Lower limb oedema is the most prevalent form of peripheral oedema in clinical practice, commonly affecting the legs, ankles, and feet (O’Neill and Harris, 2024). Although it may arise from benign causes, such as prolonged sitting or extended periods of standing (Pearse et al, 2024), it can also result from more serious underlying conditions, including systemic diseases such as cardiac failure, liver disease, renal impairment or cancer (Cabrera, 2022).
It is crucial to determine the cause of oedema as the cause will guide the management plans. Proper identification of the cause enables targeted treatment strategies to be introduced, helping to prevent irreversible changes to the skin and subcutaneous tissue and improving patient outcomes. Table 1 outlines the common causes of lower limb lymphoedema. Lymphoedema is chronic swelling characterised by the excessive accumulation of protein-rich lymphatic fluid in the tissues due to a defect in the lymphatic network (Bowman and Rockson, 2024). It is a progressive condition that causes a significant physical and psychological burden (Mezzarobba and Chierici, 2024).
| Classification criteria | Categories | Description |
|---|---|---|
| Based on the vessel Involved | Venous | Increased capillary filtration that cannot be drained by normal lymphatic drainage, resulting in a low viscosity, and transudative collection |
| Lymphatic | Lymphatic dysfunction leads to exudative oedematous fluid within the skin and subcutaneous tissue | |
| ■ Primary | Present at birth | |
| ■ Secondary | Acquired due to lymphatic system abnormality | |
| Lipoedema | A fat-rich collection that is sometimes considered a form of fat maldistribution rather than true lymphoedema | |
| Based on duration of symptoms | Acute | Less than 72 hours |
| Chronic | More than 72 hours | |
| Based on aetiology | Local causes | Trauma, infections, etc |
| Systemic causes | Heart failure, renal failure, liver failure, diabetes, etc | |
| Post-surgery | Cancer surgeries and lymph-node dissections often lead to lymphoedema | |
| Based on reaction to pressure | Pitting | Fluid drains to surrounding areas on the application of pressure, leaving a depression visible even after the pressure is released |
| Non-pitting | Fluid is pushed along the lymphatic vessels when pressure is applied and fills up rapidly as soon as the pressure is removed |
Advanced clinical practitioners (ACPs) are educated to a master's level or equivalent, equipped with the essential skills and knowledge to practise autonomously within their scope of practice (Health Education England, 2017). They encounter patients with lymphoedema in both primary and secondary care settings and, therefore, should be capable of assessing, diagnosing, treating and referring to the appropriate specialties. This clinical review aims to help ACPs effectively assess patients with lymphoedema. It encompasses classification, history-taking, examinations, investigations and management plans, ensuring a thorough and comprehensive patient care strategy.
Classification
It is crucial to determine the cause of oedema because this will guide the management plan (Figure 1). Lymphoedema can be classified into primary and secondary forms. Table 1 describes the classification criteria of lymphoedema, categorising it by the involved vessels, duration of symptoms, aetiology and reaction to pressure.
Primary lymphoedema
Primary lymphoedema comprises a heterogeneous group of disorders characterised by abnormal development of the lymphatic system, leading to fluid accumulation and swelling. At St George's University Hospital (SGH), London, a robust classification algorithm has been developed to refine the diagnosis of primary lymphoedema, guide genetic testing, and improve patient management (see Gordon et al, 2021). This classifies primary lymphoedema into five distinct subgroups based on phenotypic patterns and associated clinical characteristics.
The SGH classification algorithm, first published in 2010 and updated in 2013 and 2020, incorporates these subgroups and their known genetic markers. This algorithm uses a combination of careful clinical phenotyping and genetic testing to categorise patients accurately. It helps clinicians refine diagnoses based on specific clinical features and genetic information, guide genetic testing to identify causative mutations, and screen for associated health problems, thereby improving patient management. However, a detailed discussion of this classification system is outside the scope of this article.
Secondary lymphoedema
Secondary lymphoedema results from an acquired defect in the lymphatic system and is often linked to obesity, infections, neoplasms, trauma and chronic venous insufficiency (Devoogdt et al, 2024). In addition, it may be associated with intravenous drug use or lymph node resection in cancer treatment (Pagliara et al, 2024). Moreover, morbid obesity often impairs lymphatic return and frequently leads to lymphoedema. Table 2 sets out the most common causes of secondary lymphoedema.
| Trauma and tissue damage |
|
| Infection |
|
| Malignant disease |
|
| Inflammation |
|
| Venous disease |
|
| Miscellaneous |
|
Pathogenesis
In primary lymphoedema, lymphatic abnormalities such as congenital hypoplasia or aplasia of the peripheral lymphatics, or valvular incompetence, are present at birth but may not become apparent until years later (O'Donnell, 2024). Secondary lymphoedema arises from acquired obstructions in the lymphatic system, often due to factors such as obesity, infections, malignancies and trauma (Senger et al, 2023). Regardless of whether the cause is an obstruction of the lymph nodes or a disruption of the local lymphatic channels, the consequence is an inability to drain protein-rich lymphatic fluid from the tissue. This results in interstitial oedema and swelling of the affected area. The accumulation of interstitial and lymphatic fluid within the skin and subcutaneous tissue stimulates fibroblasts, keratinocytes, and adipocytes, leading to the deposition of collagen and glycosaminoglycans (Karayi et al, 2020). This process results in skin hypertrophy and the destruction of elastic fibres.
Clinical findings
Lymphoedema may initially present with pitting oedema, which progresses to non-pitting oedema due to the development of fibrosis in the subcutaneous fat (Karlsson, 2023). The affected skin becomes erythematous, thickened, and ‘woody.’ Over time, patients may develop localised hyperkeratotic ‘cobblestoned’ plaques, most commonly observed on the shins. This can develop into lipodermatosclerosis, which is a chronic inflammatory condition characterised by subcutaneous fibrosis and hardening of the skin on the lower legs. Lymphorrhoea, characterised by the weeping or oozing of clear, yellow or strawcoloured fluid, is also a common feature.
Patients have an increased incidence of bacterial infections, which can manifest as impetigo with golden crusts. Stemmer's sign (the inability to pinch the skin on the dorsal aspect between the first and second toes) is often positive (Guo and Schaverien, 2021). Other associated physical findings specific to the cause of secondary lymphoedema, as well as genetic disorders involving lymphoedema, may be noted upon physical examination. Table 3 outlines the clinical findings associated with various possible diagnoses of lower limb oedema.
| Clinical findings | Possible diseases |
|---|---|
| Body mass index >35 (obesity) | Venous insufficiency |
| Unilateral leg oedema | Deep-vein thrombosis, venous insufficiency, lymphoedema |
| Bilateral leg oedema | Systemic: cardiac, renal, and hepatic diseases |
| Local: abdominal malignancy compressing both femoral veins | |
| Generalised without involvement of the dorsum of feet | Lipoedema |
| Predominant oedema of the dorsum of feet | Lymphoedema |
| Tender oedema | Deep-vein thrombosis, lipoedema |
| Non-tender oedema | Lymphoedema |
| Oedema with periorbital puffiness | Renal diseases |
| Pitting oedema | Deep-vein thrombosis, venous insufficiency, early phase of lymphoedema |
| Non-pitting oedema | Myxedema, late phase of lymphoedema |
| Varicose vein | Chronic venous insufficiency |
| Positive Kaposi-Stemmer sign | Lymphoedema |
| Brownish induration of skin with papillomatosis | Chronic lymphoedema |
| Brown hemosiderin deposits of legs and ankles | Venous insufficiency |
| Warm tender skin with profuse sweating initially, followed by thin, shiny and cool skin | Reflex sympathetic dystrophy |
| Dry atrophic skin with flexion contracture | Reflex sympathetic dystrophy |
| Raised JVP, bilateral basal crackles, significant murmur/rub over the pericardium, and tender hepatomegaly | Cardiac diseases |
| Clubbing, gynecomastia, spider nevi, jaundice, and ascites | Chronic liver disease |
JVP=jugular venous pressure Adapted from Tiwary, 2022
Investigations
The diagnosis of lymphoedema is primarily based on clinical findings. However, assessing liver function, urea and creatinine levels, and conducting a urinalysis are beneficial when renal or hepatic causes are suspected. If malignancy is a concern, specific markers should be evaluated. A full blood count is recommended if an infection is suspected (Alsararatee, 2024). Although imaging is not required for diagnosis, it can be useful for assessing the extent of involvement and monitoring the response to treatment. Ultrasonography can be used to evaluate the lymphatic and venous systems (Kondra et al, 2024). Furthermore, lymphoscintigraphy is the preferred investigation as it provides detailed visualisation of the lymphatic channels with minimal risk (Mohos et al, 2024). Table 4 shows the possible investigation tools for patients with lower limb oedema.
| Basic investigations | Further investigations | |
|---|---|---|
| Condition | Investigations | |
|
|
DVT | DVT Wells score, D-dimer and colour Doppler study |
| Heart failure | ECG, chest X-ray, NT-pro-BNP and echocardiogram | |
| Liver failure | ALT, AST, albumin, bilirubin total and direct, PT, APTT | |
| Renal failure | Complete urine analysis, blood urea, serum creatinine and electrolytes, USG-KUB | |
| Nephrotic syndrome | Urine protein:creatinine ratio, urea and electrolytes, liver functions, serum lipid profile, urine analysis and nephrology review | |
| Malignancy | Abdominal/pelvic CT and tumour markers | |
| Lymphoedema | Lymphoangiography and lymphoscintigraphy: to distinguish lymphoedema from venous oedema | |
ALT=alanine aminotransferase; aPTT=activated partial thromboplastin time;AST=aspartate transferase; CT=computed tomography; DVT=deep vein thrombosis; ECG=electrocardiogram; NT-pro-BNP=N-terminal pro b-type natriuretic peptide; PT=prothrombin time; USG-KUB=ultrasound of kidney, ureters and bladder
Management
In secondary lymphoedema, addressing the underlying cause is essential. The primary goals of treatment are to restore function and prevent recurrent episodes of infection. The patient should be referred to a lymphoedema specialist, if available, to educate the patient on how to manage and treat the condition. The patient should be informed about how to ensure effective skin care, perform appropriate exercises and apply compression stockings.
It is important to note that not all patients with lymphoedema require specialist care. ACPs and generalist practitioners including practice and community nurses can manage mild cases effectively with proper training and support. However, patients with complex, severe or rapidly progressing lymphoedema should be referred to a lymphoedema specialist for comprehensive management and advanced treatment options. Other management strategies for lymphoedema include manual lymphatic drainage (MLD), self-massage, kinesiotaping, intermittent pneumatic compression and photobiomodulation (Lee et al, 2013). Although these are important treatments, this review focuses on the fundamental principles applicable to ACPs, practice or community nurses.
Skin care
Regular skin examination and hygiene
It is imperative that the patient or carer conducts daily inspections of the skin, particularly focusing on the feet and toes, for any signs of damage, redness or swelling (Guo and Schaverien, 2021). Early identification of these changes is crucial for preventing complications and enabling timely intervention. In addition, ensuring thorough drying of the interdigital spaces after bathing is essential to prevent fungal infections such as athlete's foot, which should be promptly treated to avoid exacerbation of lymphoedema (Elia and Maruccia, 2024).
Minor injury management and skin protection
Immediate and appropriate care of minor cuts and abrasions through thorough cleaning and antiseptic application is vital. In cases where injuries exhibit signs of increasing redness, heat or swelling medical evaluation is recommended to mitigate infection risk and prevent lymphoedema aggravation (Simon, 2014). Protective measures against sunburn are also crucial, as sunburn can exacerbate fluid retention and inflammation. The use of electric razors for shaving and careful toenail trimming with nail clippers, rather than scissors, are recommended to minimise skin trauma and subsequent infection risks (O’Neill and Harris, 2024).
Avoidance of localised trauma
To prevent localised trauma and potential infection, it is advisable to avoid administering injections in the affected leg or buttock (Matcuk et al, 2024).
Environmental and clothing considerations
The avoidance of very hot baths is recommended, as they can increase blood flow and fluid retention, thus exacerbating swelling (Lee, 2020). Similarly, wearing restrictive clothing, including tight underwear, should be avoided because it can impede lymphatic drainage.
Leg elevation and mobility
Elevation of the legs during periods of rest is advocated to facilitate fluid drainage and reduce fluid accumulation (Lee, 2020). Specifically, adopting a semi-recumbent position can help open up the inguinal pathways, enhancing lymphatic drainage. Furthermore, avoiding prolonged standing by incorporating periodic walking or sitting with legs elevated can effectively manage swelling (Pearse et al, 2024).
Use of emollients and keratolytics
Regular application of emollients is advised to maintain skin hydration and integrity. The use of keratolytics, such as salicylic acid, can be beneficial in managing secondary epidermal changes associated with lymphoedema (Zhu et al, 2024).
Exercises
It is essential to consider the patient's age and performance status, because these factors affect the amount and type of exercise that can be undertaken. In addition, if mobility or balance is impaired, exercises can be adapted to be done while the patient is seated on a chair or in bed. It is advisable to perform exercises slowly because gentle, controlled movements are more effective than more vigorous exercises in promoting lymphatic drainage without causing additional strain.
Facilitating lymphatic drainage
Engagement in targeted physical exercises is crucial for facilitating lymphatic drainage in patients with lymphoedema. The rhythmic muscle contractions during exercise promote the movement of lymphatic fluid, an effect that is further enhanced by the application of compression garments, which exert a gentle external pressure on the affected limb (O’Neill and Harris, 2024).
Maintaining joint mobility and functionality
Regular physical activity is essential for maintaining joint mobility and overall functionality. Despite the limited availability of specific evidence-based exercise programmes for lymphoedema, the British Lymphology Society (BLS) (2023) recommends that patients with lymphoedema should be encouraged to engage in consistent physical activities, including lifting and carrying, to enhance lymphatic flow and improve limb function.
Improving posture
Exercises aimed at improving posture are beneficial for strengthening the musculature that supports proper body alignment. This contributes to overall musculoskeletal health and reduces the risk of related complications (Elia and Maruccia, 2024).
Weight management
Weight management is a critical component for patients with obesity-associated lymphoedema. Weight loss is strongly recommended to alleviate the burden on the lymphatic system and improve clinical outcomes (Cornely, 2023).
Preventing prolonged immobility and over-exertion
Patients should avoid prolonged immobility of the affected limb to prevent impediments to lymphatic flow and exacerbation of swelling. It is also advisable to avoid over-exertion, straining, and excessively vigorous activities, because these can increase fluid accumulation and place additional strain on the lymphatic system.
Compression
For severe lymphoedema, the lymphoedema specialist may advise the use of multi-layered compression bandaging to be applied in the first instance (Figure 2). However, it is important to check for arterial insufficiency before applying any compression dressing, as compression can exacerbate poor circulation, leading to tissue ischaemia, delayed healing or further complications in patients with compromised arterial flow.
The use and management of compression garments
Compression garments play a vital role in managing lymphoedema by reducing swelling and improving lymphatic flow (Lee, 2020). Patients should be advised to apply their compression garments first thing in the morning. If any fitting issues arise, consultation with their GP, community nurse, dermatology team or lymphoedema specialist is recommended. The assessment and fitting of these garments is typically conducted by trained lymphoedema specialists or clinicians with expertise in lymphatic disorders, ensuring that they are worn daily and adjusted as necessary for optimal efficacy (BLS, 2022).
Patients should be instructed to gradually ease the garment up the limb to ensure even distribution, avoiding creases or wrinkles that can chafe the skin and cause fluid build-up. The garment should feel firm and supportive, but not too tight or loose, and it should not cause pain or discolouration of the toes (Santaniello, 2021). If the garment is too long, excess material should be evenly distributed down the limb, and patients should be advised never to roll the tops of the garment down, as this can cause fluid build-up lower down.
Night compression
For patients whose lymphoedema worsens overnight or for those who sleep in a chair, night compression is increasingly recommended to maintain continuous lymphatic drainage. Guidance on when to consider night compression should be provided by a lymphoedema specialist (Lee, 2020).
Compression garments and skin care
Maintaining good hygiene is crucial for patients using compression garments (BLS, 2022). They should use donning gloves when applying the garment to smooth out wrinkles and should immediately remove the garment and consult their lymphoedema specialist if they experience pins and needles, loss of sensation, increased pain or blue toes.
In cases of cellulitis infection, patients should contact their lymphoedema specialist. If wearing the usual compression garment causes pain during an infection, it should be removed but replaced as soon as the affected area is comfortable enough to tolerate it (BLS, 2022).
Conclusion
ACPs should be familiar with the strategies for managing lymphoedema, and they and generalist practitioners can provide routine skin care, exercise and basic compression garment use. Referral to a lymphoedema specialist is necessary for patients with persistent, severe or complicated lymphoedema, requiring advanced diagnostic and therapeutic interventions.