Part 2 | How to support a patient with lymphoedema

Q: How can podiatrists best support a patient with lymphoedema?

A: Podiatrists can make a big difference in so many ways, particularly by looking at how to reduce the load on the lymphatic system. For example, bandaging and garments are absolutely essential. They’re one of the three things that are very critical in terms of lymphoedema management, being: compression, massage and skincare. 

Q: Can you discuss some more about each of these three interventions?

#1 Massage

A: In the intensive phase, massage will be quite frequent and combined with compression bandaging and compression garments or sometimes wraps (these can be adjusted by the patient). However, as we get into the management phase when we’ve got the swelling down, we’ve then got some degree of control. This is where the patient or their partner can help to take over. 

At this stage, the lymphatic drainage massage can be less frequent and it can be done by a well trained patient themselves or a well trained partner, combined with other patient-led activities like breathing (yoga or tai chi based for example) as well as making sure they are not constipated or bloated and so forth. 

Patient-led activities are really important. Perhaps there is a bit of tension building in a limb and some associated swelling which has been picked up by doing a pitting test in one of the lymphatic territories. So the patient might think, ‘Well, there’s a bit more fluid here, let’s get in and do something’. By telling the patient about the pitting test described earlier, it can help them to help themselves in between podiatry visits.

When it comes to the actual massage, lymphatic drainage massage generally should be light and very gentle. The reason is that if we go back to the lymphatic system, it’s a low pressure, low volume, low flow system. This is really important to remember. Intra-lymphatic pressures rarely go above 10 or 15 millimetres of mercury, unless there’s a big blockage when the system’s pumping hard. Remember also that the volume of lymph fluids draining from each leg is only about  400 millilitres a day.  This is 20 millilitres per hour!  Not much you say – but it’s crucial that it gets removed, otherwise the leg and foot continues to swell.  

So, ideally the patient does their own massage when it looks like it’s needed in the maintenance phase. Yet this should be done under the guidance of a therapist (who they don’t have to see too much but certainly some therapeutic advice is important). For example, podiatrists should be aware of signs that the lymphoedema is not being resolved or getting worse, and they should help to educate the patient to be alert to these signs too. 

#2 Compression

A: Compression gets a bad reputation sometimes because the patient hasn’t been prescribed (or hasn’t selected) the right compression or the right compression gradient. 

There are two things with lymphoedema we’ve got to remember. Let’s imagine we have a swollen foot, a swollen ankle or such. If there’s fluid down there, it’s got to find its way up past the knee, past the groin, through the abdominal area, through the thoracic area, to a junction at the left subclavian jugular right up in the left shoulder. I keep on saying this I know, but never let it out of your mind!  That is why holistic whole body care is important.

So if we put compression on – down distally in the foot or the ankle – and there’s a lot of fluid already in the system proximally, then that fluid is going to have a tough time getting out of that leg. No matter how much compression we put on there, it’s going to be a problem. This is related to what you may remember as Pascal’s Law – fluids move down a pressure gradient. The greater the gradient, the better the flow is likely to be!

The take away point is this: before you even use compression, you’ve got to clear out the area proximally. I use the analogy that if you want to get a good result from compression, you need to, ‘Empty the buckets’. You can’t put water in a bucket full of water. And with a lymphoedema patient, you’ve got to actually do that sort of thing proximally, such as looking at all the possible external compression around the groin that could be caused by the elasticity of underwear and so forth, because that may compromise the optimum outcome from a compression garment. Otherwise, despite good intentions, unwanted outcomes can take place, like the swelling can arguably be trapped to some extent through the use of compression garment. 

Speaking of unwanted outcomes, we also tend to see some examples where the compression garment is inappropriately selected. Say there’s a higher pressure proximally than there is distally. This means that the fluids get forced down distally. So you might see a patient with a compression garment over the knee and the leg, and there’s nothing compressing it over the toes or the foot. And of course, if the pressure gradient is not right, if there’s too much pressure proximally, then the pressure goes back down a failed lymphatic system into the foot and exacerbates it.

#3 Skincare

A: The other big role for podiatrists is to look at the skin. Perhaps the podiatrist can see plantar fibromas and so forth, or warts and other skin issues around the nail beds and such. It is helpful if a podiatrist can remember that the lymphatic system effectively works not too dissimilar to a sewage system; it’s part of our defence system. So if there is a nail bed infection for example, it is likely to be exacerbated if lymphatic drainage is poor which is why it is so important to recognise these potential underlying causes, because if that’s not recognised and dealt with, then things get worse!

Conversely, podiatrists should not do or suggest massage or even compression if a patient has cellulitis. No manual lymphatic drainage should be given. If a podiatrist sees cellulitis in a patient with lymphoedema then they should be aware of what needs to be done in terms of referring that patient on to a qualified lymphoedema therapist or their GP. The Australasian Lymphology Association has a National Lymphoedema Practitioners Register (NLPR) which can help patients find a nearby trained therapist, but not all therapists are on this register.   

Q: How else do you see the role of the podiatrist as being critical in lymphoedema management?

A: Podiatrists really do have a very important role for a number of reasons, in addition to the above points. 

I’m not sure of the level of understanding that you as a podiatrist have in terms of the lymphatics of the lower leg, but there are two major drainage pathways which we refer to as lymphotomes or territories in the lower leg and through in the upper leg, and each of those has got different drainage pathways. It’s important to be aware how they drain differently. One pathway follows the back of the knee and the other pathway goes up through the groin. The pathway that goes into the back of the knee, into the popliteal nodal group, drains the plantar surface of the foot.

So, if you are wearing the wrong sort of orthotics which put the wrong pressure on the wrong part of the foot, the ability for those planar lymphatics to pick up lymph evenly from around the plantar surface of the foot and go to the nodal system might be compromised. Or if too much pressure is being caused by a particular shoe in an area where there’s a crucial lymphatic drainage pathway, that may influence the ability of that system to drain effectively. This in turn may exacerbate anything else the patient is doing in terms of managing their lymphoedema, which shows just how big the role of a podiatrist can be here.

Q: When it comes to red flags, are there any that podiatrists should be alert to?

A: If a podiatrist can recognise the following red flags and then refer the patient to a GP or a lymphologist, it would make a big difference.

For example, any cardiac failure, pulmonary issues and so forth will probably show up as a general edema, and through kidney and liver failure and the like. But one of the other important red flags is certainly cellulitis as I mentioned before! These all require referral onto clinicians. 

If a podiatrist has a potential feeling that there’s something going on with the venous system, deep veins, thrombosis, and so forth, or where there may be some external compression on the lymphatics up in the more proximal areas, then this would be a red flag for a podiatrist to be alert to. Likewise, the beginnings of an infection or a problem in the skin, such as in the foot or the nail beds or somewhere like that, can become serious pretty quickly if those bugs get hold of the patient’s already compromised innate and acquired immune systems, which are normally delivered by lymphatics.

Q: When it comes to patient education, do you have a favourite analogy you like to use? 

A: I think one of the most important elements is getting all people to think holistically about the lymphatic system. Remember that everything that leaks out of our vascular system from the capillary beds in the foot and so forth has to be picked up by the lymphatic system. Nowadays we are more aware that very little, if any of what leaks out of our blood vessels along the arterial side of the capillary beds goes back into the venous system, like we used to believe. It’s the lymphatics which are responsible for that! 

So one has to think holistically and be alert to symptoms from the way they are breathing, through to the types of external pressure on their abdomen which could be caused by tight underwear or jeans.