Erin Fazzari, MPT, CLT, CWS, has a well-rounded skill set having worked in a variety of settings, including outpatient orthopedics, acute care, skilled nursing, and inpatient rehab. She specializes in the treatment of patients with lymphedema, cancer-related fatigue and chronic wounds. She received her Masters of Physical Therapy from the University of the Sciences in Philadelphia in 2002.
Do you have leg swelling, skin changes or open wounds?
Are you experiencing pain, difficulty walking or an inability to do the things you love because of pain or swelling?
If you answered “yes” to any of these questions, continue reading for help and relief.
Why do I have leg swelling and skin changes?
Often, swelling and wounds on the lower legs are the result of chronic venous insufficiency—or more accurately termed phlebolymphedema. Symptoms of phlebolymphedema include leg pain and itching, swelling, skin changes (such as brownish staining, dryness, scales, rash) and open wounds. Open wounds caused by phlebolymphedema are referred to as venous leg ulcers (VLUs).
What causes phlebolymphedema and VLUs?
Your body has arteries and veins that carry blood to all its parts. Arteries are responsible for bringing blood and carrying nutrients from your heart to your tissue. Veins are responsible for returning it. Your veins have one-way valves that open to allow blood to flow up your leg toward your heart. When the valves close, blood cannot flow back down the leg. There are times when the valves begin to leak and create a backflow. Valves can become leaky with age, obesity, blood clots, varicose veins and other medical conditions.
Leaky valves in your veins increase fluid pressure in the lower leg that causes fluid and other cells from your blood to move into and build up in the tissue. This fluid then has to be removed by vessels called lymphatic collectors. If the lymphatic collectors cannot keep up with the demand, swelling and inflammation result. Inflammation is the result of a build-up of waste products in your tissue that is not being removed. Ultimately, prolonged inflammation can result in pain, itching, skin changes and open wounds (VLUs).
How do you treat phlebolymphedema and VLUs?
Compression therapy is the oldest and most widely used treatment for phlebolymphedema. Correctly applied compression has been shown to improve healing rates in people with VLUs, as well as reduce the risk of recurrence. The key to leg health is to maximally reduce swelling and maintain this reduction with appropriately prescribed compression options. Not all compression is created equal, so it is important to have your legs evaluated by a compression expert, which may include, but are not limited to, vascular doctors, wound care clinicians and lymphedema therapists.
A vascular doctor also will evaluate your legs to determine if surgery is indicated to improve the flow in your veins. Wound care clinicians will prescribe the best care to heal any skin conditions and open wounds. Lymphedema therapists will provide a treatment called complete decongestive therapy (CDT). CDT includes skin and wound care, compression therapy, exercise and manual lymphatic drainage (MLD). MLD is a massage technique that helps reduce swelling by stimulating the lymphatic collectors.
The goal of CDT is to maximally reduce swelling. All parts of CDT contribute to this, but without adequate compression, leg health is not fully achieved. To reduce swelling, lymphedema therapists use either compression bandaging, where the leg is wrapped by the therapist, a caregiver, or yourself and/or a bandage alternative device. Bandage alternative devices strap on the leg and are adjustable to allow the swelling to reduce. You can remove and reapply the devices more easily than compression bandaging. Your lymphedema therapist will help determine which is best to reduce your swelling.
After leg swelling is fully reduced, your lymphedema therapist may recommend compression stockings. These stockings can be off the shelf, circular knit or custom, flat-knit. The knit of the stocking can influence containment of your swelling, ease of donning and comfort. Again, your lymphedema therapist can help determine the best option.
What can I do to best care for my legs?
Based on clinical evidence and as someone that has treated this for 13 years, I stress that it is so important to do the following:
- See a vascular doctor to evaluate your veins to see if vein flow can be improved.
- See a wound care clinician/specialist if you have a wound.
- See a lymphedema therapist to manage your leg swelling.
- Manage your weight. Obesity makes the condition worse.
- Move! Being sedentary will make your condition worse.
Final thoughts.
I want to leave you with some encouragement. Although phlebolymphedema is presently not curable, it is manageable. Your healthcare team is here to provide you support. If you have any questions, feel free to reach out to me at erin.fazzari@pennmedicine.upenn.edu.
References
Ratliff C, Yates S, McNichol L, Gray M. Compression for Primary Prevention,
Treatment, and Prevention of Recurrence of Venous Leg Ulcers . Journal of Wound,
Ostomy, and Continence Nursing. 2016;43(4):347-364.
Zuther JE, Norton S. Lymphedema management: the comprehensive guide for
practitioners. New York, NY. Thieme Medical Publishers, Inc. 2018.
Bjork R, Ehmann S, S.T.R.I.D.E. Professional Guide to Compression Garment Selection
for the Lower Extremity. Journal of Wound Care. 2019; 28(6): 3-33.
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