What is Lymphedema?
The lymphatic system plays an important role in immune health and maintaining homeostasis through fluid drainage.
Everyday, the lymphatic system returns around 2 litres of fluid from the capillaries back to circulation.
The lymph system works similar to veins, as it functions with muscle contractions and contains valves to direct the flow of the fluid in one direction.
However, when the lymphatic system is impaired, serious complications can occur.
Lymphedema is caused by impaired lymphatic drainage in the presence of normal capillary function.
The congestion of the lymphatic system induces chronic inflammation, which therefore leads to fibrosis and further lymphatic drainage.
Lymphedema refers to localised swelling of the body.
This swelling is caused by an irregular collection of protein-rich fluid in the interstitial space, which is caused by obstruction of lymphatic drainage.
This obstruction therefore causes an increase in the protein content of the extravascular tissue, resulting in excessive retention of water and swelling of the soft tissue.
The increase in the extravascular protein stimulates the proliferation of fibroblasts, organisation of the fluid, and ultimately the development of non-pitting swelling of the affected extremity.
There are two types of Lymphedema, Primary and Secondary
Primary lymphedema
Primary lymphedema is rare.
It results from genetic mutations, leading to underdevelopment of lymphatic vessels and reduced lymphatic drainage.
Nearly 30% of primary lymphedema patients have identifiable genetic mutations, most commonly in the signaling pathway for vascular endothelial growth factor C.
Primary lymphedema can be an isolated disease or part of a complex syndrome.
Based on age of onset, primary lymphoedema is subdivided into 3 categories:
- Congenital lymphedema which presents at or shortly after birth
- Lymphedema praecox which presents around puberty
- Lymphedema tarda which present in those above 35
Secondary lymphoedema
Secondary lymphedema is much more common than primary lymphedema.
It is acquired by damage or blockage of previously normal lymphatics by disease, infection, trauma, surgery, obesity, or as a consequence of malignancy.
Both chronic venous hypertension and venous ulcers can be associated with impaired lymphatic function.
In patients with chronic venous disease, 20% will also have secondary lymphatic damage from fluid overload.
In tropical areas of the world, the most common cause of secondary lymphoedema is a parasitic disease acquired from flies and mosquitoes known as Filariasis.
In other areas of the world, the etiology of lymphedema is mostly cancer-related, involving surgical intervention and radiation damage to the lymph vessels.
How is lymphedema assessed?
When assessing and treating lymphedema, the following information should be obtained and understood:
- Extent, location and duration of the oedema
- Presence swollen lymph nodes
- Involvement/quality of skin and underlying tissue
- Degree of shape distortion of the affected area
- Circumference and volume of the affected limb
- Presence of pitting
When assessing and diagnosing Lymphoedema it is important to rule out venous oedema, lipedema, obesity, and drug-induced swelling before making a diagnosis.
In a podiatric setting we play an important role in the prevention and management of Lymphedema.
Approximately 90% of cases can be diagnosed through thorough history and medical documentation.
Travel history and surgical history is also important.
Thorough history taking is essential to determine whether the onset of symptoms is consistent with lymphedema, as it is a progressive condition.
A patient with the clinical appearance that is consistent with lymphedema and is positive with the Stemmers signs assessment, can be referred to confirm the potential lymphoedema with imaging such as an MRI or Venous Duplex Ultrasound. This can determine whether the condition is classified as primary or secondary.
Measuring Limb Volume
Limb volume measurement can be used to determine the extent and severity of lymphedema. It may also be used to assess whether treatment is effective or not. Limb volume should be assessed at the first visit, after two weeks of multilayer lymphedema bandaging and at follow-up.
When one limb is affected, both the affected and unaffected limbs are measured and the difference between the two is recorded as a percentage or in milliliters (ml). A diagnosis of lymphedema can be made if the volume of the swollen limb is 10% or more than that of the unaffected limb. When both limbs are affected, both are measured in order to track the progress of treatment.
Water Displacement Method
- The water displacement method is the gold standard for measuring limb volume and is the only reliable method available to assess edema of the hands and feet. This method follows the scientific principle that an object will displace its own volume of water. However, its use is limited by hygiene issues and ability to access this modality.
Circumferential Measurement
- This is the most widely used method of calculating volume. It is reliable when a standard protocol is adhered to. Circumferential measurements of limbs can be entered into a computer program (such as a spreadsheet) designed to determine both individual and excess limb volume.
Perometry
- This method uses ultraviolet light beams to measure the limb outline. Limb volume can be calculated from these measurements. The cost of the equipment limits its use, as does its inability to be used for the measurement of hand and foot volume measurements.
Bio-impedence
- This method measures tissue resistance to an electrical current to measure fluid volume. A drawback to this method is that it is not very useful when bilateral swelling is present.
Limitations of Limb Volume Measurement
- Measurement of limb volume is not particularly useful when both limbs are affected; however, measurements can be used to assess the effectiveness of treatment rendered. Also, limb volume measurements are less accurate in patients who have severe thickening of the outer skin layer (hyperkeratosis) or hardening of the skin with deep skin folds (elephantiasis).
How does Lymphedema present?
Lymphedema can present both unilateral or bilateral.
Often you may sense of heaviness and discomfort of the affected limb, especially at the end of the day.
Early-stage lymphedema mimics other causes of tissue swelling, such as venous edema.
Chronic lymphedema is characterized by skin thickening and tissue fibrosis.
As lymphedema progresses, the skin becomes hard with a leathery texture, which is due to the skin thickening and appears pitted or dimpled.
Non-pitting edema indicates an irreversible stage of lymphedema.
An inability to pinch the fold of skin at the base of the second toe is a sign for chronic lymphedema.
The skin over the affected area has a can have a “mossy” or “cobblestoned” appearance.
Skin in chronic lymphedema is prone to fissures, ulceration, and recurrent cellulitis.
Weeping and oozing of clear to light yellow fluid in this presentation of lymphedema is common.
How is Lymphedema treated?
A management plan may consist of compression devices, exercises, manual lymph drainage, good skin care, patient education and psychological support.
Treatments that can be very effective in reducing swelling are full body exercise and phase 2 complete decongestive therapy. This involves the ongoing management of manual lymph drainage, compression therapy, skin care and exercise to prevent swelling progression.
Who does Lymphedema affect?
It has been reported that lymphedema affects as many as 200 million people worldwide.
In general, incidence in females is twice than in males.
Lower extremity lymphedema is much more common than upper extremity lymphedema and is usually associated with infection, chronic venous insufficiency, obesity, and malignancies.
Lymphedema is chronic, progressive, and often requires lifelong treatment.
Patients with primary lymphedema have a lower morbidity compared to patients with secondary lymphedema because they have a better ability to compensate for lymphatic malfunction.
How do podiatrists help with Lymphedema?
Podiatric care is essential for lower limb lymphedema.
Routine foot and nail care is essential to reduce the risk of damaging the skin and creating a portal for infection if left unattended.
Wearing appropriate footwear to accommodate swelling is very important and ensures that shoes are not the cause for any discomfort or skin breakage. and, closed in protective shoes to reduce the risk of an accidental break in the skin.
If you suffer from Lymphedema, why not book in to see us here at Watsonia Podiatry? We can help you manage the health of your feet. We can also help you with any pain or discomfort you may be experiencing in your feet and/or lower limbs. Book in to see us by calling 03 9432 2689 or online here.