Lymphedema and Massage

What You Need to Know

By Ruth Werner
[Pathology Perspectives]

Edema and lymphedema are topics of great relevance to massage therapists and bodyworkers. While I have avoided writing about it because it involves a tiny bit of—gulp—biochemistry, it seems time to visit the edema/lymphedema conversation.

Picture for a moment what it’s like in the interstitial spaces between our cells. When everything works well, the environment is moist and slick, and the fluid here is not stagnant; it is always moving and changing. Circulatory capillaries connect, weblike, throughout every part of us, and every living cell is within close proximity to one of these supply lines. Capillary walls are so thin that oxygen, carbon dioxide, certain white blood cells, and other substances can easily cross in and out. As the heart pumps blood through increasingly tiny vessels, the force of blood pressure pushes some plasma (the liquid that suspends our blood cells) out through the capillary walls and into the interstitial spaces. Fortunately, osmotic pressure pulls most of it back into the circulatory capillaries, leaving about 10 percent to stay between the cells as interstitial fluid (ISF).

What happens to that leftover 10 percent? It can’t just accumulate. Instead, we have an overflow system: lymphatic capillaries that also completely permeate our tissues. Along the length of these tiny vessels, the endothelial cells that form the walls are hooked by tiny filaments to other nearby cells. This feature means that as ISF pushes cells apart, our lymphatic capillaries open up to draw fluid in, with the assistance of osmosis. (See It’s All About Pressure, page 44, for more information on osmosis and hydrostatic pressure.) In addition, lymph vessels can take in cellular debris that is too big to reenter circulatory capillaries. These molecules are often hydrophilic, meaning they attract water.  

The lymph capillaries carry ISF—now called lymph—toward larger collector vessels, and ultimately toward lymph nodes, where everything is filtered and shunted through the largest lymphatic vessels and back into the circulatory system, where it becomes plasma again. The junction between the cleaned-up lymph and the circulatory system occurs at the left and right subclavian veins, just above the superior vena cava.

A large portion of lymphatic capillary activity occurs in the superficial fascia. The tiny lymph vessels here process an enormous amount of fluid, feeding it into the collector vessels that take it toward the lymph nodes. Other lymphatic capillary activity takes place in the muscles and viscera, but when obstructions anywhere in the system occur, the backflow almost always leads to congestion in the most superficial tissues.

Under ideal conditions, the forces that move fluid into and out of circulatory capillaries and lymphatic capillaries are equal. The plasma-ISF-lymph cycle continuously repeats, and the flow of material from one container to another is even, controlled, and balanced.

What Is Edema?

According to Stedman’s Medical Dictionary, the definition of edema is “an accumulation of an excessive amount of watery fluid in cells or intracellular tissues.” Notice that this definition does not identify a cause for the excessive amount of watery fluid.  

The most common kind of edema that massage therapists see is probably the swelling that occurs in minor injuries: think of a sprained ankle or an infected hangnail. This kind of edema is part of the inflammatory process, when our bodies produce chemicals that promote capillary dilation and the migration of white blood cells to fight potential infection.

Other forms of edema are likely to be connected to systemic infection or organ dysfunction. Pulmonary edema, for instance, refers to the accumulation of fluid in and around the lungs. Glaucoma describes edema in the eye that can pose a risk to the optic nerve. And of course, heart and kidney dysfunction can cause backups throughout the entire system if these key organs cannot keep up with demand.

The uniting factor in all these forms of edema is that, while the forces that promote the production of ISF outweigh the forces that reverse it, the condition is triggered by something other than damage to lymphatic vessels. By contrast, lymphedema occurs specifically because some aspect of the lymph system itself is impaired.

Lymphedema: An Incompetent Lymph System

Primary lymphedema—lymphedema caused by an anatomical anomaly—is relatively rare, and usually involves the absence of major collecting vessels. Much more common is secondary, or acquired, lymphedema, which is a result of surgery, radiation, other trauma, or elephantiasis (a disease caused by a parasitic worm, the most common form of acquired lymphedema worldwide).

In our country, the most common trigger for lymphedema is the removal of lymph nodes as part of cancer staging. Radiation and surgery can also damage lymph tissues, so lymphedema can be a complication of these interventions as well. The problem with damaged lymphatic structures is that lymphatic vessels regenerate slowly and inefficiently, and lymph nodes don’t regenerate at all. When lymph structures are damaged, ISF is trapped in the tissue and backs up toward the superficial fascia. Large, hydrophilic molecules that should be processed in the lymph system have nowhere to go. These attract water, and the problem continues. 

If this situation persists, the lymphatic walls become fibrotic and inelastic. Failed valves and thrombi accumulate within the vessels, closing off the remaining openings. Functioning lymph nodes harden and shrink, and may fail altogether. Local circulation of white blood cells is dangerously limited. Infection, deep vein thrombosis, gangrene, and amputation are possible complications. And lymphedema that involves long-term changes to the tissues raises the risk of lymphangiosarcoma: cancer of the lymphatic vessels. 

Lymphedema occurs in these stages:

• Latency: Lymph processing capacity is diminished, but no signs or symptoms are evident.

• Stage I: This is a reversible stage. The tissue is soft, and pitting edema may be present.

• Stage II: In this stage, the tissue becomes brawny, fibrotic, and indurated. Damage to the tissue is irreversible.

•Stage III: This involves permanent hardening of the extremity and significant skin damage.

Implications for Massage

The most important takeaway from all this information is that massage therapists who are not trained in some form of lymphatic drainage work need to have their eyes open for clients at risk for lymphedema. The risk is significant: a flare-up of lymphedema can easily lead to skin damage, infection, and worse.

It is also important to remember that a person may have no visible signs of lymphatic damage, and years may pass without symptoms of pain or impairment. But even minor irritants like a blood pressure cuff that’s too tight, a scraped knuckle, sunburn, or a massage therapist who works too deeply on the extensor compartment can trigger a relapse.

The most concrete guideline for clients at risk for lymphedema is to be extra-conservative on the entire quadrant of the body where the lymphatic system is impaired. Pressure must be no deeper than that used for typical application of lotion: this means bodywork should not evoke redness or pain. The whole quadrant includes not just the extremity but the trunk, anterior, and posterior as well. It’s safer working on the rest of the body, but some experts recommend caution here as well, at least until the client has a chance to see what changes massage brings about.

Therapists trained in lymphatic drainage learn the detailed anatomy of the lymph system, including where the watersheds are. These are the places where ISF enters the network of vessels that carry it to groups of lymph nodes. Because the lymph system is open—that is, the vessels can accept fluid all along their length—lymphatic flow can be rerouted to alter the watershed system. Lymphatic work has a good success rate, especially when combined with careful exercise, skin care, and compression garments, but it is a specialized field and should not be undertaken without appropriate education.

Some of the complications of lymphedema include depression, poor self-image, and social isolation. Massage is well suited to address all of these, and can then lead to better self-care and an improved prognosis. The prospects for helping people with lymphedema are exciting, and they present a great way for massage therapists and massage therapy to be welcomed in medical settings. I urge interested practitioners to pursue this work through the many avenues that are available. Then report back to me: write a case report about your experience to share your wisdom with your colleagues! 


A special thanks to Helen, Lisa, and Kate, who generously contributed their wisdom to this piece.

  Ruth Werner is a writer and educator approved by the National Certification Board for Therapeutic Massage & Bodywork as a provider of continuing education. She wrote
A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2012), now in its
fifth edition, which is used in massage schools worldwide. Contact her at or


It’s All About Pressure

Four different forces influence the direction of the fluid that, depending on where it is found, is called plasma, interstitial fluid (ISF), or lymph.


Capillary hydrostatic pressure: This is the force of the heart pushing blood through the circulatory capillaries with so much power that some fluid seeps out into the interstitial spaces.


Interstitial hydrostatic pressure: If the interstitial space is very packed with fluid, material can be pushed back into circulatory capillaries. Under normal circumstances, however, interstitial hydrostatic pressure is negative, so it acts as a suction pump, supporting the movement of fluid out of the capillaries and into the interstitial spaces.


Capillary osmotic pressure (osmosis toward the vessels): Osmosis is the force that brings water to dilute a highly concentrated solution. It is the main factor in the reabsorption of fluid back into circulatory capillaries at the cellular level, and it also promotes the movement of ISF into the lymphatic capillaries.


Interstitial osmotic pressure (osmosis toward the interstitium): Again, osmosis brings water to dilute a highly concentrated solution, this time in the spaces between the cells. In the case of lymphedema, a major component in interstitial osmotic pressure is the presence of large molecules that attract water—we call these hydrophilic molecules.



Difference Between. “Difference Between Edema And Lymphedema.” Accessed December 2012.

Lymphedema People. “Leg Lymphedema.” Accessed December 2012.

Lopez, Martin M. et al. “Manual Lymphatic Drainage Therapy in Patients with Breast Cancer Related Lymphedema.” BMC Cancer 11 (2011).

Medscape. “Lymphedema.” Accessed December 2012. 

Park, J. et al. “Quality of Life, Upper Extremity Function and the Effect of Lymphedema Treatment in Breast Cancer Related Lymphedema Patients.” Annals of Rehabilitation Medicine 36, no. 2 (2012): 240–47.

Premkumar, K. “Edema and Lymphedema: Are They Different? Implications For Bodyworkers.” Massage & Bodywork (December/January 2005): 46–52.