Does lymphedema spare the toes?

From the Guidelines

Lymphedema does not spare the toes, and in fact, the toes are commonly affected in lower extremity lymphedema, particularly in later stages of the condition. Lymphedema typically progresses from proximal to distal areas, meaning it often begins higher in the limb and gradually extends toward the extremities, eventually involving the toes 1. When lymphatic drainage is compromised, fluid accumulates in the interstitial spaces, causing swelling that can affect the entire foot including the toes. This swelling may cause the toes to appear sausage-like, with limited visibility of normal toe creases. The skin over the toes may become thickened, fibrotic, and develop a characteristic squared-off appearance in advanced cases.

Proper management of lymphedema includes:

• Complete decongestive therapy
• Compression garments that should extend to include the toes
• Meticulous skin care to prevent infections
• Toe exercises to promote lymphatic drainage Early intervention is crucial as untreated toe lymphedema can lead to complications such as difficulty wearing shoes, skin breakdown, infections, and decreased mobility. According to the most recent and highest quality study, patients with lymphedema should be referred to specialists, such as lymphedema therapists, for treatment 1. The principle of treatment is decongestive therapy, which includes physiotherapy and compression therapy, and these approaches must be regularly repeated to maximize treatment effect.

It is essential to note that lymphedema can have a significant impact on quality of life, and patients should be educated on ways to reduce their risk, such as maintaining a healthy weight and engaging in regular physical activity 2, 1. Additionally, patients should be counseled on the importance of avoiding inactivity and returning to normal daily activities as soon as possible after diagnosis, and aiming for at least 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week, including strength training exercises at least 2 days per week 3.

From the Research

Lymphedema and Toe Involvement

• Lymphedema is a chronic condition characterized by the abnormal accumulation of protein-rich fluid in the interstitial tissue, leading to swelling of the affected limb 4.
• The toes can be preserved in patients with lymphedema if there is only swelling without previous cellulites or verrucous hyperkeratosis and neither deformity nor osteomyelitis of the toes 4.
• A study found that preserving the toes is essential in the control of infection, as the toes are a major cause of infection in advanced lymphedema 4.

Treatment of Lymphedema

• Various treatment methods are available for lymphedema, including manual lymphatic drainage, compression therapy, skin care, and exercises 5, 6.
• Complete decongestive physiotherapy (CDT) is a combination of four methods (manual lymphatic drainage, lymphedema rehabilitation exercises, compression therapy, skin care) that can achieve a 45-70% reduction in lymphedema volume 5.
• Compression devices, such as adjustable compression wraps, can be effective in reducing lymphedema volume, especially in cases where compression stockings are insufficient 7.

Preservation of Toes in Lymphedema Treatment

• A study found that preserving the toes is crucial in the treatment of advanced lymphedema, as it helps to prevent infection and improve foot hygiene 4.
• The surgical technique to treat the toes includes excision of the soft tissue at the dorsum of the toes with preservation of the extensor tendon and its paratenon, and preservation of skin flaps at the web spaces 4.
• Proper aesthetic and functional results can be obtained in patients with lymphedema if the toes are preserved, and careful selection of patients and correct surgical procedure are essential for success 4.