Podiatric Insights on Lymphedema

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Podiatrists are often the first clinicians to identify lymphedema during routine foot exams. In this video, Dr. Loan Lam highlights key clinical signs, appropriate vascular assessment, and safe use of compression therapy to improve outcomes—especially in complex diabetic patients.

Key Clinical Takeaways 

1. Early recognition starts at the foot exam: Asymmetrical swelling, pitting or non-pitting edema, skin bronzing, papillomas, a positive Stemmer sign, and a dorsal midfoot hump are hallmark signs of lymphedema frequently first identified by podiatrists.

2. Vascular assessment guides safe compression: An ABI is essential—patients with ABIs between 0.6 and 0.8 can typically tolerate mild compression (18–25 mmHg), particularly after revascularization, with close follow-up within days to assess tolerance.

3. Compression supports wound healing, not infection spread: Contrary to common myths, compression and decongestive therapy reduce inflammatory fluid, lower bacterial burden, and improve circulation—even in patients with active wounds.

Transcript

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

So podiatrists, many times, are the first to see signs of lymphedema in patients. So look for signs of pitting or non-pitting edema, especially asymmetrical swelling, with or without a significant history of trauma. There are skin manifestations such as bronzing of the skin, skin lesions such as papillomas, papules - in the distal leg and ankles. And that can out be indicative of phlebolymphedema or what we call lymphedema of venous etiology. So the Stemmer sign at the base of the second toe in the foot, as well as the dorsal midfoot hump, that edema that you get in the midfoot, are usually signs of later stages of lymphedema, and that's usually first spotted by podiatrists during a normal foot exam.

So the first essential step is always getting a vascular workup in a diabetic patients assessing for ankle brachial index, which is an ABI. And in many cases, diabetics have mixed disease with the arterial vein as well as lymphatic systems being affected. And so generally, if an ABI is between 0.6 and 0.8, you can safely start mild compression of 18 to 25 millimeters of mercury for a patient. And this is especially important after revascularization procedure. So once that patient's arterial disease has been addressed, that extra fluid volume is a strain on the venous and lymphatic system for them to process. So the priorities of this population include careful monitoring after that first round of compression. Bring that patient back within a few days to a week to evaluate the tolerance to the compression.

There's a fallacy that performing compression therapy or manual decongestive treatments in an active wound patient spreads infection or can reduce circulation. And actually the opposite is true. So reducing the volumetric burden of the inflammatory fluid to the wound and the area around the wound actually reduces that bacterial bioburden as well as increasing circulation by pushing the fluid back from the surrounding tissues back into the blood vessels.

Dr. Lam is the Medical Director of Wound Services at United Vein and Vascular Centers