Lymphedema - Jeffrie C. Leibovitz, DPM


Swelling is one the most overlooked and undertreated problem in the lower extremities.

As it turns out, it is also one of the easiest problems to prevent and treat – if we get to it early. It’s like those devastating California fires. If only the first sparks were recognized, we could have stomped them out quickly. Give them time, though, and they become much more challenging to handle.

Why do ankles swell?

There are a multitude of reasons feet swell.

Sir Isaac Newton was the first to describe swollen feet. Well, not directly, but he is given credit for observing the effects of gravity.

Gravity is the problem. We know that an apple only goes one direction when dropped. The same thing happens when you spill a glass of water – it heads down to the lowest point. The lowest part of the body is the foot and ankle, and that is often where you will first notice swelling. It is the basement of the body.

Now, let’s talk about circulation.

The way to a man’s heart is through…

The body’s circulation has two transport systems: the delivery system (arteries) and the return system (veins and lymph vessels). 

The venous (not Venus) system is the way blood returns to the heart. It is the 5-lane I-70 that runs through downtown Indy. On the other hand, the lymphatic system is the alleyways and side streets that also get you downtown. 

The vessels in the lymphatic system rarely get any credit. They are truly the Rodney Dangerfield of the body. Let’s call them “lymphettes.” Their job is to sponge up and transport all fluid that surrounds all the organs, tissues and cells of the body. Both the veins and the lymph vessels work together to ferry fluid away. But like a sink, if more fluid goes in than can be drained, we’ll have an overflow.

What goes down must come up

As I mentioned, the blood and fluid pumped away from the heart has to make its way back up. That means it has to beat Sir Isaac’s gravity. This is one of the best magic tricks that the body performs. It is accomplished by pumping, squeezing, and blocking, using muscles and valves inside the vessels.

The valves in your heart keep blood flowing forward when it pumps. There is a lot of pressure in the heart and these valves are large and robust. A smaller and delicate version of these valves are in the veins and “lymphettes.” 

If you have ever owned a house that had a sump pump in the basement, you may know about stop valves. This pump pushes water out of the basement when water collects in the overflow well. When the pump stops, you do not see a flood of water coming back in the basement. This is because a one way valve lets fluid move up but not down. 

When either the pumping actions of the circulatory system or the “stop valves” do not do their job well, more fluid accumulates in the “basement” of your feet. This is when swelling becomes noticeable. Fortunately, there are multiple veins/drains in the leg. But if one vein goes bad, the others veins have to do more work. This leads to further vein failure like a row of dominos. The valves will eventually become “incompetent” and allow fluid to flow downward. Gravity is now an enemy.

Who is at higher risk for swelling in the feet?

People that are not active are prone for swelling. Examples are people that travel a lot, couch potatoes, post-op patients, and paraplegics. 

Another category would include pregnant women. Their growing bundle of joy sits on the large veins and blocks returning venous flow. This is like bending a garden hose to stop the water. 

People that stand without movement are also prone to swelling. This is why a military guard can lose consciousness and collapse. There is not enough blood that returns to the heart because leg muscles are not pumping fluid. This can also happen when standing in line for Black Friday sales, standing up to quickly, or in hot weather. This is known as a “head rush” and is a result of diminished blood flow to the brain.

Other instigating factors are obesity, medications, oral birth control, bleeding disorders, and trauma.

Boring trivia: My surgery patients wear a knee-high compressive sock. But on the opposite side of surgery. The chances of a blood clot/phlebitis is greater on the nonsurgical side following lower extremity surgery. After 2-3 weeks, they will switch to the side of surgery to control any lingering swelling.

What makes bad veins bad

If blood pressure is too great or if there is too much fluid in the body, there will be valve damage. 

Your kidneys play a critical role in condoling the body’s fluid level and blood pressure. Both of these problems can lead to fluid accumulation/swelling. Anything that impedes return flow will cause damage. Over a long period of time, the valves get damaged and cannot repair themselves. Unfortunately we cannot repair or replace valves in these small vessels like we can with heart valves.

An ounce of prevention is worth 100 pounds of cure

Unless you are an astronaut, it will be pretty hard to beat gravity. But we can definitely try to control it.

The first step is to turn the table on gravity. It is pretty easy to get the foot ABOVE the heart. It is pretty hard to keep it there. If the problem is acute, like an ankle injury, then elevating may not be required for very long.

If swelling is a chronic issue, elevating will be a lifestyle. Every time to sit down is an opportunity to elevate. Elevation is even simpler when sleeping. Elevating the foot off the bed 2-3 inches should do the job.

If swelling is controlled in the early stages, such as pregnancy, it will dramatically reduce or eliminate future problems. Varicose veins will make their appearance following birth. It may take years before they escalate to a significant problem. Game over with having nice legs at this point.

So what can be done? glad you asked!

Gravity is not our friend while standing, walking, or sitting with the feet hanging down. This is where something so simple becomes so difficult.

Compression garments will be needed for aggressive and chronic swelling. The challenge is wearing them. If they provide adequate compression, they will be difficult to get on. You will most likely be out of breath or need a nap after putting these socks on. This can also be an extreme barrier with arthritis or in the third trimester of pregnancy.

You can double the benefit of compression with activity. Muscle contracture along with external pressure from the socks is extremely effective. Just moving your ankles in circles while using compression socks is helpful. Note: compression socks and garments should be worn during the waking hours and removed while sleeping.

Compression socks have become mainstream because of endurance athletes. It has been proven that reduction of swelling with compression not only aids in recovery but increases performance. There is now an unlimited choice of designs and colors, and the increase in availability has also driven down the price significantly.

Diuretics are commonly used to address swelling. They are intended to reduce the overall fluid content of the body, but do not address the specific area of swelling or lymphedema. Diuretics and compression hose will increase the frequency of running to the bathroom. This is another way to make sure that you stay active.

Laser therapy is also an option to help with the pain and swelling within your leg.

(My million dollar idea)

People with hypertension can measure their blood pressure. Diabetics can measure blood sugar multiple times during the day. Swelling can also be measured. Simply using a tape measure to check the circumference of the foot, ankle and mid-calf. I have seen a reduction in calve size by 2 – 3 cm within 24 hours with compression and elevation. If I had a late-night commercial promising to reduce your waist size by this amount within 24 hours I could be a multi-millionaire.

What could possibly go wrong?

If the treatment sounds just too hard to do…. well, the potential complications are even more difficult to deal with. As veins swell they become a prime target for blood clots (phlebitis or deep vein thrombosis). This may lead to hospitalization and long-term anticoagulation therapy. If a clot migrates to the heart, lung or brain, using a compression hose is the least of your worries.

After veins are damaged enough, they will begin to leak fluid. This will first show up as a dark pigmented area before a venous stasis ulceration develops. These are painful and can take a very long time to heal in a swollen leg. These types of ulcerations will rapidly resolve once swelling is controlled.

The skin will become fragile over a leaky vein or a previous ulcer site. It takes only a small insult to have the skin fail again. I use the term “recovering ulcer” patient. The problem will never go away – it can only be controlled. One slip and the cycle is repeated.

The best treatment is early treatment. NEVER have prolonged swelling that develops to lymphedema. I am here if it is past this phase. But just like the old Fram oil filter commercial said “you can listen to me now, or listen to me later.”

If you have a disease affecting your feet, we’ll do everything we can to help you beat it, including providing referrals to other specialists and keeping in regular contact with your general practitioner (and other appropriate members of your medical team).

For more information or to request an appointment with Dr. Leibovitz, give us a call at (317) 545-0505.

lymphedema stage diagram
diagram showing a normal leg vs one with edema
a person taking their shoe off who has lymphedema