Clouds at sunset over James Island in LaPush, Washington on the Pacific Ocean


Manual Lymphatic Drainage massage technique

Manual Lymphatic Drainage (MLD) is a specialized massage technique that is used to treat edema.  MLD is best known for the treatment of lymphedema, a swelling problem that is commonly seen in people who have had cancer treatments to remove lymph nodes surgically or undergone radiation treatments.  I have been studying, teaching, and using the MLD technique for treating lymphedema and began years ago to use it for swelling from all types of problems.  This technique is the most helpful tool I have found to reduce swelling (edema).

It has been remarkable to me to see many patients since 1997 when I first learned about MLD, get pain relief from this technique.  My thought is that the fluid pooling or pocketing in an area must be pushing up against the nerve bullying it which causes the pain.  By guiding the fluid out of those areas it allows the nerve to function normally and the pain signals stop.


I began using MLD with patients who had knee surgery to replace the knee bones also known as a total knee replacement or arthroplasty.   This led me to my doctoral study on controlling knee pain using MLD. My thought was that by reducing swelling, could we then reduce knee pain?  If so, could we possibly prevent knee replacement surgeries?  As part of my doctoral study on reducing knee pain, I had patients use MLD four times a day in addition to wearing 20-30mmHg knee-high compression stockings.

During the study, patients were reporting knee pain they experienced while walking through a large warehouse store (Costco) reduced from 8/10 to 2/10 in two weeks with the compression socks and MLD.  After withholding these treatments for 2 weeks, the knee pain increased to 6/10.

See information on this doctoral study performed at the University of Puget Sound, in Tacoma, Washingon:



Clinical MLD versus patient home program

When a therapist, such as a physical therapist, occupational therapist, or massage therapist, or a nurse performs MLD in the clinic it is a series of highly specialized massage strokes.  Most of the patients I have done this technique on felt it was quite relaxing and very comfortable.  I can only recall one patient who did not like it because she did not like to be touched.  I did what I could to make her comfortable, but I definitely had to touch her to do the MLD.  


A significant honor of my lifetime was to be able to study in Hinterzarten, Germany, with Drs. Michael and Ethyl Földi.  Both of these doctors are world-renowned edema specialists.  They have a clinic in Hinterzarten where they employ around 10 doctors and 30 therapists to treat the 100 or so patients who stay at the clinic for treatment of lymphedema.


Dr. Michael Földi was quite specific that the most important concepts of MLD are to go in the right direction, performed in the right order while creating a wrinkle in the skin.  Unfortunately, as with many different medical treatments, there is a lot of disagreements with the specificities of this technique.  There are several people who think that only Certified Lymphedema Therapists should be allowed to treat patients with this technique.  I respectfully disagree.  I have trained several patients and family members to perform this technique as well as hundreds of healthcare practitioners across the country and they get great results.

It is my feeling that the technique needs to be performed more often rather than by a specific practitioner. My finding was that when I initially worked on patients doing clinical MLD, they thought that they needed to continue to have me work on them rather than doing the technique for themselves.  In fact, when I started treatment by teaching patients how to perform MLD on themselves, their compliance with a home program of MLD increased dramatically.  I have rarely performed it clinically in the last 10 years other than on my husband, or my dog.  Because after all, it does feel really good!


Another thing I learned over the years after experimenting with my patients, was that the simpler I made the MLD, the greater the patient was likely to do it.  When I taught them all of the swooshes and circles, they got overwhelmed quite easily.  Instead, I teach patients longitudinal strokes, or to simply drag their hand along the body stretching the skin upward toward the heart.

MLD mechanics

The lymphatic system is a series of vessels or tubes connected to lymph nodes that continue connecting until they reach back to the heart.  This system helps move fluid back to the heart.  The primary job of the lymphatic system is to move protein molecules back into the heart.  There are lymphatic vessels that live right under the skin.  The lymphatic vessels have smooth muscles in the wall surrounding them.  When a muscle gets stretched it contracts or shortens.  This is the mechanism that causes your leg to swing when the patellar tendon (the thick collagenous band that encases the kneecap) is struck with a reflex hammer. There are special nerve structures that are specifically tuned in to wait for a quick stretch of a muscle. When that quick stretch signal occurs the nerve yells at the muscle to fire.  The muscle is like the enlisted personnel that does what its commanding officer tells it to do.  The muscle contracts and shortens.

In the case of smooth muscle, it surrounds the vessel and causes a constriction.  


When fluid moves inside the lymphatic vessel and fills the chamber it stretches the wall of the vessel which makes the muscle react with a strong contraction.  This constriction squeezes the fluid in the chamber out into the next chamber and this continues moving fluid up the tube to the heart.  The same mechanism happens when you stretch the skin.  By holding onto the skin and therefore the lymphatic vessels under the skin the muscles get stretched and that makes them contract harder and faster so they move more fluid out of the vessels. Lymphatic vessels have valves inside of them so they lift fluid up to the heart just like an elevator shaft.


The sequence or order of the MLD is important.  Since all of the fluid of the body comes back to dump into the heart it is important to start by emptying these tubes first.  Imagine having a traffic jam.  If you are sitting at the end of a long line of cars, you can honk all you want but you will not move until the accident that is blocking the traffic is cleared away.  In the body, if there is swelling in the foot or hand, the fluid blocking its path back to the heart has to move out of the way first so the fluid from the foot or hand can move up to the next station.

Fluid moves from high pressure to low pressure.  Imagine drinking out of a straw.  You put your lips on the straw and suck creating a low-pressure space so the fluid moves up the straw.  Once the fluid at the top of the straw is in your mouth, the fluid from the bottom of the straw moves to the top.  This suction pump is exactly how the lymphatic vessels work.  By moving fluid out of the space behind the collar bones just before they enter the heart, this creates a vacuum so the fluid connecting to these tubes in the belly move up to the collar bones.  Then the fluid from the groin can move up into the tube in the belly, and so on down to the foot.

MLD recipe

I am convinced that physical therapists can only count to ten.  We seem to always have people start with 10 reps of every exercise we teach. For MLD, it is no different.  Each of the exercises and skin stretches is done 10 times.

MLD is always started near the heart by the collar bones.  This can be done a few different ways.  For people who have a healthy body type and are under 60 years of age, a simple massage stroke above the collarbone works.  But for those older than 60, it is best if they simply do neck and shoulder exercises to get the stretch to the lymphatics behind the collar bones.

After clearing the neck lymph nodes and vessels, the abdomen gets cleared.  This is best done through exercises of deep breathing and stomach exercises.  Patients are taught to breathe in through the nose and let the belly expand just like a balloon filling with air.  Then they blow out through their mouth while squeezing the stomach pulling the belly button toward the spine like a balloon deflating.   It is important to breathe out twice as long as breathing in or you may get dizzy or lightheaded.


Once the neck and the belly are cleared, attention is then focused on the lymph node groups in the armpits (for chest or arm swelling) or front of the groin/hip (for leg or genital swelling).   All of the fluid of the arm and chest drains to the armpit on the same side of the body.  All of the fluid of the leg and genitals drains to the groin on the same side of the body.  Stimulating the lymph node groups in these areas is done by holding onto the skin in the crease and pulling the skin, holding briefly, and then letting go which pulls your hand back to the starting place.

A very important thing to learn is that when the lymph nodes are radiated or surgically removed they are not able to help fluid move up the vessel to the heart.  In this case, the fluid is guided to a different set of lymph nodes.  For example, in breast cancer, the fluid is guided down to the inguinal or front of the groin lymph nodes.  In the case of leg cancer, fluid is guided up to the armpit on the same side of the body.  The fluid can be moved across the body to the opposite armpit or opposite groin crease.  However, according to Dr. Michael Földi, the pathway along the side of the body is the most powerful.

Once the fluid from the pits has been encouraged to move out, the fluid from the top of the arm or leg is then brought out by stretching the skin from the elbow or knee up to the pit.  Then the back of the knee or front of the elbow crease is pumped.  FInally, the skin from the hand or foot is stretched up to the elbow or knee.

Frequency of MLD

The frequency of MLD is one of the most important parts of this technique.   My personal recommendation is to do it every hour initially or as often as you can when you have bad swelling or pain.  I know people cannot do it every hour, but a minimum of four times a day.  People find it easiest to do when using the bathroom or taking a bath/shower soaping up and toweling off.  It is important to remember to stretch the skin so it is best to not use lotion.


When someone has pain, I encourage them to pay attention to their pain level first.  If  0 = no pain and 10 = the worst imaginable pain.  Determine the pain level 0-10/10.  Then do the neck exercises and reassess the pain.  Perform the deep breathing and stomach exercises.  Reassess the pain.  Perform the pit pulls and reassess the pain.  Continue reassessing the pain after each section.  Many of my knee patients have found that they have less knee pain after doing neck exercises.

Consider doing the MLD as often as needed to keep the symptoms under control.  Symptoms other than pain have been reduced using MLD, such as peripheral neuropathy, burning, cramping, numbness, tingling, electrical sensations.  Some people find that they might only have to do the neck exercises, deep breathing, and pit pulls to keep their symptoms controlled.