Same symptom. Different mechanisms. Different questions.

Someone has a swollen ankle. Or perhaps one leg has gradually become bigger than the other. Their rings are tighter. Their arm feels heavy after cancer treatment. Their socks suddenly leave deep marks.

And increasingly, people know the word lymph.

That is a good thing.

But there is a little problem.

Not all swelling is lymphoedema. And not all swelling needs to be “drained”.

Sometimes the lymphatic system itself is struggling. Sometimes it is being asked to cope with far more fluid than usual. Sometimes another system — venous, cardiac, renal or hepatic — is part of the picture. And occasionally swelling is telling us something that needs medical attention rather than a treatment couch.

So perhaps the first question shouldn’t be:

“How do we get rid of the fluid?”

Perhaps it should be:

“Why is the fluid there?”

First things first: what actually is lymphoedema?

Our tissues are not dry.

Fluid continually moves out of the blood circulation into the tissues, carrying nutrients and supporting normal cellular activity. The lymphatic system has an important role in collecting fluid and substances from those tissues and returning them towards the circulation.

Lymphoedema occurs when lymphatic transport is insufficient and swelling develops in the tissues.

It may be primary, arising from an intrinsic abnormality in the development or function of the lymphatic system, or secondary, where lymphatic function has been damaged or impaired by something else — including cancer treatment, infection, trauma, inflammation and venous disease.

The International Society of Lymphology also makes an important point in its current consensus document: lymphoedema isn’t an area in which every question has a beautifully neat answer. Evidence varies, clinical presentations vary and there remain gaps in high-quality research.

I rather like that acknowledgement.

Bodies don’t always read textbooks.

It can appear at different stages of life and isn’t necessarily something that will have been obvious from birth.

Things worth noticing or asking about: When did the swelling begin? Is there a family history? Is one limb affected or more than one? Have there been recurrent skin infections? Have the skin or tissues changed?

This is one reason a history matters so much.

2. Cancer and cancer treatment

This is probably the association most people have heard about.

Cancer itself can obstruct lymphatic flow, while surgery may remove or disrupt lymphatic structures. Radiotherapy can also cause tissue changes that affect lymphatic drainage.

And lymphoedema doesn’t necessarily appear immediately after treatment. It can develop months or even years later.

But there is another important message:

Having cancer treatment does not mean that somebody will inevitably develop lymphoedema.

For someone who has had cancer treatment, I’d want to know what surgery they had, whether lymph nodes were removed or treated, whether they had radiotherapy, when the swelling started and whether it is changing.

A feeling of heaviness or fullness can also be worth reporting rather than waiting until obvious swelling develops.

3. Venous insufficiency — when the veins and lymphatics meet

I think this is one of the most interesting parts of the story.

Blood travelling down into our legs has to make its way back upwards again. When the veins aren’t working effectively, venous pressure can increase and more fluid can enter the tissues.

That creates more work for the lymphatic system.

Over time, chronic venous disease can therefore contribute to lymphatic overload and eventually lymphatic dysfunction. The NHS specifically recognises damaged or abnormal veins, including DVT and varicose veins, among conditions that can contribute to secondary lymphoedema.

This is where terms such as phlebolymphoedema enter the conversation: it isn’t really sensible to think of the venous and lymphatic systems as two completely separate plumbing systems.

Clues worth discussing: Does swelling worsen as the day progresses? Is there a history of varicose veins or DVT? Are there skin-colour changes around the lower leg or ankle? Is there aching or heaviness?

Same swollen ankle.

Potentially quite a different story.

4. Lipedema — similar spelling, different condition

Lipedema and lymphoedema are not interchangeable diagnoses.

Current international consensus describes lipedema as a condition characterised by abnormal adipose-tissue distribution, predominantly affecting women, usually accompanied by pain or discomfort. Diagnosis remains clinical and involves history, examination and consideration of other possible diagnoses.

The distinction gets more complicated because lymphatic dysfunction can coexist with lipedema, but current evidence does not establish primary lymphatic dysfunction as the cause of lipedema itself.

That distinction matters.

A person can also have lipedema and obesity, venous disease or lymphoedema.

So once again, a label based purely on what a leg looks like isn’t enough.

5. Obesity and the lymphatic system — more than simply “extra weight”

This deserves a thoughtful conversation rather than blame.

Research increasingly suggests that severe obesity can affect lymphatic structure and function. Studies describe changes including impaired lymphatic pumping, leakiness and reduced clearance, while extreme obesity can itself lead to secondary lymphoedema — often described as obesity-induced lymphoedema (OIL).

There also appears to be something of a vicious circle: lymphatic dysfunction promotes inflammation, fibrosis and adipose deposition, while increasing adiposity can further impair lymphatic function.

That is much more interesting — and much kinder — than:

“Your legs are swollen because you’re overweight.”

Biology is rarely that simple.

6. Cellulitis — where cause and consequence can meet

This one really matters.

Lymphoedema increases vulnerability to cellulitis, an infection of the deeper layers of the skin.

But severe or recurrent cellulitis can also damage tissues and lymphatic structures and contribute to lymphoedema.

So the relationship can travel in both directions.

Hot, painful, increasingly swollen skin — particularly if accompanied by feeling unwell, fever or shivering — is not something to massage and “see how it goes”. NHS guidance recommends urgent assessment for suspected cellulitis.

More on that in our traffic lights shortly.

7. Injury, surgery and inflammation

Think about what happens when you sprain an ankle.

It swells.

That doesn’t mean you’ve suddenly developed lymphoedema.

Inflammation increases fluid movement into an area as part of the normal response to injury. Surgery similarly produces inflammation and tissue fluid as part of healing.

Usually the body manages that changing fluid load.

But substantial trauma, surgery or persistent inflammation can sometimes damage lymphatic structures or contribute to longer-term lymphatic problems.

So again:

swelling ≠ automatically lymphoedema.

The timeline matters.

8. Heart, kidneys and liver — sometimes swelling is a bigger-body story

This is an important distinction because swelling isn’t always primarily a limb problem.

Heart failure, renal disease and liver disease can all be associated with peripheral oedema. Medication, thyroid disease and other systemic conditions can also contribute.

That’s why someone presenting with two swollen ankles doesn’t automatically need somebody to start moving fluid around.

We need context.

Is the swelling new? Both sides? Is there breathlessness? Has body weight changed quickly? Has medication recently changed? Is there known heart, kidney or liver disease?

Sometimes the appropriate next step isn’t MLD.

It’s a conversation with the GP or medical team.

And recognising that is part of good lymphoedema practice too.

9. Medication-related swelling

This is easily overlooked.

Some medicines can contribute to peripheral oedema, which is why medication history forms part of the assessment of unexplained swelling.

That doesn’t mean stopping medication because you’ve noticed swollen ankles.

It means asking:

“Could my medication be contributing to this, and should I discuss it with my prescriber?”

Never stop prescribed medication without appropriate medical advice.

10. DVT — the one we don’t massage first and ask questions later

A deep vein thrombosis is a blood clot in a deep vein, usually in the leg.

Pain and swelling can be symptoms, and NICE recommends proper clinical assessment when DVT is suspected rather than attempting to diagnose it from appearance alone.

If symptoms suggestive of DVT occur alongside chest pain or shortness of breath, NHS advice is to call 999 or attend A&E because a clot may have travelled to the lungs.

🟢 GREEN — notice, record and ask

You may already have a known explanation for your swelling and be under appropriate care.

Things worth noticing include:

Swelling that changes through the day; heaviness or fullness; clothes, jewellery or shoes becoming tighter; subtle differences between sides; and changes following surgery or cancer treatment.

Don’t panic.

But don’t ignore persistent change either.

Early lymphoedema can initially be soft, variable and more noticeable later in the day.

🟠 AMBER — unexplained means investigate

New or persistent swelling without an obvious explanation deserves assessment.

Particularly worth discussing are swelling that is gradually increasing, a significant change from your usual pattern, new skin or tissue changes, recurrent infections, swelling after cancer treatment, or swelling occurring alongside known venous, cardiac, kidney or liver problems.

This is where I would much rather somebody asked:

“Why am I swelling?”

than simply:

“Can you drain this?”

🔴 RED — don’t wait for a lymphatic appointment

A suddenly swollen and painful leg needs medical assessment because DVT is one of the diagnoses that needs to be considered.

Painful, hot and swollen skin may indicate cellulitis and NHS guidance advises urgent GP/111 assessment.

And leg pain/swelling accompanied by chest pain or breathlessness is an emergency — call 999 or go to A&E.

Those aren’t “let’s try some MLD” situations.

The lymphatics don’t live on an island either

I seem to keep coming back to islands.

We talk about the lymphatic system as though it exists separately from everything else.

It doesn’t.

Fluid exchange involves the blood circulation, tissues and lymphatics. Movement matters. Inflammation matters. Veins matter. Skin matters. Surgery matters. Body composition can matter. Medication can matter. Our wider health matters.

And sometimes several of those things are happening in the same person at the same time.

That’s why I don’t think treating swelling should begin with a technique.

It begins with a story.

When did it start?
What happened beforehand?
One side or both?
Does it change overnight?
Does it hurt?
What does the skin look and feel like?
What medical treatment have you had?
What medication do you take?
What else has changed?

And perhaps most importantly:

Does this make sense — or is there a piece of the puzzle missing?

Before we move the fluid, let’s understand the fluid

Manual lymphatic drainage can be a valuable part of lymphoedema management for appropriately assessed people, alongside other elements such as compression, skin care, movement/exercise and self-management.

But MLD isn’t the answer to every swollen ankle.

Sometimes good treatment means treating.

Sometimes it means asking more questions.

And sometimes it means saying:

“I’d like you to get that checked before I put my hands on you.”

I don’t see that as not treating somebody.

I see it as part of treating the whole person.

A note from Fi

My work combines lymphoedema and Manual Lymphatic Drainage training with my background in cancer rehabilitation, movement, scar work and bodywork.

If you’re living with diagnosed lymphoedema, are experiencing changes following cancer treatment, or have persistent swelling and aren’t quite sure what questions to ask, an assessment can help us look at the bigger picture and decide what is appropriate — including when the appropriate next step is medical assessment rather than treatment with me.

Because before we ask “How do we move it?” I’d quite like to know “Why is it there?”

Not sure what your swelling is telling you?

If you’re living with lymphoedema, noticing swelling following cancer treatment, or have changes that you’re not quite sure about, you don’t have to work it out alone.

An initial lymphoedema/MLD appointment with me starts with the story behind the swelling — your medical history, what has changed, what I can see and feel, and whether lymphatic treatment is actually appropriate for you.

Sometimes that leads to treatment and a plan for managing things yourself. Sometimes it means working alongside your existing healthcare team. And occasionally the most useful thing I can do is say, “I think we should get this checked first.”

Because good lymphatic care isn’t simply about moving fluid. It’s about understanding why it’s there.

📍 Appointments available in Clacton-on-Sea and monthly in Bury St Edmunds.
Find out more or book an initial appointment via my website.

And if you’re unsure whether an appointment with me is the right place to start, you’re welcome to get in touch first.