Lymph system and Lymphedema

Dull, aching upper limb pain can occur before obvious arm swelling, after breast cancer treatment. It may be intermittent and is likely to be associated with a tight, heavy or bursting feeling in the arm.

Any swelling is likely to be soft and dint if pressed for a couple of minutes. At this early stage, it goes away if you put your limb up for a considerable time. The same symptoms can occur in the lower limb after surgery in the groin.

Lymphoedema fortunately only occurs in a minority of people after axillary lymph node dissection and radiotherapy, which damage the lymph system.

Your lymphatic system consists of tiny lymphatic capillaries which collect debris, lymphatic channels which pump this away and lymph node filters along these channels.

Lymph nodes are an important line of defense against germs which have gained access to our body. Causes of swollen lymph nodes are mostly bacteria and viruses.

Enlarged lymph nodes fighting infection are usually tender and may cause pain. Lymph node cancer deposits do not cause pain and tenderness usually.

Prevention of lymphatic oedema

The natural history of lymph edema is that once you've got it, you've mostly got it for good.

Prevention therefor makes a lot of sense.

The measures below are mostly good common sense anyway. Remember that your risk is low, just be careful without getting too concerned about it.

Get a check up quickly, if you develop any on the symptoms mentioned above. Early treatment is very useful.

Keep your skin healthy, with a minimum of soap (with low pH,) and use moisturizer as needed.
If shaving, be careful to avoid damaging your skin.
Wear gloves when gardening
Avoid getting insect bite or sunburn on the limb
Have blood pressure measurements, injections and blood tests on another limb
If you have to have an ambulatory 24 hour blood pressure monitor test, have it on the other arm
Ensure clothing doesn't get tight around your arm
Look after fingernails and toenails.
Remove thickened skin to avoid cracks on heels.
Keep your body healthy, so the lymphatics smooth muscle can function well and replace cells as needed. This really covers everything to do with health.
If you've had surgery putting you at risk, assume that there has been some loss of lymphatic channels. This means that the remaining ones are having to work harder and are at risk of wearing out quicker if there is limited supply of essential nutrients or excess of toxins.⁵
Check for food intolerances, which are a very common cause of fluid retention in our body.
Wear a compression garment when you fly, even if the risk is small.
Keep fit with regular gentle exercise such as Tai Chi and lymphoedema hydrotherapy classes.

Compression garments need fitting by a trained lymphoedema practitioner, and must be worn carefully to avoid them cutting in anywhere.
Try before you fly - wear a few times to ensure they're OK.
Wear for the entire flight, plus a couple of hours after.

Lymphoedema can appear a decade or more after the original treatment.

It is an analogous situation to post polio syndrome. The remaining lymphatics (or neurones) have been working at full capacity, so wear out quicker.

Everything talked about in anti-aging medicine applies here. The tissues concerned need more than an average amount of help. Look for a good naturopath or doctor interested in this field.

This is particularly so if you have had chemotherapy.

Consider using one of the natural remedies mentioned below.

Cancer specialists are modifying their management to help avoid it. Sentinal node biopsy before axillary clearance, is one of the measures introduced to help this cause of limb pain..

Another decision is whether to have radiation to just the chest wall or to the armpit as well.

When people are given the shocking news of a cancer diagnosis, they are in no fit state to think rationally.

Time is needed before one can even take in one's options, let alone weigh up pros and cons of each.

You do have time in this situation. It has been estimated that the time a breast cancer has been present at diagnosis is probably 3 to 10 years. This is based on the known doubling time of breast cancer cells.

A few weeks is not going to alter anything.

The average woman with early-stage breast cancer goes from diagnosis to operating room in two weeks. This is just not enough time to get over the shock to some extent, so you can think.

More reading is available at beasurvivor.com.

Primary lymphoedema

Here the condition comes on without prior damage to the lymphatic system.

The lymphatics either don't develop properly in the first place, or become diseased later.

This is often a familial condition, and some of the genetic faults are known.

Always remember, genes don't invariably "express" their potential bad effects - that depends on environmental factors as well, usually - a lot of which are under our control.

Harm minimization in lymphedema

All the measures mentioned above become even more important now.

Find your local lymphedema support group. They will know the best professionals and be a source of practical help.

You need to learn manual lymphatic drainage massage technique.

This is quite gentle, not a cause of limb pain.

Lymphatic massage and exercises need to be a priority, for 20 minutes of each day, to avoid more limb pain.

A good book or two.

Professor Neil Piller and Maree O'Connor have written a very readable and comprehensive little book...

"The Lymphoedema Handbook"

A very good book on Breast Cancer by John R. Lee, David Zava and Virginia Hopkins.

"What Your Doctor May Not Tell You About Breast Cancer : How Hormone Balance Can Help Save Your Life"

Natural limb pain remedies to consider

1000 mg per day of calcium dobesilate² - see below

150 mg three times a day of butcher's broom extract

900 mg of diosmin plus 100 mg of hesperidin plus 30-50 mg per day of quercetin. - citrus bioflavonoids

3 grams per day of hydroxyethylrutosides (Paroven)

Prof Piller et al published a positive trial using Paroven.

2 capsules twice a day with meals, of Venotone (horse chestnut)

1/4 teaspoon twice a day of Life Extension's Rutin Powder

20 mg three times per day of rutin

80-160 mg three times per day of extract of bilberry

As in virtually any condition anywhere, acupuncture is worth a few tries to see if symptoms and limb pain are eased.

Back to home page from limb pain page

Waking with cramps at night?

Pain in you calf on walking?

Or is the pain in your shins, when you run?

restless legs syndrome - deep in your bones, at night.

Suitable guidlines for starting exercise in limb pain states

To page on skin burns, ulcers and wounds

To page on compression therapy for venous disease

Varicose veins and limb pain

Here discomfort below your knee - aching limb pain or heavy feeling - is relieved by putting your legs up.

There may be little in the way of obvious surface varicosities, because the veins leading into and in your calf muscles are at fault.

Perforating veins pass blood from our skin into the calf muscle pump mechanism. They go through holes in the deep fascia - the strong fibrous envelope surrounding our muscles.

All veins have one way valves, here such that blood can only pass into the muscle, not back out to the skin - and from the muscle up the leg towards our heart.

With each step, our calf muscles pump blood back up towards our heart. As we swing the leg forward for the next step, blood enters the relaxed muscle from the skin.

This mechanism can fail for various reasons - here because of enlarged veins with stretched valves no longer closing, allowing blood to shoot back at high pressure to under our skin, as we walk.

This high pressure in the veins under our skin is responsible for the limb pain or varicose eczema seen now.

It also commonly fails when some painful condition prevents us from walking with the normal spring in our step - just shuffling along without using our calf muscles.

Sitting for long periods in a bus or plane, similarly stops it working. The exercise to do when traveling, is to repeatedly lift your heel sharply, with toes still on the floor.

It is believed that blood clots in "economy class syndrome" are also partly due to the lower oxygen in planes. There's nothing one can do about that, so the exercises and "anti embolism" compression stockings are very important.

Prescription of compression stockings ideally should be done by someone who is trained to measure the blood pressure in the limb.

Just feeling pulses at your foot isn't good enough. In two large series⁴ of people with leg ulcers, 1/3 and 2/3 respectively with reduced ABPI had pulses recorded as present.

The pressure needs to be aligned to the reason for the stockings, and the diastolic blood pressure here. Different pressures are needed for varicose ulcer management, purely swelling or prevention of pulmonary emboli.

The compression must not be enough to cut off the artery circulation. This happens more easily if your arteries are blocked.

Horsechestnut seed is a herbal remedy for heavy legs from varicose veins, cramps in calves at night and swollen itchy legs.

Paroven, a derivative of the bioflavonoid rutin, is also good for some limb pain of vascular origin.

Putting your legs up is good - do it often. We all need some R & R in our lives.

Calcium dobesilate² has been found useful some symptoms, especially in severe cases.

Superficial venous thrombosis (SVT) - Thrombophlebitis

This limb pain is when ordinarily painless (and often varicose) veins become sore, red and swollen - clotted up and surrounded by often an inch wide band of inflamed subcutaneous tissue.

This can happen because of a direct bump or overenthusiastic massage on the vein, or illness such as cancer. Many times no obvious underlying cause can be found.

It has been thought of as of minor nuisance value mostly, but in a recent French study³ of 844 people, one quarter also had deep venous thrombosis (DVT) or symptomatic pulmonary embolism.

Deep vein thrombosis and pseudo DVT as causes of limb pain

Sometimes DVT happens just out of the blue, but usually when ill or immobilized for one reason or another.
"Stasis is the basis" - blood needs to always be on the move,or it may clot.

Sitting still for long periods, our calf muscle pump not operating, the veins will be full of blood - opened up full bore.
From a mountain gorge to a coastal delta, a river slows down.
It's the same here, wider channels, same overall flow, blood flows slower.

After surgery or childbirth, and especially with serious illnesses, our blood is more inclined to clot anyway. It all adds up.

Clots in the muscle veins of the calf, cause pain and swelling and increased warmth of the skin.
Changes may be very subtle, but even a little ankle swelling in the above type of circumstance, warrants a check, by you and your doctor.

Lay on your face, with both legs uncovered.
Your helper feels the temperature of one leg after the other, by placing some part of their hand on the middle of your calf.

Then just loosely grab the whole calf muscle, to assess its bulk. Your dominant side should be bigger.

Then prod deeply down the middle of the upper calf, for tenderness on one side compared to the other. Don't be put off by lack of tenderness, as this comes some time after the clot develops.

Pseudo DVT has the same findings, but this limb pain is due to leakage of irritating synovial (joint) fluid from our knee joint causing painful swelling in our calf muscles.

You may have previously been aware of a soft swelling directly behind your knee. This may be a Baker's cyst - a fluid filled bulging backward of the synovial cavity of your knee.

You may also have been aware of limb pain from your knee joint, as osteoarthritis is the usual cause of Baker's cyst formation.

Statin drugs and limb pain

In a letter to the Australian prescriber¹ an Adelaide doctor described his arm and leg pain due to a statin. He repeatedly got rid of the pain by temporarily stopping the statin. It involved his right lateral thigh and left shoulder, could wake him from sleep, and was relieved by walking to the bathroom. To quote him...
"I graduated in medicine 54 years ago. Having experienced both, I find old age much easier to take, so far, than the adverse effects (limb pain) I have experienced with the statins."
It is not just generalized muscle pain that statins can cause but quite localized pains one could easily attribute to local pathology.

Notes and references for limb pain page

1. Australian Prescriber Dec 2005 28 (6) p139

2. Agustin Ciapponi et al Angiology 2004 55: pp147-154

3. Observations of the Relationship Between Surface and Deep Leg Blood Vein Clotting. Ann Intern Med February 16, 2010 152:I-48

4. Moffatt C, O'Hare L. Ankle pulses are not sufficient to detect impaired arterial circulation in patients with leg ulcers. Journal of Wound Care 1995;54: 134-8.

Callam M, Harper D, Dale J, et al. Arterial disease in chronic leg ulceration: an underestimated hazard? BMJ 1987;294:929-3 1.

5. This is extrapolating from known examples of this mechanism, as in late effects of poliomyelitis. Post polio syndrome comes on many years after the polio attack, as the remaining overworked "motor units" buckle under their increased load.

Calcium dobesilate (2,5 dihydroxy benzene sulfonate) and limb pain

This is also known as Doxium, Dexium, Rasexinium, Toraxine and Nugatex.
This compound was discovered more than 40 years ago and is apparently registered for the treatment of diabetic retinopathy in some countries.

It acts on capillary endothelium and its underlying basement membrane, to block hyper-permiability and reduce the amount of work your lymphatics have to do. It also improves lymphatic drainage.

The reference² is to a "meta analysis" of published "randomized placebo controlled clinical trials."

These are trials where some people with the condition are taking a dummy treatment, some the real thing - but during the trial no one including their doctors, knows which.

Pre-existing beliefs about the treatment on the part of the doctors, and hopes and fears on the part of the patients, can lead to faulty observation and reporting.

In this type of trial, these errors will be spread evenly between the real and the dummy treatment, so the overall result wont be mucked up.

A meta-analysis is a study of all such trials published on a particular problem, looking very carefully at the quality of the studies and their results.

The above meta analysis was conducted on trials in people with chronic venous insufficiency (CVI,) not lymphoedema. The results are very relevant to lymphoedema as well, as leaky capillaries increase the work load on your lymphatics.

Only 3 of the 10 suitable trials were found to be of high quality.

The authors' conclusion was...
It can be concluded that calcium dobesilate administered orally for 4 weeks to patients with CVI significantly improved symptoms like night cramps and discomfort. The number needed to treat is small (4 to 8 patients). There was no conclusive evidence on the effect of calcium dobesilate on leg volume reduction, pain, paresthesias, and malleolar swelling. Calcium dobesilate was not associated with more short-term adverse effects than placebo. Subgroup analysis suggests an increased beneficial effect in more severe patients and also suggests that a dose greater than 1,000 mg is not associated with better outcomes.
Some concern has been expressed about the rare possibility of bone marrow damage with agranulocytosis. This is a very serious condition where the white blood cells are not present in enough numbers to fight infection.

I had a look at this report. The patient was also put on cloxacillin, which has been associated with agranulocytosis on many occasions, compared to just two for calcium dobesilate. They had also just been given a flu injection, which has been reported to increase the risk of this complication from another drug.

Tight Junction Proteins Occludin and Zonula Occluden 1 , and limb pain?

I do all this reading, so you're for it. Pleeaasse read on, please do. It's just to understand a little of the way our capillaries and lymphatics work.

The smallest vessels are tubes made of just one layer of (endothelial) cells. Their function requires them to be capable of very variable permeability (leakiness) in different circumstances.

This diagram of a capillary is from health-pictures.com

capillary from health-pictures.com

Capillaries allow oxygen, carbon dioxide, fluid, wastes and nutrients free passage. Lymphatics allow larger items like proteins and cells free passage.

When our body needs to repair damage or fight infection, capillaries then allow inflammatory cells and proteins free passage. One may then see swelling, weeping or pus formation.

Adjoining endothelial cells have specialized connecting structures, to allow for these changes. These junctional complexes include "tight junctions," "adherens junctions," and "gap junctions."

Gap junctions are communication structures, which allow the passage of small molecular weight solutes between neighboring cells.

Tight junctions serve the major functional purpose of providing a barrier within the membrane, regulating paracellular (between cells) permeability and so tailoring the extracellular microenvironment. Occludin is a protein in the tight junctions.

Adherens junctions play an important role in contact inhibition of endothelial cell growth (stopping abnormal growth) and paracellular permeability to circulating white blood cells and solutes.

"Focal adhesions" composed of integrins (another protein) anchor the endothelial lining to underlying materials in the vessel wall. Focal Adhesion Kinase is another component. Both components play central roles in controlling the barrier function of the lining cells.

Focal adhesions are molecular bridges between inside and outside the cells, that mediate 2-way crosstalk between the extracellular matrix and the cytoskeleton (within the endothelial cell.)

They are targets for biochemical and mechanical stimuli that evoke crucial developmental and injury response mechanisms including cell growth, development and movement.

Interruption of integrin–matrix binding or other parts of these mechanisms, leads to leaky microvessels, which places a greater load on our lymphatics. Anything which leaks out of the capillaries will eventually have to be carried away by the lymphatics.

All of this multitude of proteins have to be manufactured continually, from good quality (complete) protein we eat. Understanding of dietary protein requirements is a hot potato in medicine.

Protein is made of units called amino (nitrogen containing) acids. The conventional method for telling how much protein is needed, is to measure the nitrogen going into and out of the body.

A person is in positive nitrogen balance if they are retaining nitrogen, as protein, a lot of which is structural (muscle.) Inadequate protein intake causes negative nitrogen balance.

The zone diet is currently not accepted by dietitians. This suggests higher protein content than they do, for reasons other than nitrogen balance.

As well as enzymes, we need amino acids for making our neurotransmitters which pass messages between nerve cells.

New Guinea highlanders on a sweet potato diet could survive with only half of what is conventionally regarded as adequate protein. Most people are not as well adapted to low protein as they are, and modern toxic living has increased our needs.

To quote Dr. Barry Sears, who coined the term zone diet...
"The hormonal rules for humans haven't changed in the past 150,000 years, and they probably won't change tomorrow."
This probably seems a long stretch from limb pain, but in the end most health topics come back to diet and exercise.

limb pain in children - "growing pains"

Never accept this as a "diagnosis." It isn't one!

Vague general limb pain will probably be due to spinal problems causing tight leg muscles.

One thing to consider apart from juvenile rheumatoid arthritis, is atypical rheumatic fever.
Rheumatic fever causes joint pains about two weeks after a sore throat from the group A beta-haemolytic Streptococcus. This germ also causes acute nephritis and scarlet fever.

A typical attack involves swelling and pain in peripheral limb joints, but the swelling may not happen. A rapid pulse out of keeping with the degree of fever is also a feature.

The sore throat may have been quite mild and easily forgotten.

Anti Streptolysin O is a blood test for checking on this possibility. It isn't used much these days, in investigation of limb pain. It probably should be.

Osteochondritis of various bones can also cause limb pain. This is a condition or a number of conditions where growing bones break down.
The cause is generally unknown, but I would bet it is nutritional (deficiency.)

Pain from the hip joint in young people, felt anywhere down to the knee...

See page on hip conditions

Scurvy can easily happen if children are fed only well cooked food. Limping and tenderness of their lower limbs are typical symptoms.


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The contactpage.

Ankle to brachial (arm) pressure index (ABPI) compares BP reading in the two limbs to detect leg artery blockage.

Subcutaneous tissue is the layer which underlies our skin. It is loose material to allow movement of skin over bony bumps and therefore capable of considerable swelling.

Pulmonary embolism is when a clot is dislodged from a leg vein and is swept up to the lung arteries - very dangerous. This cannot come directly from superficial veins, only if there is DVT as well.

If you are interested in a home study course on examination of the spine, please send me your e-mail address by the contact form.