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Stages of Lymphedema

Janice Bruckner, PT, PhD, CLT-LANA

July 31, 2018



What are the four stages of lymphedema?  


Stage Zero. In Stage Zero, there are no clinical signs of lymphedema. The patient may indicate that something is wrong, or their limb feels heavy. If they just went through surgery, you can expect that something's going to feel not quite right. If you have access to imaging of the lymphatic system, you would be able to see the blockage. A little later on in the presentation, I'm going to show you images of the lymphatic system so you can see what a blockage looks like. At the University of Texas in Houston, they were doing surgery with a patient who had breast cancer and she said, "There's something wrong. My limb feels very heavy." They conducted this diagnostic imaging, they saw the blockage, and they immediately started lymphedema treatment. As a result of their prompt attention, she never developed lymphedema.

Stage One. Stage One has swelling present, but it resolves on its own. Perhaps in the morning, when the person has been asleep all night, we don't see any swelling. However, when they're on their feet all day, we see some swelling by the end of the day. Then, when they go to bed and they put their feet up, the swelling resolves. Swelling with orthopedic patients in Stage One usually is pitting edema. It's at an early stage, and it responds well to exercise, compression, manual lymphatic drainage, and all the other things that are in our lymphedema treatment toolkit.

Stage Two. Stage Two lymphedema involves swelling that does not resolve on its own and requires some sort of intervention to help reduce the swelling. We may see this in our patients with orthopedic problems. Not only do they need the orthopedic protocols, but they also need some lymphedema management. They do present with pitting edema. Our goal is to try our best to avoid it turning into this hard lymphedema where the lymph fluid turns more gel-like. At the same time, we need to be mindful of the surgical scar and the risk of infection. We want to make sure that any kind of swelling is neither lymphedema nor infection.

Stage Three. Rarely do we see Stage Three lymphedema with our orthopedic patients. Stage Three is a chronic form of lymphedema characterized by enormous swelling, called elephantiasis. The skin cannot contain all this lymph fluid, resulting in lobules, or huge globs of skin. The skin cells die, they turn black, and to touch the skin, it feels like you are touching the bark of a tree. People with Stage Three lymphedema have wounds and lymph leakage. Again, this is seen much more commonly in cancer patients and more rarely in orthopedic patients.

janice bruckner

Janice Bruckner, PT, PhD, CLT-LANA

Jan Bruckner, PT, PhD, CLT-LANA, has been a physical therapist for forty years with an academic background in anthropology, philosophy, physical therapy, and lymphology. While working for United Cerebral Palsy, she learned about the horrific abuses that occurred at Willowbrook State School. Her reaction led her to a six-week National Endowment for the Humanities summer symposium on allied health ethics and doctoral studies where she wrote a theory of physical therapy ethics for her PhD minor. She taught in academic physical therapy programs, did research and worked as a clinician. She served as a physical therapist in the US Peace Corps and consulted to both the US Indian Health Service and the Canadian First Nations Health Service. She provided pro bono services to the US Army in Indianapolis, IN during Desert Storm, to people in Les Cayes, Haiti after the 2010 earthquake, and in a shelter for men who are homeless in Philadelphia, PA.  The case studies in her ethics seminar draw on her experiences in these varied settings.

Related Courses

Lymphedema Management of the Orthopedic Patient
Presented by Janice Bruckner, PT, PhD, CLT-LANA
Recorded Webinar


Janice Bruckner, PT, PhD, CLT-LANA
Course: #2957Level: Intermediate3 Hours
  'it was clearly written'   Read Reviews
This three-hour course examines ways to use lymphatic therapy techniques to manage patients with orthopedic problems, such as joints replacements, fractures, sprains, and strains. Topics include: anatomy and physiology of the human lymphatic system, techniques, such as manual lymphatic drainage, compression, elevation, diaphragmatic breathing, therapeutic exercise, kinesiotaping, and skin care, program planning, including problems, short term goals, long term goals, and treatment plan, and case studies to illustrate the application of the material presented. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Editor's Note: Regarding Pennsylvania credits, this course is approved by the PA State Board of Physical Therapy for 2 hours of general and 1 hour of Direct Access CE credit.

Scar Management for Therapists; Synthesizing and Utilizing Best Evidence
Presented by Patti Sharp, OTD, MS, OTR/L
Recorded Webinar


Patti Sharp, OTD, MS, OTR/L
Course: #2345Level: Intermediate1 Hour
  'Informative'   Read Reviews
This course will present best practices in management of hypertrophic scarring, as well as methods used to synthesize best available evidence into practical recommendations at the point of care. These methods can be applied to all areas of practice. This course is directly related to the practice of physical therapy is therefore appropriate for Physical Therapists and Physical Therapist Assistants.

Wound Management in the Home
Presented by Kenneth L. Miller, PT, DPT, GCS, CEEAA, Lena Rome, RN, MSN, CWOCN
Recorded Webinar


Kenneth L. Miller, PT, DPT, GCS, CEEAALena Rome, RN, MSN, CWOCN
Course: #2862Level: Introductory2 Hours
  'I work in acute care and home health'   Read Reviews
This course will enhance the participants' knowledge base regarding treatment plans for wound management In the home. This course is directly related to the practice of physical therapy and therefore appropriate for the PT and PTA.

Burns-Evaluation and Treatment
Presented by Jennifer A Gardner, PT, DPT, MHA, CWS
Recorded Webinar


Jennifer A Gardner, PT, DPT, MHA, CWS
Course: #2880Level: Intermediate2 Hours
  'Info was well written and clear'   Read Reviews
This course will describe types of burns and the different levels of severity. It will also define some psychosocial aspects to consider when caring for patients with burns. Finally, this course will identify basic treatment for burns, including the role of the medical and therapy interventions. The content of this course is directly related to the practice of physical therapy and is appropriate for the PT and PTA.

Swell to Well: Wound Management for Clients Living with Lymphedema
Presented by Neely Sullivan, MPT, CLT-LANA, CDP
Recorded Webinar


Neely Sullivan, MPT, CLT-LANA, CDP
Course: #3666Level: Introductory2 Hours
  'deal with patients at work daily'   Read Reviews
This seminar will describe the anatomy and physiology of the lymphatic system in relation to risks for developing wounds. This session will also focus on different types and stages of wounds commonly occurring and outline wound management interventions for individuals living with lymphedema. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.