HandLab Clinical Pearls

October 2021 No. 70

Is It Edema or Lymphedema?

Karol S. Young OTD, OTR/L, CHT


How do you determine if lymphedema is present in a patient who has a history of breast cancer or who has had a significant injury to the upper extremity with prolonged or uncharacteristic swelling? In recognition of October as breast cancer awareness month, we collaborated with Sarah B. Compton, MSRS-PT, CLT to better understand how to identify early-stage lymphedema and to learn some early treatment techniques to use perhaps as your patient awaits referral to a lymphedema specialist.


When evaluating a patient with a history of breast cancer ask the following questions:

  • Did you have a lumpectomy or a mastectomy?
  • Did you have radiation?
  • Were lymph nodes removed; did you have a sentinel node biopsy?

The greater the extent of the surgery (mastectomy) and the more lymph nodes resected suggest a greater likelihood of lymphedema developing. Radiation to the breast and/or axilla is particularly prone to compromise the lymphatic system. The resulting decreased lymphatic drainage and the changes to the skin from the radiation creates the sensation of tightness/fullness in the chest, breast, under the arm, or in the arm itself. (1)

Ask the patient to describe how the arm, shoulder, and chest feel and listen for the trigger words of “tight,” “heavy,” and/or “full.” A sense of tightness, heaviness, and/or fullness may be present in the upper quadrant even before there is visible swelling in the arm or hand.


Think of the lymphatic system as a highway. If there is an accident, the resulting traffic backup causes congestion. The traffic congestion can only clear when the accident has been cleared.

Even though the swelling is seen in the arm and hand, the damage to the lymphatic system more proximally in the breast, chest, and/or axilla must be first addressed to accept lymph fluid from the swollen arm and hand. A lymphatic drainage specialist uses manual techniques to relieve the proximal upper quadrant congestion to promote lymphatic flow in this area. (2) Without proximal treatment, edema management techniques used in the distal extremity are ineffective.


You can begin the following exercises while your patient is awaiting treatment from a lymphedema specialist:

  1. Shoulder Passive Range of Motion (PROM): A tight shoulder complex will restrict lymphatic flow; Stretching the shoulder assists in decreasing joint and soft tissue limitations. Passive stretching into flexion and abduction can be accomplished manually or with the assistance of pulleys or dowel. See Figure 1A&B.

Figure 1A & B: Passive shoulder range of motion

Figure 2A, B, & C: The Bon Voyage Waver
  1. The “Bon Voyage” wave: The “Bon Voyage” wave uses active muscle contraction throughout the entire upper extremity to promote lymphatic flow. The patient begins with the involved arm at the side and waves the hand by flexing and extending the wrist. The wave continues as the shoulder is brought into full flexion. Once reaching full shoulder flexion, the wave continues as the arm returns to the side. Repeat this exercise for shoulder abduction, performing each exercise 5 repetitions and 4 times daily. See Figure 2A, B, & C.
  1. Light Manual Lymphatic Drainage (MLD): The patient begins to stimulate the axillary lymph nodes of the affected arm by applying MLD with light pressure from the weight of the hand, which is sufficient to activate the lymphatic system. Have the patient apply gentle circular pressure with the palm of the hand in and around the axilla. The pressure applied should pull the skin gently towards the trunk and the skin relaxes when the pressure is lifted. Perform 10 repetitions with each of the three hand placements shown in Figures 3, 4, and 5.
Figure 3: Begin with gentle full palm pressure in circular motions just proximal to the axillary crease (radial side of the index finger is at the crease).
Figure 4: Move the hand slightly distal and perform the circular motions with the palm centered over the axillary crease.
Figure 5: Move the hand just distal to the axillary crease and perform the circular motions (ulnar side of the little finger is at the crease).

Either breast cancer treatment or massive trauma to the upper extremity can damage the lymphatic system, causing lymphedema. Educating the patient on the cause for their prolonged swelling will help them understand the need to see a lymphedema specialist. The Lymphology Association of North America and the National Lymphedema Network provide directories for locating lymphedema specialists in your area.


1. Brunelle CL, Swaroop MN, Skolny MN, Asdourian MS, Sayegh HE, Taghian AG. Hand edema in patients at risk of breast cancer-related lymphedema: Health professionals should take notice. Phys Ther. 2018;98(6):510-517. doi:10.1093/ptj/pzy007

2. Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily L, Tuppo CM, Williams AF, Karadibak D. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015 May 21;(5):CD003475. doi: 10.1002/14651858.CD003475.pub2. PMID: 25994425; PMCID: PMC4966288.


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Disclaimer: BraceLab Clinical Pearls are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.

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