Lymphe-what?? A Beginner’s Guide to Lymphedema

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Lymphe-what?? A Beginner’s Guide to Lymphedema

Author: Lisa Cheek, PT, DPT, CLT

It’s time to admit it….I am CRAZY about the lymphatic system.  I never thought that this would be such a passion for me.  In fact, I had never really even heard of physical therapy for the lymphatic system before I became involved in pelvic floor rehabilitation.  These days I can’t imagine doing anything else, and if I do my job well you will understand why I love the lymphatic system so much…even when it’s not working like it should.

I was really excited to earn my lymphedema therapy certification!

What is the lymphatic system, anyway?

If you are scratching your head, trying to delve into your memories of high school anatomy lectures to remember just what the lymphatic system is, you aren’t alone.  Any time I try to explain to friends and family what I do, I’m inevitably greeted by blank stares and/or forced, polite nodding. This underappreciated system has so many vital functions, yet it usually flies under the radar to some of the other, more glamorous body systems.

Like this one.

The lymphatic system is made up of a number of different structures, including lymph vessels, lymph nodes, the spleen, tonsils, white blood cells called lymphocytes, and many others. Of all of these, most people are familiar with lymph nodes, because they sometimes swell up and become tender when you are sick.  This is because the lymph nodes are packed with immune cells, and serve as little filters for the lymph fluid that is transported in the lymph vessels. The vessels live underneath the skin, deep in the joints, and also around the internal organs.  The bigger vessels tend to take a similar path to the circulatory system.  That’s why you may see them depicted as side by side in drawings, the circulatory system in red and blue and the lymphatics in green.

Like so.

The main function of the lymphatic system is to transport lymph fluid from your body’s tissues and get it back into your circulation.  Lymph fluid consists of water, cell waste, protein, fats, and blood cells.  You might be wondering: how does all that stuff get into the tissues in the first place?  Long story short, in the tiniest little blood vessels called capillaries, all this stuff comes out on the arterial end ( the red side of the diagram).   What really blows my mind is that we used to think that all the fluid was taken back up by the venous end of the capillaries (the blue side), and it was the job of the lymphatics to mop up all the protein, waste, and whatever was left.  However, new research suggests that the lymphatic system does pretty much all the work of getting this stuff back into circulation.

This is a big deal when you consider two things.

Number 1:  We need protein to live.  It’s the building block of everything, and our bodies recycle protein constantly.  Our lymphatic system transports 75-100 grams of protein back into our bloodstream where it can be used by our body.  Think about it:  a 4 ounce serving of chicken has about 30 grams of protein.  Your lymphatic system transports over three times this amount of protein back into our bloodstream, and without that recycled protein we would die within 24 hours.  True story.

Number 2: The lymphatic system transports a massive amount of fluid out of your tissues and back into your bloodstream, so that it can be eliminated through the kidneys later on.  A healthy lymphatic system can transport up to four liters of fluid per day.  That’s two big bottles of soda worth. We used to think that the venous system would pick all that up, but now we know that without the lymphatics, that would all just be sitting in your body tissues.  This isn’t even to mention all the other stuff that the lymphatics clean up: cell waste, fats, old blood cells, etc.  Do you see now why I am so amazed by this system?

It does happen, though, that this system doesn’t work at full capacity…and I’ll explain to you what happens next.

What can go wrong with the lymphatic system?

The lymphatic vessels are laid out in a beautiful and organized fashion, and usually do an excellent job at draining fluid and waste from the body.  It’s even organized in such a way that if there is too much fluid (think swelling from an injury, etc.) the lymph vessels can either up their game and transport more fluid,or they can re-route that fluid into other areas that can handle the extra load.

A work of art.

However, there are some instances in which the lymphatic system will stop working like it should, causing lymph fluid to build up in places it shouldn’t.  This condition is called lymphedema.  Some causes of lymphedema include:

  • Cancer
    • This is the most common cause for lymphedema in the United States.  Most commonly, it is caused by surgical removal and/or radiation of the lymph nodes in the armpit following breast cancer.  However, it can occur in any type of cancer that involves the lymph nodes, including (but not limited to) prostate and gynecologic cancers.
  • Obesity
    • The presence of excessive fat can damage the lymphatic to the point of no return, either by inflammation or by simply pressing too hard on the nodes and vessels over time.
  • Genetic syndromes
    • There are a number of genetic conditions that cause malformation/malfunction in the lymphatic system.
  • Parasites
    • Filariasis, a nematode spread by mosquitos, is the number one cause of lymphedema worldwide.  This little bug inhabits invades the lymphatic system and causes widespread swelling.
  • Other causes
    • There are so many different reasons why people get lymphedema, too many to list here.  Think about anything that causes blockage the the lymphatic vessels, or causes long term swelling that overwhelms the lymphatic system over time

As you can well imagine, nothing good happens when a bunch of fluid and cell waste sits in the tissues.  Lymphedema is usually localized to the part of the body where the lymphatics aren’t working.  This might include arms, legs, torso, genitals, or head and neck.  In addition to swelling, which can be massive, all that protein and waste can cause the skin to harden (fibrosis) and also makes an excellent home for bacteria (cellulitis).   This condition can be devastating for patients.  It can lead to inability to wear normal clothing, body image issues, difficulty working and performing daily tasks, and increase risk of wounds and infection.

So what can you do about it?

Now we come to the part that gets me really excited.  The gold standard for treating lymphedema is something that we can perform in the clinic with two hands and a few inexpensive supplies.  This treatment is called Complete Decongestive Therapy, and it involves three parts

1)Manual Lymphatic Drainage or MLD

This is a wonderful treatment that involves using my hands to move lymphatic fluid from an area where it is pooling to an area that is better equipped to handle it.  It feels like a wonderful, firm but gentle massage.  My patients sometimes get so relaxed that they fall asleep on the table…it feels that good.  In addition to feeling like a day at the spa, it is also very effective at stimulating the lymph vessels to pump fluid out of the swollen areas.

Below is  a wonderful video showing fluorescent imaging of the lymphatic system before and during MLD.  In the beginning of the video, the bright green spots are areas where the lymph fluid has pooled.  Once MLD is applied, you can see the fluid gushing through the lymph vessels, away from the swollen areas.  Patients often tell me that they literally feel lighter after a good MLD session.  It’s powerful stuff.


2) Compression bandaging

Once MLD has been used, it is absolutely necessary to apply compression bandages to make sure that all the fluid I just drained doesn’t rush back into the swollen area.  The bandages look like ACE bandages, except they are a bit stiffer.  This is a good thing, because it means they don’t squeeze you all the time.  They just provide a stiff surface for your muscles to push on when they are working, which helps to pump fluid out of the affected area.  I always put some type of padding, either cotton or foam, underneath the bandages.  This actually makes the bandages quite a bit more comfortable, and also helps to break up the hardened tissue (fibrosis) we talked about earlier.  The bandages are changed several times per week, and most of my patients learn to do it themselves so they can do it in between our visits.  They are worn 24 hours a day—which can be a little intimidating for some people!  I always tell my patients that they more they wear their bandages in the beginning, the less time they have to wear them overall.  If patients stick with it, we can get rid of swelling surprisingly quickly.

It’s kind of cozy!

3) Skin care

Remember how I told you that bacteria loves lymph fluid?  Well, I meant it.  It is so important for patients to take excellent care of their skin in order to keep bacteria out.  Patients with lymphedema are very susceptible to a skin infection called cellulitis, which can be life threatening.  I have all kinds of tips and tricks to help my patients keep their skin fresh and clean

4) Exercise

We all know that exercise is good, right?  It’s extra good when you are being treated for lymphedema, because it allows your body to use its own mechanisms to get fluid out.  I like to incorporate exercises that my patients already like to do, like walking, hiking, and aerobics.  It is especially helpful to exercise with compression bandages on, as this will increase the effectiveness of the bandaging system.

Your lymphatic system loves when you get your blood pumping!

But does it work?

Short answer: yes.

Long answer: Like any type of therapy, it depends on what you put in.  Complete Decongestive Therapy can be overwhelming for some.  It involves time and commitment.  It can be a long road, and it is easy to get weary.  However, if you stick with it, this is a highly effective way to deal with chronic swelling.  In fact, it’s the best treatment there is, and I am so proud to be able to offer it to the Denver community.

Lymphatics, I love you.

I hope that this has shed some light on the lymphatic system and what can go wrong with it, as well as how we treat it.  The more I study this system, the more I am amazed by what a beautiful system it is.  The more I work with patients with lymphedema and chronic swelling, the more I realize how much I love to treat it.  Complete Decongestive Therapy works.  It gives patients their lives back, and helps patients to feel good about themselves again.  If that isn’t the most lovable thing in the world, I don’t know what is.

Are you or you know someone affected by lymphedema or chronic swelling? Come see me at the Chancery location in Capitol Hill and get started on the road to recovery.

Lisa’s Provider Page

Don’t live in Denver?  We have Certified Lymphedema Therapists at the Englewood and Louisville locations, too!

Contact Us


Patient resources:

National Lymphedema Network

Lymphedema Treatment Act


Földi M. Földi’s Textbook of Lymphology, For Physicians and Lymphedema Therapists. Mosby; 2012.

Zuther JE, Norton S, Armer JM. Lymphedema Management, The Comprehensive Guide for Practitioners. Thieme Medical Pub; 2013.

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About the Author:

Lisa Cheek, PT, DPT, CLT-LANA
Lisa received her Doctorate of Physical Therapy from Regis University in Denver, Colorado. She was born in New Mexico, and relocated to Denver to pursue a Bachelor of Arts at Regis University. Lisa’s yoga practice inspired an interest in the “medicine of movement,” and ultimately led to her passion and life’s work in Physical Therapy. She has a strong background in Orthopedics and she is passionate for helping underserved communities including the LGBTQIA+ population and people with pelvic floor dysfunction, lymphedema, oncology, pregnancy, and chronic pain syndromes. She is progressing through her pelvic health certification through the Women’s Health APTA, and is a Certified Lymphedema Therapist through Klose Training. Her treatment philosophy emphasizes care for the whole person, and considering the big picture when treating musculoskeletal dysfunction. Lisa believes in empowering patients through education and incorporating principles of modern pain science.