Lower Extremity Lymphedema: Why Your Legs Swell and What You Can Do About It
Many people experience puffy legs or ankles, especially toward the end of the day. This can get worse during the warm months of a Central Valley summer. But when does swelling become abnormal, or signify that something deeper may be going on?
Many patients who have significant swelling on an ongoing basis are diagnosed with lymphedema. Lymphedema is a buildup of protein rich lymph fluid in the tissues, caused by a lymphatic system that cannot move fluid out of the tissues as efficiently as it needs to. While this can relate to a deficiency in the lymphatic system itself, it can also relate to overload from other conditions that cause chronic swelling.
Lymphedema can occur in any part of the body, but in our practice we typically see patients suffering from lymphedema in the legs. It is often a lifelong condition, but it is also highly manageable, and how well it is managed or controlled can depend on how early it is recognized.
Why Lymphedema Can Affect the Legs: Why It Happens in the Legs
Your lymphatic system runs alongside your veins and is in charge of draining the fluid, protein, and cellular debris that your bloodstream leaves behind. In the legs, that fluid must travel the farthest distance against gravity to get back to where it intersects with the circulatory system, with no pump of its own. It relies almost entirely on muscle movement and one way valves. Anything that damages, blocks, or overwhelms that network allows fluid to settle in the ankles, feet, and calves.
Primary lymphedema comes from lymphatic vessels that were formed abnormally before birth; however, symptoms of primary lymphedema can first appear in childhood, adolescence, or well into adulthood. Secondary lymphedema is far more common and develops after the system is damaged by something else, including pelvic or abdominal surgery, lymph node removal, radiation therapy, a serious infection, or repeated trauma to the leg. Obesity is a common contributing factor to secondary lymphedema, as obesity creates more pressure that the lymphatic system must labor against.
There is another cause of lymphedema that is especially relevant to our patients. Long standing chronic venous insufficiency floods the tissues with more fluid than the lymphatic vessels can handle, and over years that constant overload wears the lymphatics down. The result is phlebolymphedema, a combined venous and lymphatic problem that may be the most frequent cause of leg lymphedema in the United States. For these patients with lymphedema caused by vein disease, treating the vein disease can be extremely helpful in reducing the amount of swelling they experience.
Early Warning Signs Worth Acting On
Lymphedema in the legs usually builds gradually, and the earliest stage often has no visible swelling at all. Pay attention if you notice:
Swelling in one or both legs, ankles, or foot that keeps occurring on a regular basis
A heavy, tight, or full sensation in the legs, before any swelling is obvious
Socks leaving deeper marks than they used to, or shoes no longer fitting
Skin on the top of the foot or the base of the second toe that has become thick and difficult to pinch
Swelling that involves the toes, which is very characteristic of more advanced lymphedema
Skin that grows firm, dry, or leathery over time rather than staying soft and malleable
Recurrent bouts of cellulitis, redness, or warmth in one or both legs
We will mention a couple of conditions that can be mistaken for lymphedema. The first is lipedema, which involves symmetric fatty enlargement of both legs that spares the feet and is often tender to the touch. Some patients do have both lipedema and lymphedema; see our comparison of lipedema and lymphedema for more details. The second condition is DVT. In contrast to lymphedema, which comes on more gradually and does not usually cause severe pain, a DVT or blood clot can cause sudden swelling in one leg with pain and warmth. Symptoms of a potential DVT require urgent medical attention rather than a routine appointment. Our overview of deep vein thrombosis explains what to watch for.
Getting an Accurate Diagnosis
Most lymphedema is diagnosed clinically, through a careful history and a hands on examination of the skin, tissue texture, and limb measurements. Because venous disease drives so many cases, duplex ultrasound is typically part of the workup to check whether your vein valves are allowing blood to flow backward. Some lymphedema specialty centers offer lymphoscintigraphy, which maps how lymph fluid actually moves through the leg, but most patients with lymphedema do not require lymphoscintigraphy for diagnosis or to begin the foundational strategies for managing lymphedema.
Managing It Day to Day
A practical order of operations:
Treat the underlying vein disease first when it is present. Correcting venous reflux reduces the fluid load for your lymphatic system.
Commit to compression. Depending on the stage of lymphedema as well as patient preference, elastic or inelastic compression garments may be used. While many patients prefer elastic compression stockings, others get the most benefit out of the inelastic compression wraps, some of which are adjustable with Velcro. Our guide to choosing the right compression covers how fit and class are decided. Sometimes, if the size of the leg changes significantly after decongestive therapy, new garments will have to be purchased to maintain an adequate strength of compression.
Add manual lymphatic drainage. A certified lymphedema therapist uses light, directional strokes to move fluid toward working lymph nodes, and can teach you a version of this specialized lymphatic massage to do at home. This is an important part of what is called complete decongestive therapy.
Use a pneumatic or non-pneumatic compression device. These devices are designed to be used for about 1 hour each day. A special boot covers the leg and applies sequential pressure to help the lymphatic system drain more efficiently.
Move the calf pump every day. Walking, ankle pumps, and aquatic exercise push lymph along, with water providing gentle compression at the same time.
Protect the skin. Wash and moisturize daily, treat cuts and insect bites promptly, avoid going barefoot outdoors, and call your provider at the first sign of spreading redness as this can indicate infection.
Elevate strategically. Raising your legs above heart level for fifteen to twenty minutes a few times a day supports, but never replaces, compression.
Manage weight and sodium. Excess weight measurably worsens lymphatic function, as we discuss in our post on obesity and venous disease.
Consistency matters greatly. Patients who stay with a simple routine may be able to keep their swelling in check for many years, while those who stop compression often lose the ground they gained within weeks.
When to Call Us
Schedule an evaluation for leg swelling that isn’t going away, swelling that involves your toes, skin that is thickening near the ankle, a leg that feels heavy without a clear reason, or an open sore that will not heal. Early stage lymphedema is far easier to control than advanced disease, and the venous component is frequently treatable.
Start with a vein self assessment, then schedule a consultation so we can determine what is behind your swelling and build a plan around it.
Elmore Medical Vein & Laser Treatment Center is the premier vein specialty medical practice in the Central Valley. Dr. Mario H. Gonzalez and his staff offer years of experience and medical expertise that you won’t find anywhere else. Contact us to set up a consultation appointment.