SWELLING SPECTRUM

Ediz Hook overlooking Port Angeles Harbor - Port Angeles, WA

I am a certified lymphedema therapist from the Földi Klinic in Hinterzarten, Germany. The credentials behind my name are MPT for my master’s degree in physical therapy, DPT for my doctorate in physical therapy, and CLT-Földi for certified lymphedema therapist at Foeldi clinic. This means that I am a swelling specialist and have been trained in edema management. When people have swelling in their body it is actually called edema but most people know it as swelling so I often use this term even though it is not technically correct.

Anatomy and physiology of the circulatory system

The heart is a pump that pushes all the blood out into the body through vessels or tubes called arteries. These arteries are like soaker hoses flooding the garden. The arteries are wrapped with smooth muscles which contract and cause the fluid to be moved from one section to another. Veins are the vessels or tubes that carry the blood and fluid back to the heart. They do this by using valves that capture the fluid. The muscles next to the veins smash into them which forces the blood up to the next set of valves. Fluid from the legs gets lifted back up to the heart through this system that acts as an elevator. The lymphatic system starts near the ends of the veins and helps to move fluid back to the heart just like the veins. This system has a set of big doors that open up to allow the protein molecules from the blood to come inside the lymphatic tubes or vessels. These protein molecules are too big to fit back into the veins.

The lymphatic vessels have smooth muscle in the wall that contracts moving the fluid up the tube and they have valves that help direct the fluid up to the heart once it is inside the vessel. When the valves of the veins get stretched out the lymphatics kick into an overdrive or turbo capacity to help move the fluid out. Eventually, however, this system gets overloaded and cannot do the work as efficiently. Once that happens, the fluid is left out in the interstitium or tissue spaces and pools which cause the skin to stretch out and swelling occurs in that area. Very often this takes a long time to see the swelling unless it is acute trauma. In a long-term problem, it takes decades for the lymphatic system to fail once the veins have stopped working efficiently.

Inflammatory Cascade

Any trauma that occurs to the body causes an inflammatory reaction. A flood of chemicals known as the inflammatory cascade rushes to the area, just like the paramedics and police officers will rush to the scene of an accident and blockade the area that has the problem until the scene is clear. This inflammatory cascade of chemicals acts in the same way. It fills the area with fluid creating a splint for the area and sends signals up to the brain just like flares set out at an injury site warning you of the danger ahead. The brain gets these painful signals and tells the body to stop trying to use the injured area. Some of the chemicals that rush to the area act like the paramedics helping to heal the area and some act like the cleanup crew once the injured victims are removed.

This inflammatory reaction occurs as a response to any trauma in our body, be it an accident like a car accident, bad skin tear from falling down, breaking a bone, burn, bug bite or pet scratch, sports injuries, gardening injuries, chain saw injuries or rough-housing injuries. Other types of trauma that cause inflammatory reactions are those that are voluntary such as surgery, radiation treatments or tiny traumas such as getting a shot or an injection. Regardless of the cause, our body responds in the same way, it sends a signal out and calls the inflammation to the area.

This inflammation is good in that it helps to heal the area, but it is also the main cause of our pain and often becomes a problem that stays around. After a fracture, once the bone is set in place and we leave it alone, the bone heals.

However, if inside the cast we are not completely still in the area of the injury we continue to cause the fracture to open back up. The same thing happens with soft tissues that get injured such as muscle, tendons, ligaments, and skin. If we keep using an injured area and ignore the signals the body is trying to give us to let it heal adequately, then we keep ripping those injured tissues that are trying to knit back together. The cells that act like little knitting needles knitting tissues back together are called fibroblasts in soft tissue and osteoblasts in the bone. When the tissue that has been knit back together is torn apart again, this virtually creates a new injury and the signal gets sent out to call more inflammatory chemicals to the area.

Time to heal tissues

Typically it takes soft tissue 6 weeks to heal adequately and bone 8 weeks. We are patient for healing for perhaps ¼ of that time and then we get bored with resting and icing. We get so anxious to get back to our lives that we keep causing repeated new injury and then we are upset that we still have pain. The body does not care that your garden needs tending, family needs feeding, or house needs cleaning. The body works in a very specific way and when you recognize this and respect the work it is doing and take care of yourself you can stop prolonging the injury and get the body part healed and back to a normal life. It is best to learn from the previous injury. If you fell because you were not paying attention, then pay more attention. Or if you fell because you have bad balance and do not want to use a cane, use a cane or go see a therapist to learn how to improve your balance.

Testimonial

As a 71-year-old very active outdoorswoman, with a history of over 30 years of running, I found myself scheduled for a total knee replacement. Even though I felt I was in pretty decent shape I knew the surgical procedure would affect my lower extremity with pain and swelling. Enter my home health physical therapist, Loraine Lovejoy-Evans. The first day I met her she emphasized that the pain would be reduced when the swelling was reduced. Loraine instructed me in manual lymphatic drainage massage and to do it twice a day. From the onset, the swelling reduced daily, as did the pain level. The range of motion increased as the swelling and pain subsided.

Then I had a self-imposed set-back. Wanting to enjoy the sunshine and warmth of the day I decided to walk, with my walker, back and forth across my front porch. About twenty minutes later I went inside and then my leg started to ache and swell and range of motion was less. By the next day, when Loraine visited my leg girth measurements were increased and the range of motion was less since the last visit. I knew I had overworked my leg. Back to square one and I worked hard on the manual lymphatic drainage massage. By Loraine's next visit I had markedly less swelling and aching and improved range of motion. I learned two things: how important the massage was and how important not to overdo it.

Now a month out I have no swelling and range of motion of 0-127degrees. I only have aching after being too active, no obvious pain. I continue twice a day to do the massage. Every day is better. I feel that the manual lymphatic drainage made all the difference in my recovery.

Marilyn P., RN, BSN

Causes of swelling

Other causes of swelling can be less obvious such as having lymph nodes removed from surgery (due to cancer) or simply getting older and having the skin and veins stretch out. Traumas from an accident or injury that causes inflammation to stay in an area much longer than it should which puts extra pressure on the skin and stretches it out. When the skin loses the ability to tighten back up it virtually turns into a flophouse allowing more unsavory characters to hang out and become problematic. More water and protein molecules are allowed to stay outside in the interstitium or tissue spaces rather than getting back inside the vessels to get carried back up to the heart. This occurs because of the mechanical damage to the structures that help carry fluid back to the heart, the veins, lymphatic vessels and nodes and even the tightness of the skin.

When the structures like lymph nodes are removed or damaged badly enough they will let the fluid stay in the area and the swelling begins. Initially, it is a very small amount, so small no one really knows it is there. But over time, it fills the area. Eventually. it starts causing the skin to stretch even more and the swelling becomes more obvious. Swelling in a body part that is outside of a joint is actually called edema, but we will use the term swelling for the sake of education.

Since we begin to age from the time we are born and we all have soft stretchy skin we are all at risk for developing swelling across our lifetime. If we manage to heal adequately and resolve the inflammation then it will take us a lot longer to see swelling problems that will stick around. However, if you have a lot of trauma to your body in your youth, it will likely catch up with you in your older years when the skin is so stretched out it can no longer keep the fluid pushed back inside the vessels to be carried up to the heart.

Basically, we are all on the swelling spectrum, most of us are on the bottom edge and do not realize there may be a problem until we get to the middle or top edge of the curve. There are several techniques or tools you can use to help manage swelling problems. It is your decision when you want to jump in and control the mechanical damage that has occurred. If you have a trauma that starts the swelling, the more RICE (rest, ice, compression, and elevation) and Manual Lymphatic Drainage (MLD) massage technique you do immediately after the injury the less fluid you will create and the faster it will go away.

The longer you take to finally rest well enough for long enough and do the treatments to resolve the swelling, the more stretching you cause to the skin and the sooner you will likely see swelling that will not resolve. You might be 50 instead of 80 years old, but it will likely catch up. If you have surgery to remove lymph nodes or stripped veins, once the body can no longer keep up with the fluid levels that are present you will see swelling.

Treatment approaches for managing swelling

Doing a simple massage technique called Manual Lymphatic Drainage or MLD to help pull (suck) the fluid back up to the heart and using compression (socks or stiff wraps) can dramatically help move fluid out of the area and prevent it from staying in the area of injury. The more fluid is present and the longer it stays, the harder it becomes to get it out of the area and the stronger amount of compression you will need to keep it under control. If you wait so long that you become a water balloon, it will take several times a day of doing the massage technique and it will take much tighter compression to overcome the fluid and keep it pushed into the tubes. Recognize swelling early and do something about it quick to make it easier to manage.

Loraine's Knee

After breaking a leg when I was 13 years old, at 44, I found that if I did not wear compression stockings after about 5 days I got knee pain again. So for me, every morning is a choice. If I want to control the knee pain and prevent the swelling from worsening, I put on compression socks. I am able to use a very light amount of compression. But daily I see people who have a water balloon for a leg and this encourages me to keep using my socks so I do not get that bad.

I have worked with people who have such stretched out skin and the fluid pressure is so strong they have to wear a compression sock in the shower so they can get their sock on afterward. They also have to wear a sock that is at least 3 times stronger than mine which means it takes 3 times the effort to put it on. It feels about like trying to put on a wet-suit. Me, I will stick with my easier-to-get-on compression sock and prevent the knee pain and swelling. I want to stay on the left side of the swelling spectrum. Prevention really is a gentler road to take. But it is always a choice.

Choosing knee pain

It is now summer and I have chosen knee pain. I have worn sandals all week and have not been wearing my compression socks. So guess what? I have knee pain. I knew it was coming but didn’t really care. The photo shows my very swollen ankle. Typically I can see the bones of my ankle well-defined and the tendons on my foot. However, this shows loss of definition of the bony structures of the foot. The discoloration on my forefoot near my toes is something I will talk about later when I discuss chronic venous insufficiency. Off of the menu today, I chose knee pain.

Loraine's swollen ankle in the summer: Loraine's less swollen ankle, note veins, and tendons. Choosing knee pain after not wearing compression socks

Handout:

Swelling Spectrum Handout

Presentation:

Swelling Spectrum Presentation