Edema is everywhere! Working in healthcare, we as therapists and nurses often see edema that might be occurring for a variety of reasons. Here, we discuss and characterize 7 types of swelling that you are likely to encounter clinically.
1. CHRONIC VASCULAR INSUFFICIENCY:
Chronic Vascular Insufficiency occurs when the venous wall and/or valves in the veins of the legs are not working 
effectively, making it difficult for blood to return to the heart from the legs. This causes blood to “pool” or collect in these veins.
Edema caused by this etiology is usually symmetrical in both legs. It has a slow onset and develops over a long period of time. You will notice that the edema is predominantly in the gaiter distribution area of the legs- meaning that the swelling is concentrated in the front of the shins and the top of the foot. This edema progresses distally- and the lower leg/below the knee is the area most usually affected.
Unlike some other types of swelling, the edema associated with chronic vascular insufficiency does reduce (at least initially) in response to elevation. The person with this symptom will experience pain in the form of achiness, which they may report worsens as the day progresses.
Their skin may appear to be brawny, or darkened; taut and tightly stretched; hemosiderin staining may be present; varicose veins are common. This condition may also lead to wounds, dermatitis, and lipodermatosclerosis in the person affected.
2. LYMPHEDEMA:
Lymphedema is a chronic condition, caused by continuous overload of lymphatic fluid, or by a disease of the lymphatic system itself. Whatever the underlying cause, the lymph system cannot effectively transport the lymph fluid- thereby resulting in edema.
The type of edema in lymphedema is characterized by a slow onset, usually progressing over many years. Stemmer’s sign is positive- meaning the skin at the second finger or toe has undergone changes and may be thickened or difficult to move. This is related to the build-up of protein in the skin. Lymphedema is asymmetrical in presentation and may affect one leg or arm without the other. Swelling will progress distal to proximal. Elevation does not reduce the swelling.
Skin may appear to be lumpy or crusty; it may harden and become fibrotic. Ulcers are not common, but because of lymphorrhea the skin may break down if not cared for. Hyperkeratosis, an overgrowth of the epithelial layer of skin may occur as this condition progresses untreated. Recurrent cellulitis and fungal infections are also not uncommon in persons with lymphedema.
3. LIPEDEMA:
Lipedema or lipo-lymphedema is swelling caused by abnormal fat metabolism and deposition. It presents as large hips and thighs, with disproportionately small trunk and arms, and small feet. It can often be mistaken for obesity, and though there is an association with adipose tissue, there is a separate etiology and physiological cause for lipedema.
Lipedema may be recognized by its characteristic shape of larger legs with small feet and arms. It mainly affects females and its onset is very slow. Stemmer’s sign is negative as the skin changes associated with lymphedema may not be present in those with Lipedema.
Bilateral legs are symmetrically affected and the tissue is painful to palpation, bruising easily secondary to fragile capillaries. Skin will appear and feel loose and lobular.
4. CONGESTIVE HEART FAILURE:
Congestive Heart Failure is a chronic condition in which the heart is unable to function adequately. Lower extremity edema occurs as a result of a weakened hearts inability to effectively pump blood throughout the body, causing fluid to build up.
Unlike other types of edema, this is characterized by a rapid onset, and it reduces rapidly in response to elevation. Stemmers sign is negative as the swelling is not a high protein edema. Both legs are usually symmetrically affected.
The person affected by swelling related to congestive heart failure has several recognizable skin symptoms. Skin may be soft and doughy; it ‘pits’ deeply. You may notice a “buffalo hump” on the dorsal aspect of the foot. The skin may also look cyanotic; and commonly is affected by wounds and weeping or watery blisters.
5. MALIGNANT LYMPHEDEMA:
Malignant lymphedema is caused by physical obstruction of the lymphatic vessels by a malignant tumor. This edema is easily recognized as one of the only types of swelling that will progress proximally to distal. It also is characterized by pain, muscle guarding, and asymmetry. Tingling, numbness and weakness may be present as the tumor compresses the nerves in the affected area.
Malignant lymphedema causes skin to redden, become firm and inflamed, and may lead to tangelectasis or spider veins on the surface of the skin. Masses and enlarged nodes are common. Because of the toxins building in the fluid, cellulitis can be commonly seen in this presentation of edema.
6. ORTHOPEDIC INJURY
Post surgery or injury, edema and swelling can occur as a result of the initial damage to the tissue. This is a normal and protective reaction from the body, but it can become problematic when left untreated. Swelling limits mobility, impair quality of life, and develops into a chronic, immovable swelling if it is not addressed during rehabilitation.
This type of edema can be recognized by its localization to the injured tissue, warmth and erythema associated with congestion, and onset which usually occurs 24 hours/ several days after injury/surgery. The skin may be reddened or bruised, feel firm to touch, and can be very painful to the person experiencing the injury.
7. DEPENDENT EDEMA
Dependent edema can occur in persons who are immobile or are not able to range their limbs independently. A lack of muscle pumping and a prolonged dependent position (like sitting in a wheelchair) can lead to a buildup of fluid in the lower body. This again can lead to a breakdown in the lymphatic system and develop into a chronic, un-resolving condition.
Edema is a chronic, under-recognized and under-treated condition. Recognizing the types of swelling that you are working with in healthcare is critical to forming a plan of care. By including the treatment of edema in your patient care, you will improve their quality of life, mobility, improve skin care and decrease re-admissions.
Want to learn more about types of swelling, assessment, creating a plan of care, and providing effective management? Check out our ever popular course, Edema Management in Inpatient Rehab for a comprehensive, practical information. You are going to love the hands-on, evidence based techniques that you can use to greatly improve your patient outcomes!
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