Managing Lower Extremity Lymphedema in the Wound Care Setting: Diagnosis, Treatment, and a Novel Application for Pressure Ulcers

Presenters:

• Rummana Aslam, MD 
  • Chief, Physical Medicine and Rehabilitation, Yale School of Medicine; Medical Director, Lawrence + Memorial Wound Care and Hyperbaric Medicine; Program Director, Yale Chronic Wound Care and Regenerative Medicine Fellowship
• Elizabeth Garfield, PT, CLT
  • Physical Therapist and Certified Lymphedema Therapist, Fox Rehabilitation

Moderator: Leticia Graves Dixon, DNP

 

Why This Topic Matters for Wound Care Clinicians

Most clinicians who work in wound centers see lymphedema every day, often without recognizing it as the underlying driver of the chronic wound they are trying to heal. Patients arrive with years of recurrent ulceration, weeping legs, and multiple rounds of antibiotics, but the lymphatic system behind the wound is rarely addressed directly.

In this WHS Education Committee webinar, Dr. Rummana Aslam and Elizabeth Garfield, PT, CLT, walked through the practical diagnosis and management of acquired lower extremity lymphedema, with a focus on the patients we actually see in wound clinics rather than cancer-related presentations. They also introduced a novel clinical application of complete decongestive therapy (CDT) principles for chronic pelvic pressure ulcers in spinal cord injury patients.

 

Understanding the Lymphatic System in Wound Healing

The lymphatic system works alongside the arterial and venous systems as one integrated circulatory network. Lymphatic vessels collect interstitial tissue fluid, move it through lymph nodes where it is filtered, and ultimately return it to venous circulation through the right lymphatic duct and thoracic duct.

When that system is impaired, protein-rich fluid accumulates in interstitial and fibroadipose tissues, triggering chronic inflammation. That inflammation is the key point many clinicians miss. Lymphedema is not a passive fluid problem. It is an active inflammatory condition that drives adipose tissue growth, further compresses the lymphatics, and creates a self-perpetuating cycle.

There are two categories of lymphedema:

• Primary lymphedema is inherited, caused by congenital defects in lymphatic vessels or nodes. It is rare.
• Secondary lymphedema is acquired through damage to the lymphatic system from other causes. This is what wound clinicians encounter daily.

A useful clinical reframe: all edema is lymphedema. Any patient with edema has some degree of impaired lymphatic transport, and treating the lymphatic component is often the difference between a wound that heals and one that does not.

 

Diagnosing Lymphedema: A Clinical Process

Lymphedema is a clinical diagnosis. Advanced imaging exists (lymphoscintigraphy, ICG lymphography, MR lymphangiography), but these are primarily used to plan lymphatic surgery in selected cases, not for day-to-day diagnosis or management.

History

A thorough history identifies the factors that have damaged the limb and the systemic factors that worsen the condition. Key areas to cover:

• Venous insufficiency, including incompetent valves, post-thrombotic syndrome, and prior vein stripping. Referring patients to vein clinics early can prevent disease progression.
• Trauma to skin, subcutaneous tissue, and bone, including surgery, fractures, burns, wounds, scars, recurrent cellulitis, and chronic skin disorders.
• Mobility limitations, including Parkinson’s disease and other conditions that reduce the calf muscle pump.
• Congestive heart failure, which contributes to edema and complicates compression management.
• Sleep habits. Patients with CHF and lymphedema often sleep in recliners because they cannot lie supine or lift their legs into bed. Hip flexion in a recliner kinks off the inguinal lymph nodes and blocks lymphatic flow overnight.

Physical Exam and Staging

Lymphedema progresses through recognizable stages:

John Hopkins Lymphedema Stages

 

• Stage 1. (Abnormal Flow):  The lymphatic system has abnormal flow, but there are no outward signs or symptoms.
• Stage 2 (Fluid Accumulation):   Fluid begins to build up, causing swelling that typically resolves when the limb is elevated.  Pressing on the area may leave a dent (pitting).
• Stage 3. (Permanent Swelling):  Swelling is permanent and does not resolve with elevation.  The skin may start to change, becoming thickened or scarred.
• Stage 4:  This advanced stage is characterized by severe swelling, significant skin thickening, “wart-like” growths, and extensive scarring. 

Two quick bedside tests help confirm the diagnosis:

• Stemmer sign. Pinch the skin at the base of the second toe. If you can lift it cleanly, lymphedema is less likely (though not excluded). If the skin is too thick to lift and your fingers roll over it, lymphedema is almost certainly present.
• Bjork Bow-tie test. Gently pinch, roll, and twist the skin between thumb and forefinger at another body region. Inability to perform the maneuver indicates thickened, fibrotic skin consistent with lymphedema.

Basic vascular studies (ankle-brachial index, pulse volume recordings) should be part of the workup to confirm that arterial circulation can tolerate sustained compression.

 

Complete Decongestive Therapy: The Cornerstone of Management

Management happens in two phases: an intensive phase to bring uncontrolled lymphedema under control, and a maintenance phase to preserve those gains for life.

The intensive phase combines four components into complete decongestive therapy (CDT):

1. Aggressive skin care
2. Manual lymph drainage (MLD)
3. Compression bandaging
4. Exercise

Skin Care

Chronic erythema in lymphedematous skin is usually inflammatory, not infectious, though clinical judgment is essential. The skin is typically dry and scaly, and sometimes hyperkeratotic, with thick plaques that need to be removed.

Practical steps:

• Wash the skin meticulously with pH-balanced soap and water.
• Soften dry skin with emollients. Sharp debridement of hyperkeratotic plaques may be appropriate.
• For lymphorrhea (droplet leakage of lymph fluid, sometimes described by patients as “my leg is crying”), a one to two week course of topical steroid plus antifungal combination cream often resolves the leakage and allows compression to be applied.

Manual Lymph Drainage

MLD is a specialized manual technique performed by trained clinicians and therapists. The goal is to mobilize stuck lymphatic fluid from the subcutaneous tissues and redirect it from congested areas to regions with functional lymphatic drainage. MLD is most effective when paired with compression, which helps maintain the fluid movement initiated by the massage.

Compression Bandaging

Compression is the single most important component of CDT, and the type of compression matters significantly.

Short-stretch bandages (low resting pressure, high active pressure) are safe and effective and are the clinical standard for the intensive phase. They are 100% cotton, stretch only a few inches, and reach a maximum point where they stop stretching. Layering short-stretch bandages creates a rigid wall around the limb that generates a massaging effect during movement without the discomfort of overtightening.

For comparison:

• Zinc paste (Unna boot) has no elasticity. It can feel tight and uncomfortable on limbs with skin folds or massive edema.
• Long stretch/ACE bandages: (high resting pressure, low active pressure). They do not generate the stiffness needed and must be wrapped very tightly, which is uncomfortable and can cut circulation. ACE bandages are inappropriate for treating lymphedema

 

The clinical principle: compression is in the clinician’s hands, not in the bandage. Short-stretch bandages do not need to be applied tightly. The stiffness comes from layering.

A typical bandaging sequence:

1. Clean and moisturize the skin.
2. Apply a stockinette to protect the skin.
3. Apply cotton cast padding to even out the contour of the limb. Narrow areas need to be “fluffed up” so the bandage does not create a tourniquet effect.
4. If the toes are edemetous then wrap the first four toes with a conforming gauze wrap or other specialized lymphedema toe wraps. The toe wrapping with confirming gauze is done in a manner where we start with an anchoring wrap around the forefoot and then each toe is wrapped individually. When wrapping individual toes it is important to avoid a tight tourniquet effect. This is achieved by alternating the wrap around the toe with a wrap around the forefoot and this step can be repeated a few times for each toe before moving to the next adjacent toe. Skip the fifth toe, which is prone to injury and rarely develops lymphedema.
5. Move up in bandage width (8, 10, 12 cm) to wrap the ankle, calf, and thigh in overlapping layers. Three to five layers is standard; severe cases may require seven.
6. Hold the foot at 90 degrees during ankle and forefoot wrapping. Tell the patient to point their toes toward their nose.

Bandages stay on between changes. If there is no drainage, they can be left in place for two to seven days. Wounds with drainage require more frequent changes but are still treated with standard absorptive wound dressings underneath the compression.

Safety considerations:

• Educate patients on signs of overcompression: numbness, pain, friction.
• Do not apply sustained compression when ABI is less than 0.5 or ankle pressure is less than 60 mmHg. These patients need vascular evaluation first and collaboration with vascular specialists
• Intermittent pneumatic compression designed for arterial insufficiency may be an option when sustained compression is contraindicated.

Exercise

The calf muscle is the pump of the venous system. Venous return flows against gravity, and muscular compression of the veins during movement drives blood back to the heart.

Patients are often told to sit with their legs elevated all day, which is wrong. Elevation is only appropriate for sedentary activities longer than thirty minutes. Patients who can walk should walk, and patients who cannot walk should do ankle exercises to activate the calf pump.

Research from Dr. Hugo Partsch demonstrated that short-stretch bandages generate roughly 80 mmHg of counter-pressure during ankle dorsiflexion and walking, which is enough to counteract the effect of gravity on venous pooling. Compression stockings generate significantly less counter-pressure during movement.

The practical takeaway: walking on a treadmill, wearing short-stretch compression bandages, is the most effective anti-gravity force available.

 

Obesity and Lymphedema: A Self-Reinforcing Cycle

Lymphatic vessels sit in close proximity to subcutaneous adipose tissue. Most studies have shown that lymphatic leakage drives both hypertrophy and proliferation of adipose tissue cells, which then compress the lymphatic vessels and worsen the dysfunction.

Clinically, this means patients with obesity and lymphedema need both conditions addressed in parallel. Weight loss alone will not cure the lymphatic damage, but ongoing lymphatic congestion will continue to drive adipose accumulation if left untreated.

 

Congestive Heart Failure: A Special Case

CHF complicates lymphedema management in two important ways.

Fluid mobilization risk. When compression returns several liters of fluid to circulation over a few days, a poorly compensated heart can decompensate into pulmonary edema. Close coordination with cardiology is essential.

Diuretics. Diuretics used solely to reduce leg swelling in lymphedema are contraindicated. They remove water while leaving protein and macromolecules behind, concentrating the lymphatic fluid, increasing viscosity, and worsening inflammation. Diuretics for CHF itself must be balanced carefully against lymphedema management.

Compression for lymphedema is not contraindicated in chronic stable CHF; however, communication with the specialists treating CHF is essential so they are aware. 

The Maintenance Phase

Once edema is controlled and wounds have healed, patients move into lifelong maintenance. The lymphatic damage does not reverse. Treatment is not a cure.

Maintenance options, often used in combination:

• Compression stockings (replaced every 6 months)
• Velcro-style compression garments for patients who cannot manage stockings
• Self-applied short-stretch bandages for flare-ups
• Pneumatic compression pumps are used in conjunction with compression garments, either in the mornings before donning garments or in the evenings after doffing them, or when care partners are not available to don garments. 
•  Continued exercise

Patient education is the foundation of maintenance. Patients who understand that this is a chronic condition requiring lifelong management are dramatically more adherent than those who believe they were “cured.”

 

Surgical Management

Surgical options exist for selected patients, including lymphovenous anastomosis, vascularized lymph node transfer, and debulking procedures. Debulking with plastic surgery is sometimes appropriate for patients with massive thigh or leg lymphedema that restricts mobility. These are specialist referrals and are not part of routine lymphedema/wound care management.

 

A Clinical Case: Six Years of Chronic Ulceration Resolved with Managing Underlying Edema

Dr. Aslam presented a 50-year-old patient who had carried a circumferential lower extremity ulcer for six years. He was over 400 pounds, diabetic, with massive lymphedema and lymphorrhea, and had been hospitalized multiple times for sepsis. His wound care had been aggressive and well-executed, but the underlying lymphedema had never been addressed.

The treatment plan:

• Wound care protocol unchanged (antiseptic cleaning, absorptive dressings)
• Compression bandaging added, initially every other day due to drainage, then three times per week and then twice weekly
• Weight loss (he refused bariatric surgery but lost 100 pounds in a few months with daily exercise and healthy eating)
• Physical therapy including treadmill walking with compression bandages

Results by timeline (after initiating multilayer compression bandaging of the leg and physical therapy):

• Day 12: Slough resolved without debridement. New skin islands visible in the wound bed.
• 4 months: Substantial re-epithelialization across the wound.
• 6 months: Complete healing.

The case illustrates the central principle of the session. A wound that will not heal despite excellent wound care is often a wound where the lymphatic component has not been addressed.

A Novel Application: CDT Principles for Chronic Pelvic Pressure Ulcers

Elizabeth Garfield, PT, CLT, presented a novel clinical framework for patients with chronic pressure ulcers on the greater trochanter, sacrum, and ischial tuberosities. These wounds persist for years through multiple surgeries and antibiotic courses because fluid around the wound harbors microorganisms, blocks oxygen delivery, and prevents healing.

Her proposal is to apply CDT principles to decongest the peri-wound tissue, reduce bioburden, improve oxygenation, and facilitate wound healing.

MLD Rerouting for Pelvic Wounds

For pressure ulcers in the pelvic region, MLD can reroute fluid along two pathways:

• Downward and anterior toward the inguinal lymph nodes, decongesting the buttocks and lateral hip.
• Upward along the thoracic and lumbar spine toward the axillary lymph nodes, using the upper body lymphatic system to decongest the lower trunk.

These rerouting techniques borrow directly from cancer-related lymphedema management but apply them to chronic pressure wounds.

Temperature Monitoring with Handheld Infrared

A handheld infrared thermometer provides a simple, objective measure of wound status. By comparing the involved limb to the uninvolved limb:

• A wound three to five degrees hotter than the opposite side suggests infection or heavy bacterial load and inflammation
• A wound cooler than the opposite side suggests hypoxia, poor blood flow, and fluid accumulation.

As CDT progresses and the wound improves, the temperature on the wounded side should normalize

Exercise Through Neuromuscular Electrical Stimulation

For SCI patients, or any patients with impaired mobility exercise in the traditional sense is not possible. Garfield proposes neuromuscular electrical stimulation (NMES) with electrodes placed laterally around the peri-wound area. Effective muscle contraction of the gluteus medius or maximus creates the pumping effect that manual exercise would otherwise provide.

For patients at risk of autonomic dysreflexia, monitoring blood pressure during stimulation is important, and passive range-of-motion by a therapist can be substituted.

Compression for Pelvic Ulcers

Biker shorts or pelvic compression undergarments provide the compression component of CDT for this region.

Skin Care

• Barrier ointments protect peri-wound skin from exudate and incontinence damage.
• Creams (higher oil content) are preferred over lotions (higher water content). Creams seal in moisture; lotions can actually accelerate evaporation and dryness.
• Avoid creams with perfumes that can cause reactions.

 

Common Patient Misconceptions

Clinicians should anticipate and correct several persistent misconceptions:

• Restricting fluid does not reduce leg swelling. Older adults often dehydrate themselves, believing water intake drives lymphedema. It does not.
• Leg elevation alone is not a treatment. Patients are often told to sit with their legs elevated all day. This is the opposite of what they need. Walking and /or calf exercises with compression is the treatment.
• Diuretics are not a primary treatment for lymphedema. They worsen the condition when used only for this purpose.
• TED hose are not compression hose. They are anti-embolic stockings for bedbound patients and do not treat lymphedema.
• Zipper compression garments typically provide 8 to 12 mmHg, which is insufficient for true clinical lymphedema.
• Compression garments need replacement every 6 months. Old, stretched-out garments are one of the most common reasons “compression isn’t working.”

 

Getting Trained

Clinicians interested in adding MLD or full CDT to their practice have several options:

• MLD certification is available as a standalone course for clinicians who want the manual skill without full CDT training.
• Full CDT certification includes compression and is appropriate for clinicians who want to deliver the complete intensive phase.
• Skin sweeps are a simple technique any clinician can practice and teach patients. Place a hand directly on the skin and sweep toward the nearest lymph nodes, letting the hand glide and gently stretch the skin. Even without formal certification, this creates negative pressure and supports lymphatic drainage.

 

Key Takeaways for Wound Care Clinicians

1. Any edema in a wound care patient has a lymphatic component. Treat it.
2. Short-stretch compression bandaging is the cornerstone of the intensive phase. Layering creates stiffness without overtightening.
3. Exercise with compression is more effective than elevation. The calf is the pump.
4. Obesity, CHF, and venous insufficiency all drive and complicate lymphedema. Manage them in parallel.
5. Lymphedema is chronic. Maintenance is lifelong.
6. CDT principles may have applications well beyond traditional lymphedema, including chronic pelvic pressure ulcers.

 

Watch the Full Webinar

The full recording, including case images, bandaging technique demonstrations, and the complete Q&A, is available on the WHS YouTube channel and in member-only accounts on the WHS website.

 

The Wound Healing Society Education Committee does not endorse any specific products mentioned in this presentation. Product references are for demonstrative purposes only.

This article is a summary of a WHS Education Committee webinar featuring Rummana Aslam, MD, and Elizabeth Garfield, PT, CLT, moderated by Leticia Graves Dixon, DNP. It is intended as a clinical reference for wound care professionals and does not replace formal medical training or clinical judgment.