care from Tri-State Lymphedema Clinic

The skin is the body's first line of defense. It protects the body from trauma and infection and aids in temperature regulation. Therefore it is essential to keep the skin healthy. Individuals who have had any impairment of the lymphatic system are especially at risk for developing an infection. Any small cut or abrasion can allow bacteria to enter the skin and the stagnant lymphatic fluid is a perfect milieu in which bacteria can grow.

Simple measures which will promote healthy skin:

1. Inspect the skin daily for any crack, cuts or dry areas. Check carefully areas with reduced sensation or where there are skin folds.

2. Clean skin daily with non-perfumed soap

3. Dry skin completely, especially the area between the toes

4. Keep skin supple. Use a Iow pH lotion as Eucerin to keep the skin moist and pliable.

5. Check fingernails and toenails for any signs of infection, cracks, fungus, or hangnails. Do not cut nails or cuticles. Use an emery board.

6. Call your doctor at the first signs of any infection, redness or high temperature.

Foot Care for the at Risk Patient

People who have lymphedema, diabetes or vascular disease are at risk for infections.

Helpful hints:

1. To care for corns and calluses, do not use over the counter medications such as Dr. Scholl's corn pads as they contain acid. After the bath or shower, when the skin is softened, buff the skin to remove the dead skin and soften calluses.

2. Corns can develop between the 4th and 5th toes as the foot swells. Fungus can also develop, which can lead to infections. Changing to larger or wider shoes may alleviate the development of corns. Use lambs wool in between the toes to reduce friction.

3. When you trim your toe nails, round the edges to prevent ingrown toenails. Boil clippers for one minute and let cool for one hour before using.

4. Dry you feet very well after bathing, especially between the toes. Do not use alcohol on your feet. Use a Iow pH lotion.

5. If you are unable to cut your toe nails, see a Podiatrist regularly.

Lymph.com

For information on nail care, see our page How To Have Healthy Nails

See also our page on Foot Care for Lymphedema

Elective amputation of the toes in severe lymphedema of the lower leg: rationale and indications.

Ann Plast Surg. 2009 Aug;

Chen HC, Gharb BB, Salgado CJ, Rampazzo A, Xu E, di Spilimbergo SS, Su S.

Department of Plastic Surgery, E-Da Hospital/I-Shou University, Taiwan.

Entry lesions at the toes interdigital spaces, in the setting of chronic lymphedema, are strongly associated with repetitive infective episodes which cause significant morbidity. A prospective study was designed to evaluate the outcome in 2 groups of patients affected by end stage III lymphedema of the lower extremity, treated with the Charles procedure with or without simultaneous amputation of the toes.

At a mean 3 years of follow-up, 20% of the patients receiving elective toes amputation experienced recurrence of the infection and none required more proximal amputations. Among the patients not desiring elective toes amputation; 83% suffered multiples attacks of cellulitis and in 88% the toes were eventually amputated. The difference in the number of infective episodes between the 2 groups was highly significant. No cases of recurrent lymphedema were registered. Elective toes amputation in combination with the Charles procedure reduces recurrent cellulitis and long-term morbidity in stage III lymphedema of the lower leg.

*Please note this abstract included for information purposes only. Posting it does NOT constitute an endorsement of the procedure or the rationale for the procedure.*

Lippincott, Williams & Wilkins

ARTICLES FROM OUR FORUM ON LEG LYMPHEDEMA

Additional Lymphedema People links

ABSTRACTS AND ARTICLES

Lower extremity glandography (LEG): a new concept to identify and enhance lymphatic preservation.

Int J Gynecol Cancer. 2011 Apr

Burnett AF, Stone PJ, Klimberg SV, Gregory JL, Roman JR.

Source

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA. aburnett@uams.edu Abstract

BACKGROUND: Lower extremity edema remains a major postoperative complication after inguinal lymphadenectomy for vulvar cancer. This study documents the lymphatic drainage of the vulva versus the lymphatic drainage of the lower extremity coming through the femoral triangle.

METHODS: Seven patients underwent either unilateral or bilateral inguinal lymphadenectomy in conjunction with a radical vulvar resection. Preoperatively, patients had technetium-99 injected into the vulvar cancer. Isosulfan blue was injected into the medioanterior thigh 10 cm below the inguinal ligament. The femoral triangle was opened, and a neoprobe was used to locate the “hot” node bearing the technetium-99. Gentle dissection located the blue lymphatic channel and any blue lymph nodes. The blue and hot nodes were resected and submitted separately. The patients then underwent a complete inguinal lymphadenectomy.

RESULTS: A total of 11 groin dissections were performed. In 9 of the 11 groins, the hot node was identified, and in 8 of the 11 groins, blue node or lymphatic channel was identified. The hot nodes were uniformly located on the superior medial aspect of the femoral triangle. The blue nodes were uniformly located on the lateral aspect of the femoral triangle just anterior to the femoral artery or vein. Three patients had hot lymph nodes containing cancer. Of those 3 patients, one had an additional node positive. None of the blue lymph nodes contained cancer.

CONCLUSIONS: This procedure demonstrates the alternative lymphatic drainage of the leg versus the vulva. Larger studies are necessary to document the exclusivity of these 2 drainage systems. Preservation of the lymphatic drainage of the leg may result in decreased lymphedema.

Lippincott,Williams and Wilkins

Venous dynamics in leg lymphedema.

Kim DI, Huh S, Hwang JH, Kim YI, Lee BB.

Division of Vascular Surgery, Samsung Medical Center, College of Medicine, Sung kyun kwan University, Seoul, Korea.

To determine whether there is anatomical and/or functional impairment to venous return in patients with lymphedema, we examined venous dynamics in 41 patients with unilateral leg lymphedema. A Volometer was used for computer analysis of leg volume, a color Duplex Doppler scanner was used to determine deep vein patency and skin thickness, and Air-plethysmography was used to assess ambulatory venous pressure, venous volume, venous filling index and the ejection fraction. In the lymphedematous leg, volume and skin thickness were uniformly increased (126.4 +/- 21.3% and 156.9 +/- 44.5%) (mean +/- S.D.), respectively. The ambulatory venous pressure was also increased (134 +/- 60.7%) as was the venous volume (124.5 +/- 37.5%), and the venous filling index (134.5 +/- 50.5%). The ejection fraction was decreased (94.9 +/- 26.1%). Greater leg volume correlated with increased venous volume and venous filling index (values = 0.327, 0.241, respectively) and decreased ejection fraction (r = -0.133). Increased subcutaneous thickness correlated with increased venous filling index and venous volume (r = 0.307, 0.126, respectively) and decreased ejection fraction (r = -0.202). These findings suggest that soft tissue edema from lymphatic stasis gradually impedes venous return which in turn aggravates the underlying lymphedema.

Pub Med

Limb Positioning and Movement For Lymphedema Patients

Careful positioning of an affected limb when resting or sitting can help to prevent further swelling. You can also use gravity to help drain away excess fluid. Avoid standing or sitting with your legs down if you can, as this allows fluid to pool around your feet and calves. Movement of your muscles helps to push fluid around the body, so regular gentle movement can help to prevent fluid accumulating.

These guidelines will help you to position your affected limb correctly

Don't cross your legs when you are sitting.

Don't sit with your legs down for long periods – either lie with your legs up on a pillow, or have them fully supported on a footstool.

Try not to stand still for long periods of time. If standing is unavoidable, do the following exercises to stimulate the pump action of your muscles: raise yourself up on to your toes frequently to tense and relax your calf muscles; shift your weight from one leg to the other and transfer your weight from heels to toes, as if walking on the spot.

Lymphedema Care

Swollen leg and primary lymphoedema.

Wright NB, Carty HM.

Department of Radiology, Royal Liverpool Children's NHS Trust.

Children who present with unilateral or bilateral swelling of the legs are often suspected of having a deep venous thrombosis. The incidence of deep venous thrombosis in children is low and lymphoedema may be a more appropriate diagnosis. Lymphoedema can be primary or secondary. In childhood, primary lymphoedema is more common and may be seen associated with other congenital abnormalities, such as cardiac anomalies or gonadal dysgenesis. Primary hypoplastic lymphoedema is the most often encountered type. It is more common in girls, especially around puberty, and is typically painless. Atypical presentations produce diagnostic confusion and may require imaging to confirm the presence, extent, and precise anatomical nature of the lymphatic dysplasia. This article describes four patients presenting with limb pain and reviews the clinical features and imaging options in children with suspected lymphoedema.

Publication Types: · Case Reports PMID: 8067792 [PubMed - indexed for MEDLINE]

PubMed

Primary lymphedema of the leg: relationship between subcutaneous tissue pressure, intramuscular pressure and venous function.

Christenson JT, Hamad MM, Shawa NJ.

In eight patients with unilateral primary lymphedema, subcutaneous tissue and intramuscular pressure were measured in both legs using the slit-catheter technique. Venous function was assessed by venography, or Doppler or photoplethysmography. Both at rest and during exercise, subcutaneous tissue pressure was elevated in the lymphedematous leg (17.9 +/- 7.6 and 33.0 +/- 10.8 mmHg respectively) compared to healthy contralateral leg (0.4 +/- 2.6 and -0.6 +/- 3.6 mmHg; p less than 0.001). The intramuscular pressure in the anterior tibial compartment was also increased at rest and during exercise in the edematous leg (24.9 +/- 4.4 mmHg and 43.6 +/- 11.2 mmHg respectively) compared to control leg (9.6 +/- 5.6 and 25.8 +/- 10.00 mmHg). These findings suggest that derangements in both the superficial and deep lymphatic systems as well as venous dysfunction contribute to the clinical appearance of “primary lymphedema.”

PMID: 4033199 [PubMed - indexed for MEDLINE]

Pub Med

Effect of venous and lymphatic congestion on lymph capillary pressure of the skin in healthy volunteers and patients with lymph edema.

Gretener SB, Lauchli S, Leu AJ, Koppensteiner R, Franzeck UK.

Division of Vascular Medicine (Angiology), Department of Medicine, University Hospital, Zurich, Switzerland.

The aim of the present study was to assess the influence of venous and lymphatic congestion on lymph capillary pressure (LCP) in the skin of the foot dorsum of healthy volunteers and of patients with lymph edema. LCP was measured at the foot dorsum of 12 patients with lymph edema and 18 healthy volunteers using the servo-nulling technique. Glass micropipettes (7-9 microm) were inserted under microscopic control into lymphatic microvessels visualized by fluorescence microlymphography before and during venous congestion. Venous and lymphatic congestion was attained by cuff compression (50 mm Hg) at the thigh level. Simultaneously, the capillary filtration rate was measured using strain gauge plethysmography. The mean LCP in patients with lymph edema increased significantly (p < 0.05) during congestion (15.7 +/- 8.8 mm Hg) compared to the control value (12.2 +/- 8.9 mm Hg). The corresponding values of LCP in healthy volunteers were 4.3 +/- 2.6 mm Hg during congestion and 2.6 +/- 2.8 mm Hg during control conditions (p < 0.01). The mean increase in LCP in patients with lymph edema was 3.4 +/- 4.1 mm Hg, and 1.7 +/- 2.0 mm Hg in healthy volunteers (NS). The maximum spread of the lymph capillary network in patients increased from 13.9 +/- 6.8 mm before congestion to 18.8 +/- 8.2 mm during thigh compression (p < 0.05). No increase could be observed in healthy subjects. In summary, venous and lymphatic congestion by cuff compression at the thigh level results in a significant increase in LCP in healthy volunteers as well as in patients with lymph edema. The increased spread of the contrast medium in the superficial microlymphatics in lymph edema patients indicates a compensatory mechanism for lymphatic drainage during congestion of the veins and lymph collectors of the leg. Copyright 2000 S. Karger AG, Basel

Publication Types: · Clinical Trial PMID: 10720887 [PubMed - indexed for MEDLINE]

Pub Med

Effect of sequential intermittent pneumatic compression on both leg lymphedema volume and on lymph transport as semi-quantitatively evaluated by lymphoscintigraphy.

Miranda F Jr, Perez MC, Castiglioni ML, Juliano Y, Amorim JE, Nakano LC, de Barros N Jr, Lustre WG, Burihan E.

Vascular Surgery Division, Federal University of Sao Paulo, Paulista School of Medicine, SP, Brazil. fmirandajr.dcir@epm.br

Sequential Intermittent Pneumatic Compression (SIPC) is an accepted method for treatment of peripheral lymphedema. This prospective study evaluated the effect in 11 patients of a single session of SIPC on both lymphedema volume of the leg and isotope lymphography (99Tc dextran) before SIPC (control) and 48 hours later after a 3 hour session of SIPC. Qualitative analysis of the 2 lymphoscintigrams (LS) was done by image interpretation by 3 physicians on a blind study protocol. The LS protocol attributed an index score based on the following variables: appearance, density and number of lymphatics, dermal backflow and collateral lymphatics in leg and thigh, visualization and intensity of popliteal and inguinal lymph nodes. Volume of the leg edema was evaluated by measuring limb circumference before and after SIPC at 6 designated sites. Whereas there was a significant reduction of circumference in the leg after SIPC (p<0.05), there was no significant difference in the index scores of the LS before and after treatment. This acute or single session SIPC suggests that compression increased transport of lymph fluid (i.e., water) without comparable transport of macromolecules (i.e., protein). Alternatively, SIPC reduced lymphedema by decreasing blood capillary filtration (lymph formation) rather than by accelerating lymph return thereby restoring the balance in lymph kinetics responsible for edema in the first place.

PMID: 11549125 [PubMed - indexed for MEDLINE]

Pub Med

Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg.

Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. J Reconstr Microsurg. 2003 May;19(4):209-15.

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Dentistry, Okayama University, Japan.

Over the last 9 years, the authors analyzed lymphedema of the lower extremity in a total of 25 patients, comparing the use of supermicrosurgical lymphaticovenular anastomosis and/or conservative treatment. The most common cause of edema was hysterectomy, with or without subsequent radiation therapy for uterine cancer. Among 12 cases that underwent only conservative treatment, only one case showed a decrease of over 4 cm in the circumference of the lower leg. The average period for conservative treatment was 1.5 years, and the average decreased circumference was 0.6 cm (8 percent of the preoperative excess). Thirteen patients were followed after lymphaticovenular anastomoses, as well as pre- and postoperative conservative treatment. The average follow-up after surgery was 3.3 years, and eight patients showed a reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference, excluding edema in the bilateral leg, was 4.7 cm (55.6 percent of the preoperative excess). These results indicate that supermicrosurgical lymphaticovenular anastomosis has a valuable place in the treatment of lymphedema.

Publication Types: · Case Reports PMID: 12858242 [PubMed - indexed for MEDLINE]

Pub Med

Minimal Invasive Lymphaticovenular Anastomosis Under Local Anesthesia for Leg Lymphedema: Is It Effective for Stage III and IV?

Annals of Plastic Surgery. 53(3):261-266, September 2004. Koshima, Isao MD; Nanba, Yuzaburo MD; Tsutsui, Tetsuya MD; Takahashi, Yoshio MD; Itoh, Seiko MD; Fujitsu, Misako MD

Abstract: This is the first report on the effectiveness of minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema. Fifty-two patients (age: 15 to 78 years old; 8 males, 44 females) were treated with lymphaticovenular anastomoses under local anesthesia and by postoperative compression using elastic stockings. The average duration of edema of these patients before treatment was 5.3 +/- 5.0 years. The average number of anastomosis in each patient was 2.1 +/- 1.2 (1-5). The patients were followed for an average of 14.5 +/- 10.2 months, and the result were considered effective (82.5%) even for the patients with stage III (progressive edema with acute lymphangitis) and IV (fibrolymphedema), but others showed no improvement. Among these cases, 17 patients showed reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference excluding edema in bilateral legs was 41.8 +/- 31.2% of the preoperative excess length. These results indicate that minimal invasive lymphaticovenular anastomosis under a local anesthesia is valuable instead of general anesthesia.

Lippincott Williams & Wilkins

Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care.

2011 Jun

Levell NJ, Wingfield CG, Garioch JJ.

Source

Dermatology Department, Norfolk and Norwich University Hospital, Norwich NR4 7UY, U.K.

Abstract Background:  Cellulitis is responsible for over 400 000 bed days per year in the English National Health Service (NHS) at the cost of £96 million.

Objectives:  An audit following transfer of care of lower limb cellulitis managed in secondary care from general physicians to dermatologists.

Methods:  Review of patient details and work diaries from the first 40 months of implementation of the new model of care.

Results:  Of 635 patients referred with lower limb cellulitis 33% had other diagnoses which did not require admission. Four hundred and seven of 425 patients with cellulitis were managed entirely as outpatients, many at home. Twenty-eight per cent of patients with cellulitis had an underlying skin disease identified and treated, which is likely to have reduced the risk of recurrent cellulitis, leg ulceration and lymphoedema. Only 18 of 635 patients referred with lower limb cellulitis required hospital admission for conventional treatment. Conclusions  This new way of managing suspected lower limb cellulitis offered substantial savings for the NHS, and benefits of early and accurate diagnosis with correct home treatment for patients.

Wiley Online

Growth factor therapy and autologous lymph node transfer in lymphedema.

Growth factor therapy and autologous lymph node transfer in lymphedema. 2011 Feb 15

Lähteenvuo M, Honkonen K, Tervala T, Tammela T, Suominen E, Lähteenvuo J, Kholová I, Alitalo K, Ylä-Herttuala S, Saaristo A.

Source

Plastic Surgery, Turku University Central Hospital, Finland.

Abstract

BACKGROUND: Lymphedema after surgery, infection, or radiation therapy is a common and often incurable problem. Application of lymphangiogenic growth factors has been shown to induce lymphangiogenesis and to reduce tissue edema. The therapeutic effect of autologous lymph node transfer combined with adenoviral growth factor expression was evaluated in a newly established porcine model of limb lymphedema.

METHODS AND RESULTS: The lymphatic vasculature was destroyed within a 3-cm radius around an inguinal lymph node. Lymph node grafts and adenovirally (Ad) delivered vascular endothelial growth factor (VEGF)-C (n=5) or VEGF-D (n=9) were used to reconstruct the lymphatic network in the inguinal area; AdLacZ (β-galactosidase; n=5) served as a control. Both growth factors induced robust growth of new lymphatic vessels in the defect area, and postoperative lymphatic drainage was significantly improved in the VEGF-C/D-treated pigs compared with controls. The structure of the transferred lymph nodes was best preserved in the VEGF-C-treated pigs. Interestingly, VEGF-D transiently increased accumulation of seroma fluid in the operated inguinal region postoperatively, whereas VEGF-C did not have this side effect.

CONCLUSIONS: These results show that growth factor gene therapy coupled with lymph node transfer can be used to repair damaged lymphatic networks in a large animal model and provide a basis for future clinical trials of the treatment of lymphedema.

PubMed

Additional Links

Intensive decongestive treatment restores ability to work in patients with advanced forms of primary and secondary lower extremity lymphoedema. Dec 2011

PubMed

Lymphatic dysfunction in the apparently clinically normal contralateral limbs of patients with unilateral lower limb swelling. Jan 2012

Clinical Nuclear Medicine

LYMPHEDEMA LEG GARMENTS, SLEEVES AND GARMENTS

These are garments that are designed to help control the swelling and should be utilized after you have undergone treatment to reduce to the size of your arm. They are also used inconjunction with compression bandage wrapping.

Suppliers of arm wraps, compression garments and sleeves

DIAGNOSTIC ICD-9 CODES and PROCEDURE CODES

ICD-9 Codes

Covered ICD-9-CM Edema or Lymphedema Codes

   125.0-125.9      Filarial lymphedema
   457.0                Post-mastectomy lymphedema syndrome
   457.1                Other lymphedema (praecox, secondary, acquired/chronic,    elephantiasis)
   457.2                Lymphangitis
   457.8                Other noninfectious disorders of lymphatic channels (chylous disorders)
   624.8                Vulvar lymphedema
   729.81              Swelling of limb
   757.0                Congenital lymphedema (of legs), chronic hereditary, ideopathic hereditary
   782.3                Edema of Legs-Acute traumatic edema

HCPCS Procedure Codes

Procedure A manipulation of the body to give a treatment or perform a test; more broadly, any distinct service a doctor renders to a patient. All distinct physician services have ‘procedure codes’ in various payment schemes.

   97001 or 97003 initial evaluation by a physical or an occupational therapist, or an   Evaluation and Management CPT Code for physicians.
   97002 or 97004 re-evaluation by a physical or an occupational therapist,  or an     E valuation and Management CPT Code for physicians.
   97110  Therapeutic exercises
   97016  Vasopneumatic Pump
   97124  Massage therapy for edema of an extremity
   97140  Manual therapy, manual lymphatic drainage (15 minute units)
   97150  Group therapy
   97504  Orthotic training/fitting
   97530  Therapeutic activities, restoration of impaired function
   97535  Self-care home management training, instruction on bandaging,  exercises, and   self-care
   97703  Checkout for orthotic or prosthetic use

Item Codes

The items and supplies listed below are considered “incident to” a physician service and are not separately reimbursable. However, if these supplies are given to a patient as a take home supply, the claim should be submitted to the DMERC.

Code Description

  
   A4454               Tape
  A4460               Elastic bandage (e.g. compression bandage). Use this code to report compression bandages associated with lymphatic drainage
                            (CIM 60-9, MCM 2133, ASC)
   A4465               Non-elastic binder for extremity. Use for Reid, CircAid, ArmAssist, etc                               manually-adjustable sleeves and leggings. Medicare jurisdiction DME                               regional carrier (CIM 60-9, MCM 2133, ASC)
   A4490-4510   Surgical Stockings
   A4490          Surgical Stockings above knee length (each)
   A4495          Surgical Stockings thigh length (each)
   A4500          Surgical Stockings below knee length (each)
   A4510          Surgical Stockings full length (each)
   A4649          Miscellaneous Surgical Supplies, Compression bandaging kit
   E0650-0652     Pneumatic Compressor and Appliances
   E0650               Pneumatic Compressor, non-segmental home model
   E0651          Pneumatic Compressor, segmental home model, without calibrated                                         gradient pressure
   E0652          Pneumatic Compressor, segmental home model, with calibrated                                         gradient pressure
   E0655-0673     Arm and Leg Appliances used with Pneumatic Compressor
   L0100-L4398      Orthotics
   L2999          Lower Limb Orthosis, not otherwise specified
   L3999          Upper Limb Orthosis, not otherwise specified
   L4205          Repair of orthotic device, labor, per 15 minutes
   L4210          Repair of orthotic device, repair or replace minor parts
   L5000-L5999   Lower Limb
   L6000-L7499   Upper Limb
   L8000-8490     Prosthetics
   L8010              Mastectomy Sleeve, Ready-Made
   L8100-L8239   Elastic supports
   L8100-8195     Elastic Supports, elastic stockings various lengths & weights
   L8210             Gradient compression stocking, custom made
   L8220             Gradient compression stocking/sleeve, Lymphedema, Custom
   L8239             Gradient stocking, not otherwise specified. Carrier discretion.

Diagnostic Images

Leg Lymphedema with extreme inflammation. Note how slight the lymphedema is, but it still had this terrible inflammation and infection. From: Texas Wound Center

The following are pages from Lymphedema People:

Parked Pitting Edema

Mild leg lymphedema

Moderate foot edema

Assorted leg lymphedema pics

IMAGES

Lymphedema People Resources

leg_lymphedema.txt · Last modified: 2012/10/16 14:40 (external edit)