How do we diagnose lymphedema?

Lymphedema is best diagnosed with a through history and physical examination by a health care provider with experience in the field of lymphology.

Initial presenting symptoms are assessed in the temporal context of current symptomatic complaints. Past and present medical conditions are reviewed as are all prior surgical interventions. Documentation of foreign travel and infection is essential as is a comprehensive family history. A thoughtful social history is exceedingly important to include alcohol, tobacco and illicit drug use in addition to a level of daily physical activity and employment.

On physical examination, baseline height, weight and body mass index should be obtained. Inspection of the involved area should include documentation of any site-specific edema in a systematic fashion (1+: barely detectible; 2+: slight indentation with moderate pressure; 3+: indentation of soft tissues lasting 5-30 seconds after pressure release; 4+: extremity edema contributing to a size 1.5 to 2.0 times the contra-lateral limb). Circumferential limb measurements or limb volume determination by water displacement or perometry are essential for a comprehensive evaluation. Patients are examined for a positive Stemmer Sign, hemoseiderin deposition in the skin, papillomatosis, cellulitis, skin ulcerations and concomitant arterial insufficiency with ankle:brachial index (ABI) measurements to guide therapy. More complex patients may require a more sophisticated investigation with lymphoscintigraphy, indirect lymphography or CT /MRI scanning.

A through history and physical examination will provide the essential information for a qualified and experienced physician to diagnosis a lymphedema as:

Stage 0: Subjective complaints of "heaviness" or abnormal bioimpedence measurement without frank pitting edema;
Stage 1: Pitting edema that is reversible with limb elevation;
Stage 2: Pitting edema that is not spontaneously reversible combined with mild to moderate fibrosis;
Stage 3: Non-pitting edema with associated frank fibrosis, papallomatosis, and /or frank elephantiasis.