Hand undergoing compression therapy for Lymphoedema
Diagnosing and referral map

Diagnosis of oedema

  • As a general practitioner providing continuing medical care for patients in the community is key. Usually a patient's first point of contact will be their GP, either at the surgery, or in their own home or even in a care home. When diagnosing oedema and recommending the required treatment, a holistic approach has to be taken into consideration. These include the patient’s medical history and a thorough examination of the oedema and skin. Part of the diagnosis might be to refer the patient to specialists or the hospital for further assessment or treatment.

    The GP is part of a team of healthcare professionals such as tissue viability nurse, lymphoedema specialists or a podiatrist who should discuss care options for the patient with oedema and their families or carers. Involving the patient and helping them take responsibility for their own health increases the probability of success and concordance to treatment plan.

A holistic assessment of the lower limb includes

  • (hours, days, months) - acute or chronic is usually defined by the 72 hours
    • Unilateral leg oedema is generally due to a local cause such as deep vein thrombosis, venous insufficiency or lymphoedema.
    • Bilateral oedema can be due to a local cause or systemic disease such as heart failure or kidney disease.
    • Generalised oedema is due to a systemic disease (or problem with diet).
  • In a healthy person, a fold of skin can be pinched and lifted at the base of the second toe. The Stemmer sign is present and indicates lymphoedema when a skin fold cannot be pinched and lifted.
    • What is the colour of the leg, foot and toes?
    • Does the skin feel cold or hot to the touch?
    • Is the skin very sensitive to touch?
    • Does the skin bruise or break easily?
    • Are varicose veins visible?
    • Is there an absence of hair on the leg(s)?
    • What is the condition of the toe nails?
    • Is there good ankle movement or is it restricted?
    • What is the shape of the limb?
    • Is there ankle flare?
  • There are different methods to measure limb volume and limb volume change such as the water displacement method, perometer and with a measurement tape. If using a tape it is important to be consistent over time with how the measurements are taken and include considerations about the patient's limb position and the number and locations of measurements.
  • Measurements of ankle brachial pressure index (ABPI) in both legs at the initial visit. This is the ratio of the ankle to brachial systolic pressure and can be measured using a sphygmomanometer and hand held Doppler device
  • Ask the patient about the type of pain they experience such as:

    • Leg ache and pain
    • Tightness
    • Skin Irritation
    • Feeling of heaviness
    • Muscle cramps
    • Tiredness of the legs
  • Use TIMES to asses the wound: Type of tissue

    • Infection
    • Moisture/Exudate
    • Edges of ulcer
    • Surrounding skin

    Find more information about the concept of TIME on the European Wound Management Association website by downloading their position document on Wound Bed Preparation in Practice.
  • Assess the patient's (and family) past medical history. Include:

    • Has the patient had an injury or surgery?
    • Has the patient had cancer and how was it treated?
    • Does the patient have any varicose veins?
    • If the patient has had numerous infections, what was the recurrence rate and what type (cellulitis, folliculitis or phlebitis)?
    • Any previous ulcers on the legs or feet?
    • Does the patient have diabetes?
    • Does the patient have any cardiovascular, inflammatory or renal disease?
    • Does the patient suffer from any allergies?
    • Does the patient suffer from hyper/hypotension?
    • What is the BMI of the patient?
    • What is the diet and habits of the patient including hydration, alcohol consumption and smoking?
    • Occupation
    • Stress
    • Sleeping patterns
    • Mobility/immobility


Franks, P., Barker, J., Collier, M. et al. Management of patients with venous leg ulcer: challenges and current best practice, J Wound Care, 25; 6, Suppl, 1–67

  • Gaynor

    Gaynor's story

    My name is Gaynor and I have secondary lymphoedema from breast cancer related treatment. I was horrified and angry that I wasn’t told this was a possibility, never heard of this condition and didn’t realise the lifestyle changes I would have to make and how little information was available. The anger has turned to a passion to raise awareness of lymphoedema and supporting others living with this condition via social media communities, on Facebook, Twitter and LinkedIn, as well as a website.

    Follow me on instagram @lwo_lymphwhatoedema

Referral Map

The below referral maps shows possible pathways for different types of oedema. The starting point is unexplained oedema and the map suggests possible solutions. Subsequently a referral can be made to a specialist.

Referral Map1