Lymphedema: New Concepts in Diagnosis and Treatment

  • Robyn BjorkEmail author
  • Heather Hettrick
Wound Care (H Lev-Tov, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Wound Care


Purpose of Review

This review’s aim is to coalesce current evidence regarding the lymphatic system and lymphedema, bridge the gap from traditional approaches to emerging concepts, and present simple strategies that can be immediately implemented into everyday clinical practice.

Recent Findings

New evidence of the microcirculation redefines all edema as lymphedema and having the potential to result in chronic inflammation and deleterious soft tissue changes. These soft tissue changes are easily identifiable through simple manual tests that also help direct interventions. CDT is the gold standard of treatment, but components are evolving with the emergence of new technologies and new understandings of mechanobiology. The lymphatic and integumentary systems are interdependent, requiring concurrent lymphedema and wound management strategies.


Optimization of the lymphatic system is key to edema management and wound healing. Future research is needed to progress individualized diagnostics of lymphatic vasculature so treatment interventions can be customized to each patient.


Lymphedema Complete decongestive therapy Lymphedema continuum Lymphatic and integumentary rehabilitation Manual lymphatic drainage Lymphedema and wound healing 


Compliance with Ethical Standards

Conflict of Interest

Robyn Bjork is Founder, President, and Executive Director of Education for the International Lymphedema and Wound Training Institute (ILWTI). She was also a medical consultant and previous Director of Medical Education and Innovation for Sigvaris, Inc.

Dr. Heather Hettrick is faculty and Director of Wound Education for ILWTI.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
  2. 2.••
    Bjork R, Hettrick H. Endothelial glycocalyx layer and interdependence of lymphatic and integumentary systems. Wounds Int. 2018;9(2):50–5 Review of current concepts of Starlings Law vs EGL, structure and function of EGL, and impact on new lymphedema paradigm and lymphatic/integumentary interdependence.Google Scholar
  3. 3.
    Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovasc Res. 2010 Mar 3;87(2):198–210.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Bjork R, Hettrick H. Emerging paradigms integrating the lymphatic and integumentary systems: clinical implications. Wound Care Hyberbaric Med. 2018;9(2):15–21.Google Scholar
  5. 5.
    Mortimer PS, Rockson SG. New developments in clinical aspects of lymphatic disease. J Clin Invest. 2014 Mar 3;124(3):915–21.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Földi M, Földi E, Strößenreuther R, Kubik S, editors. Földi's textbook of lymphology: for physicians and lymphedema therapists. Elsevier Health Sciences; 2012 Feb 21.Google Scholar
  7. 7.
    Carlson A. Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: a locus minoris resistentiae. Clin Dermatol. 2014;32:599–615.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Shoman H, Ellahham S. Lymphedema: a mini-review on the pathophysiology, diagnosis and treatment. Vasc Dis Ther. 2017;2(3):1–2. Scholar
  9. 9.
    Ruocco E, Puca RV, Brunetti G, Schwartz RA, Ruocco V. Lymphedematous areas: privileged sites for tumors, infections, and immune disorders. Int J Dermatol. 2007;46:662.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Ruocco V, Schwartz RA, Ruocco E. Lymphedema: an immunologically vulnerable site for development of neoplasms. J Am Acad Dermatol. 2002;47:124–7.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Ridner SH. Pathophysiology of lymphedema. Semin Oncol Nurs. 2013;29:4–11.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Framework L. Best practice for the management of lymphoedema. International consensus. London: MEP Ltd; 2006. p. 3–52.Google Scholar
  13. 13.•
    Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016;49(4):170–84 Current staging of lymphedema.Google Scholar
  14. 14.
    Rockson S. Diseases of the lymphatic circulation in vascular medicine: a companion to Braunwald’s heart disease, 2nd Edition. Elsevier; 2013:697–708.Google Scholar
  15. 15.
    Greene A. Diagnosis and management of obesity-inducted lymphedema. Plastic Recon Surgery. 2016;138(1):111e–8e.CrossRefGoogle Scholar
  16. 16.•
    Wang W, Keast DH. Prevalence and characteristics of lymphoedema at a wound-care clinic. J Wound Care. 2016;25(Sup4):S11–5 Emphasizes role of comorbidities in lymphedema management.PubMedCrossRefGoogle Scholar
  17. 17.
    Rockson SG, Rivera KK. Estimating the population burden of lymphedema. Ann N Y Acad Sci 2008;1131(1):147–154.PubMedCrossRefGoogle Scholar
  18. 18.••
    Keast DH, Moffatt C, Janmohammad J. Lymphedema IMpact and PRevalence INTernational (LIMPRINT) study: the Canadian data. Lymphat Res Biol. 2019:10 Emphasizes new global recognition of chronic edema as lymphedema and demonstrates need for cross-education and incorporating lymphedema diagnosis and management into wound centers.Google Scholar
  19. 19.••
    Bjork R, Ehmann S. STRIDE Professional guide to compression garment selection for the lower extremity. J Wound Care. 2019;28(Sup6a):1–44 New resource for compression selection for optimized management of edema/lymphedema.PubMedCrossRefGoogle Scholar
  20. 20.•
    Lu IM, Dixon JB. Assessment of upper extremity swelling among breast cancer survivors with a commercial infrared sensor. Lymphat Res Biol. 2019;29 Exciting new technology using hand held scanner that makes volume calculation and tracking easier.Google Scholar
  21. 21.
    Greenhowe J, Stephen C, McClymont L, Munnoch DA. Breast oedema following free flap breast reconstruction. Breast. 2017 Aug 1;34:73–6.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    National Lymphedema Network Medical Advisory Committee. NLN position statement: the diagnosis and treatment of lymphedema. NLN. February 2011.Google Scholar
  23. 23.
    Rutkowski JM, Boardman KC, Swartz MA. Characterization of lymphangiogenesis in a model of adult skin regeneration. Am J Phys Heart Circ Phys. 2006 Sep;291(3):H1402–10.Google Scholar
  24. 24.
    Scavelli C, Weber E, Aglianò M, Cirulli T, Nico B, Vacca A, et al. Lymphatics at the crossroads of angiogenesis and lymphangiogenesis. J Anat. 2004 Jun;204(6):433–49.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Solito R, Alessandrini C, Fruschelli M, Pucci AM, Gerli R. An immunological correlation between the ancho ring filaments of initial lymph vessels and the neighboring elastic fibers: a unified morphofunctional concept. Lymphology. 1997;30(4):194–202.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Leak LV, Burke JF. Ultrastructural studies on the lymphatic anchoring filaments. J Cell Biol. 1968;36(1):129–49.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Pedersen JA, Boschetti F, Swartz MA. Effects of extracellular fiber architecture on cell membrane shear stress in a 3D fibrous matrix. J Biomech. 2007 Jan 1;40(7):1484–92.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Swartz MA, Fleury ME. Interstitial flow and its effects in soft tissues. Annu Rev Biomed Eng. 2007 Aug 15;9:229–56.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Rossi A, Weber E, Sacchi G, Maestrini D, Di Cintio F, Gerli R. Mechanotransduction in lymphatic endothelial cells. Lymphology. 2007 Sep 1;40(3):102–13.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Rutkowski JM, Swartz MA. A driving force for change: interstitial flow as a morphoregulator. Trends Cell Biol. 2007 Jan 1;17(1):44–50.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Boardman KC, Swartz MA. Interstitial flow as a guide for lymphangiogenesis. Circ Res. 2003 Apr 18;92(7):801–8.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Gerli R, Solito R, Weber E, Agliano M. Specific adhesion molecules bind anchoring filaments and endothelial cells in human skin initial lymphatics. Lymphology. 2000;33(4):148–57.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Van Geest AJ, Veraart JC, Nelemans P, Neumann HA. The effect of medical elastic compression stockings with different slope values on edema: measurements underneath three different types of stockings. Dermatol Surg. 2000 Mar;26(3):244–7.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Mosti G. Compression therapy in mixed ulcers. J Med Vasc. 2018;43(4):223–4.PubMedGoogle Scholar
  35. 35.••
    Rabe E, Partsch H, Hafner J, Lattimer C, Mosti G, Neumann M, et al. Indications for medical compression stockings in venous and lymphatic disorders: an evidence-based consensus statement. Phlebology. 2018;33(3):163–84 Reviews benefits of compression therapy.PubMedCrossRefGoogle Scholar
  36. 36.
    Alavi, et al. What’s new: management of venous leg ulcers: treating leg ulcers. J Am Acad Dermatol April. 2016;74(4):643–61.CrossRefGoogle Scholar
  37. 37.
    Ratliff CR, Yates S, McNichol L, Gray M. Compression for the primary prevention, treatment and prevention of recurrence of venous leg ulcers. J Wound Ostomy Continence Nurse. 2016;43(4):347–64.CrossRefGoogle Scholar
  38. 38.
    Harding K et al. Simplifying venous leg ulcer management. Consensus recommendations. Wounds International 2015.Google Scholar
  39. 39.
    Partsch H, Mortimer P. Compression for leg wounds. Br J Dermatol. 2015;173:359–69.PubMedCrossRefGoogle Scholar
  40. 40.
    O’donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014 Aug 1;60(2):3S–59S.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012;11:CD000265. Scholar
  42. 42.
    Partsch H, Moffatt C.An overview of the science behind compression bandaging for lymphoedema and chronic oedema In: Compression therapy: A position document on compression bandaging. International Lymphedema Framework in association with the World Alliance for Wound and Lymphoedema Care. 2012:12–22.Google Scholar
  43. 43.
    Partsch H, Junger M. Evidence for the use of compression hosiery in lymphoedema. Lymphoedema Framework. Template for Practice: compression hosiery in lymphoedema. London: MEP Ltd; 2006.Google Scholar
  44. 44.
    Muldoon J, Charles H. Clinical effectiveness and patient considerations in oedema management. Journal of Lymphoedema. 2013;8(1):51–5.Google Scholar
  45. 45.
    Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015;5.Google Scholar
  46. 46.
    Moffatt C, Partsch H, Schuren J, Quéré I, Sneddon M, Flour M, et al. Compression therapy. a position document on compression bandaging. Int Lymphoedema Framework. 2012;2012.Google Scholar
  47. 47.
    Bjork R, Ehmann S. Advanced compression therapy for venous and lymphatic disease. Session 3 presentation, symposium on advanced wound care fall; 2018; Las Vegas, NV.Google Scholar
  48. 48.
    Partsch H, Schuren J, Mosti G, Benigni JP. The static stiffness index: an important parameter to characterize compression therapy in vivo. J Wound Care. 2016;25(Suppl 9):S4–S10.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Mosti G. Stiffness of compression devices. Veins and Lymphatics. 2013;2(1):1–2.CrossRefGoogle Scholar
  50. 50.
    Neumann HM. Elasticity, hysteresis and stiffness: the magic triangle. Veins and Lymphatics. 2013;27:e6.CrossRefGoogle Scholar
  51. 51.
    Hirai M, Iwata H, Hayakawa N. Effect of elastic compression stockings in patients with varicose veins and healthy controls measured by strain gauge plethysmography. Skin Res Technol. 2012;8:236–9.CrossRefGoogle Scholar
  52. 52.
    Hirai M, Niimi K, Iwata H, Sugimoto I, Ishibashi H, Ota T, et al. Comparison of stiffness and interface pressure during rest and exercise among various arm sleeves. Phlebology. 2010;25:196–200.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Hirai M, Niimi K, Iwata H, Sugimoto I, Ishibashi H, Ota T, et al. A comparison of interface pressure and stiffness between elastic stockings and bandages. Phlebology. 2009 June;24(3):120–4.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Hirai M, Iwata H, Ishibashi H, Ota T, Nakamura H. Interface pressure and stiffness of various elastic stockings during posture changes and exercise. Vascular. 2008;16(2):95–100.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Clark M, Krimmel G. Lymphoedema and the construction and classification of compression hosiery. Lymphoedema Framework. Template for Practice: compression hosiery in lymphoedema. London: MEP Ltd; 2006.Google Scholar
  56. 56.
    Vander Wegen-Franken K, Roest W, Tank B, Neumann M. Calculating the pressure and stiffness in three different categories of class II medical elastic compression stockings. Dermatol Surg. 2006;32(2):216–23.Google Scholar
  57. 57.
    Hafner HM, Junger M. The Haemodynamic efficacy of six different compression stockings from compression class 2 in patients suffering from chronic venous insufficiency. Phlebology. 2000;15:126–30.CrossRefGoogle Scholar
  58. 58.••
    Vrieze T, Vos L, Gebruers N, et al. Protocol of a randomized controlled trial regarding the effectiveness of fluoroscopy guided manual lymph drainage for the treatment of breast cancer related lymphedema (EFforT-BCRL trial). Eu J Obstetrics & Gyn Repro Bio. 2018;221:177–88 Highlights new flouroscopy guided manual lymphatic drainage approach.CrossRefGoogle Scholar
  59. 59.••
    Suami H, Scaglioni MF. Anatomy of the lymphatic system and the lymphosome concept with reference to lymphedema. In Seminars in plastic surgery 2018 Feb (Vol. 32, No. 01, pp. 005–011). Thieme Medical Publishers. New lymphosome mapping useful with Bjork Bow Tie Test in identification of lymphedema clinically, as well as directing manual lymphatic drainage. Google Scholar
  60. 60.
    ILWTI:, accessed 05/01/19.
  61. 61.
    Granzow J, Soderberg J, Kaji A, Dauphine C. Review of current surgical treatments for lymphedema. Ann Surg Oncol. 2014;21:1195–201.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Charles H. Elephantiasis of the leg. In: Latham A, English TC, editors. A system of treatment, vol. 3. London: Churchill; 1912.Google Scholar
  63. 63.
    Rossy K, James W. Lymphedema. Medscape. Accessed April 24, 2019 at:
  64. 64.
    Corliss BA, Azimi MS, Munson JM, Peirce SM, Murfee WL. Macrophages: an inflammatory link between angiogenesis and lymphangiogenesis. Microcirculation. 2016;23(2):95–121.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Mortimer P, Pearson I. Lymphatic function in severe chronic venous insufficiency. Phlebolymphology. 2004;44:249–52.Google Scholar
  66. 66.
    Farrow W. Phlebolymphedema- a common underdiagnosed and undertreated problem in the wound care clinic. J Am Coll of Cert Wound Spec. 2010;2:14–23.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.International Lymphedema & Wound Training Institute (ILWTI)PalmerUSA
  2. 2.Professor of Physical Therapy at Nova Southeastern UniversityFort LauderdaleUSA

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