Lymphoedema

Persistent swelling caused by the lymphatic system

What is lymphoedema?

Lymphoedema is a long-term condition that causes swelling when the lymphatic system is unable to drain fluid from the tissues effectively.

The lymphatic system is a network of vessels and lymph nodes throughout the body. It helps remove excess fluid from tissues and also forms an important part of the immune system.

When lymphatic drainage is impaired, fluid can accumulate within the tissues. Lymphoedema can affect almost any part of the body, but it commonly affects an arm or leg.

What does lymphoedema look and feel like?

In the early stages, swelling may:

  • Be soft

  • Come and go

  • Become worse as the day progresses

  • Improve overnight or after elevation

  • Leave a dent when pressed with a finger, known as pitting

As lymphoedema becomes more established, the swelling may become more persistent and the tissues can become firmer.

Other symptoms can include:

  • A heavy or aching feeling

  • Tightness

  • Difficulty moving the affected limb

  • Tight-fitting shoes or clothing

  • Thickened or hardened skin

  • Deepened skin folds

  • Recurrent skin infections

  • Leakage of lymphatic fluid through the skin in more advanced cases

Early identification is important because untreated lymphoedema can progressively become more difficult to manage.

What causes lymphoedema?

There are two main types.

Primary lymphoedema

Primary lymphoedema results from abnormal development of the lymphatic system.

It is usually associated with genetic changes and may develop during childhood, adolescence or adulthood.

It is relatively uncommon.

Secondary lymphoedema

Secondary lymphoedema develops when a previously functioning lymphatic system becomes damaged or overwhelmed.

Possible causes include:

  • Surgery involving lymph nodes

  • Radiotherapy

  • Cancer

  • Previous severe infection

  • Recurrent cellulitis

  • Significant trauma or injury

  • Chronic venous disease

  • Previous DVT

  • Severe obesity

  • Reduced mobility

  • Certain inflammatory skin conditions

Cancer treatment involving removal or irradiation of lymph nodes is a well-recognised cause, but lymphoedema has many other causes too.

Can problems with the veins cause lymphoedema?

Yes.

Long-standing chronic venous insufficiency can cause persistently raised pressure within the veins.

This allows greater quantities of fluid to move into the tissues. Initially the lymphatic system tries to remove this extra fluid, but over time it can become overwhelmed and damaged.

Some people therefore develop a combination of venous and lymphatic swelling, sometimes described clinically as phlebolymphoedema.

Is lymphoedema just “water retention”?

No.

Although lymphoedema causes fluid accumulation, it is not simply an excess of water within the body.

The lymphatic fluid contains proteins and other substances, and prolonged lymphatic congestion can cause inflammatory and structural changes within the tissues.

This is why simply taking a “water tablet” does not correct the underlying lymphatic problem.

Lymphoedema or ordinary oedema – what's the difference?

Oedema is a general term meaning swelling caused by fluid within the tissues.

Lymphoedema describes oedema specifically associated with impaired lymphatic drainage.

Swollen ankles can therefore have many causes, including:

  • Venous insufficiency

  • Medication

  • Heart, kidney or liver problems

  • Injury

  • DVT

  • Infection

  • Lymphoedema

The appearance of swelling alone does not always reveal its cause.

What about lipoedema?

Lipoedema and lymphoedema are different conditions.

Lipoedema causes an abnormal and usually symmetrical accumulation of fatty tissue, predominantly affecting the legs and sometimes the arms.

One useful distinction is that in classic lipoedema the feet are usually spared, whereas lymphoedema commonly extends into the foot and toes.

Lipoedema can also cause tenderness, heaviness and easy bruising. Some people can have both lipoedema and lymphoedema.

I think Lipoedema could actually deserve its own page later rather than trying to squeeze too much into this one.

Why are the feet and toes important?

When lymphoedema affects the leg, swelling may extend onto the top of the foot and into the toes.

Over time, changes can include:

  • Increased toe swelling

  • Thickening of the skin

  • Deep skin folds

  • Difficulty fitting footwear

  • Increased pressure between or beneath the toes

  • Increased risk of fungal infection

  • Difficulty carrying out normal nail and skin care

A clinician assessing suspected lymphoedema may also look for Stemmer's sign – difficulty lifting or pinching a fold of skin, usually at the base of a toe.

A positive Stemmer's sign can support a diagnosis of lymphoedema, but a negative result does not completely exclude it.

Why is skin care so important?

Healthy skin provides an important barrier against bacteria.

In lymphoedema, the affected tissues have a reduced ability to deal with infection. Even a small break in the skin can potentially provide an entry point for bacteria.

Good skin care therefore forms a central part of lymphoedema management.

Try to:

  • Wash and dry the feet carefully

  • Dry thoroughly between the toes

  • Moisturise dry skin regularly, avoiding excessive cream between the toes

  • Treat cracks and fissures promptly

  • Treat athlete's foot

  • Avoid walking barefoot where injury is likely

  • Wear properly fitting footwear

  • Check the skin regularly for cuts, blisters and abrasions

  • Avoid attempting to cut out corns yourself

For somebody with lower-limb lymphoedema, foot care is not merely cosmetic – maintaining intact skin helps reduce infection risk.

Lymphoedema and cellulitis

This is probably the most important complication for patients to understand.

People with lymphoedema have an increased risk of developing cellulitis, a bacterial infection of the deeper layers of the skin. Cellulitis can in turn further damage the lymphatic system and make lymphoedema worse.

Seek urgent medical advice if the affected limb suddenly becomes:

  • Hot

  • More swollen

  • Painful or tender

  • Red or noticeably darker than usual

You may also develop:

  • Fever

  • Chills

  • Shivering

  • Feeling generally unwell

These symptoms can indicate cellulitis and usually require prompt antibiotic treatment.

How is lymphoedema diagnosed?

In many cases, diagnosis is based on:

  • Your medical history

  • Your symptoms

  • Examination of the affected limb

  • Measurements of the limb

Where the diagnosis is unclear or more detailed investigation is required, specialist tests may occasionally include ultrasound, MRI, CT, bioimpedance measurements or lymphatic imaging.

People with suspected lymphoedema may be referred to a specialist lymphoedema service for further assessment.

Can lymphoedema be cured?

There is currently no simple cure, but lymphoedema can often be controlled very effectively.

Early treatment can help reduce swelling, protect the skin, maintain mobility and prevent progression.

How is lymphoedema treated?

A commonly used approach is decongestive lymphatic therapy (DLT).

This combines four main components:

  • Compression

  • Skin care

  • Movement and exercise

  • Specialised lymphatic massage

After an initial treatment phase, patients are usually taught ways to manage their condition themselves over the longer term.

Compression therapy

Compression garments, bandages or adjustable wraps apply controlled external pressure to the limb.

Together with movement of the muscles, this can help encourage fluid to move out of the swollen tissues and reduce further accumulation.

However:

Compression is not automatically suitable for everyone.

People with significant arterial circulation problems may not be suitable for particular levels of compression.

This means that the arterial blood supply may need to be assessed before lower-limb compression is prescribed or increased.

Compression should also be properly measured and fitted rather than simply choosing the tightest stocking available.

Does exercise make lymphoedema worse?

Generally, no.

Movement is actually an important part of lymphatic drainage because contraction of the surrounding muscles helps move lymphatic fluid.

Walking and other suitable activities can therefore form an important part of management. NHS guidance includes regular movement and exercise as one of the main components of treatment.

What is manual lymphatic drainage?

Manual lymphatic drainage (MLD) is a specialised form of gentle massage used by trained practitioners.

It aims to encourage lymphatic fluid away from congested areas and towards functioning lymphatic drainage pathways.

Patients may also be taught simpler techniques known as simple lymphatic drainage to use as part of their ongoing self-management.

It is not the same as an ordinary deep-tissue massage.

Can lymphoedema ever need surgery?

Occasionally.

Specialist centres may offer procedures such as:

  • Lymphaticovenular anastomosis, which connects small lymphatic vessels to nearby veins

  • Liposuction for selected patients with significant long-standing tissue enlargement

Surgery is only appropriate in particular circumstances and usually forms part of specialist lymphoedema care rather than replacing ongoing management altogether.

When should I seek further assessment?

Speak to your GP or healthcare professional if you develop:

  • Persistent unexplained swelling of a leg or foot

  • Swelling that is gradually increasing

  • Swelling extending into the toes

  • Tightening or thickening of the skin

  • Recurrent cellulitis

  • Leakage of clear fluid through the skin

  • Increasing difficulty fitting shoes

  • Reduced movement because of swelling

New lymphoedema should be assessed rather than simply assumed to be ordinary fluid retention.

When is swelling urgent?

Lymphoedema itself normally develops gradually.

Seek urgent medical assessment if:

  • One leg suddenly becomes significantly more swollen

  • The limb becomes hot, painful or acutely discoloured

  • You develop fever or shivering

  • You feel suddenly unwell

These symptoms may suggest cellulitis, DVT or another acute condition.

Call 999 if leg swelling is accompanied by sudden breathlessness, chest pain, coughing up blood or collapse.

Lymphoedema and your podiatry care

Lower-limb lymphoedema can have a significant effect on the feet.

At Blackfords Footcare, we can identify and help manage some of the foot-related consequences of swelling, including:

  • Difficult nail care

  • Corns and callus caused by altered pressure

  • Footwear problems

  • Cracked or vulnerable skin

  • Interdigital fungal infection

  • Pressure damage

  • Wounds

  • Changes in skin integrity

Where appropriate, assessment of the arterial circulation can also help establish whether there are vascular concerns that need to be considered before compression therapy.

We do not provide specialist lymphoedema therapy itself, but if findings suggest previously undiagnosed lymphoedema or a deterioration in an existing condition, we can recommend appropriate onward assessment.

Good foot and skin care are particularly important in lymphoedema because preventing even small breaks in the skin can help reduce the risk of cellulitis.