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Joachim Zuther, Lymphedema Specialist. Read more
Lohmann Rauscher

Tactile Medical

Manual Lymph Drainage and its Role in the Treatment of Lymphedema


Manual lymph drainage (MLD) is one of the main components of complete decongestive therapy (CDT).  In combination with compression therapy, skin and nail care and decongestive exercises, MLD performs the crucial role of re-routing stagnated lymphatic fluid, which is essential in the treatment and management of primary and secondary lymphedema. This gentle manual treatment technique is based on four basic strokes, which were first described by Dr. Emil Vodder (1896-1986), PhD.

The goal of MLD is to stimulate healthy lymph vessels and lymph nodes, which generally are located adjacent to the area of non-functioning or blocked lymphatic drainage, and to re-route the lymph flow around these blocked areas into more centrally located healthy lymph vessels and nodes. This is achieved with specific stretches and manipulations – a common denominator in all MLD strokes – to the skin and those structures located directly beneath the skin, the subcutaneous tissues.

The resulting increase in lymphatic activity in the healthy areas creates a “suction effect”, which stimulates the accumulated fluid present in lymphedema to move into an area with normal lymphatic drainage.

What is the difference between MLD and traditional massage?

It is unfortunate that the term massage is often wrongly used to describe MLD. The origin of the word massage is derived from the Greek massain (to knead) and is used to describe such techniques as effleurage, petrissage, vibration, etc. Massage techniques traditionally are applied to treat ailments in muscle tissues, tendons and ligaments, and in order to achieve the desired effect, these techniques are generally applied with considerable pressure.

Cross section through skin, subcutis and muscle layer

MLD on the other hand is a very gentle manual technique, designed to have an effect on fluid components and lymphatic structures located in superficial tissues, i.e. the skin and the subcutis. Lymphedema almost exclusively manifests itself in the subcutis, which is a layer of connective tissue between the skin and muscle tissues.

The only commonality between MLD and traditional massage is that both techniques are applied manually. There are significant differences in technique, pressure and indications for which these two therapeutic measures are used.

There are a number of reasonable explanations why MLD and massage are often confused with each other. One is that there is a tendency to call any hands-on manual therapeutic technique a form of massage; the other is that massage can be very helpful if applied to treat edema.

However, lymphedema and edema are two very different conditions and it is important to understand the differences. Although both conditions involve swelling, edema and lymphedema have very different causes and are treated differently. A previous blog post “When is it Lymphedema?” compares these two conditions:

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27 comments to Manual Lymph Drainage and its Role in the Treatment of Lymphedema

  • Suzanne

    I attended the ACOLS course in September in OH. Recently, I had a former patient contact me re: having intensive MLD prior to and after her lat-flap reconstruction. She’s about 3 years out but has had known lymphedema for approx. one year. She has been doing a lot of research on reducing her risk of worsening lymphedema with surgery and came across this suggestion. Any thoughts? How many sessions would you recommend?

    • Joachim Zuther

      Dear Suzanne: While there is no evidence that pre-operativ MLD sessions reduce the risk of post-operative edema, post-operative MLD is certainly beneficial. I would recommend at least six post-operative MLD treatments.

  • allison

    Joe, This Q is off topic but it is something we are having difficulty w/ in the clinic. Footwear. We are encountering more and more obese pt’s w/ lymphedema. Most of these pt’s have finacial difficulties paying for custom shoes to fit them during the tx phase as the wrapping makes their feet too big to fit into regular shoes since most of these pple are already in wides. Unfortunately, most of our pt’s are going home in surgical booties (although these do not even fit at times) or cotton stockinette. I have been trying to find a low-cost better alternative. Any suggestions??

  • janis

    losing weight with leg lymphedema is one of my biggest challeng any suggestions and excersise ?

  • joan butler

    For 17 years my sister, who was trained at a MLD location I was being cared for in Ellicott City, has been caring for and wrapping my lymphatic right leg. Now, she is 84 and not able to continue. I am homebound and need a lymphatic specialist to come to my home for my treatment. I live in the Silver Spring area outside of Washington,DC.
    Can you refer me to someone?

    • Joachim Zuther

      Dear Joan: Please click on the “Find a Therapist” link on the top menu bar in order to locate a therapist in your area.

      • Joachim Zuther

        Joan – here is a therapist located in Silver Spring, who does home visits: Jill L. Nelson BS, LMT, CLT

  • Radha Persaud

    Hi – Can you suggest what I can do or doctors to contact regarding surgeriest to reduce the edema in my right leg? I live in NY and just about every doctor tells me there’s nothing to be done!

  • Joachim Zuther

    Dear Radha: Please use this link for a list of MD’s specializing in lymphedema

    You may also contact the National Lymphedema Network or the Lymphatic Research Foundation for more contacts.
    Hope this helped, Joe

  • Kelley Hill

    Hi, my 13 year old son has primary lymphedema in his right leg. He was diagnosed at age 8. Currently he is not receiving any therapy for MLD, I was wondering how often you think he should have that done or is it something we could learn and do more often at home to help in his lymphedema treatment? Thank you for your time.

    • Joachim Zuther

      Dear Kelley: Pediatric lymphedema can be very effectively treated withcomplete decongestive therapy. Ideally, treatments should be given 5x/week until the leg is down to a normal or near normal size, or until the measurements taken weekly by the therapist plateau. An important aspect in the treatment of pediatric cases is to involve the parents in the treatment. The therapist will show you and instruct you in some easy to learn techniques, which you can apply in order to keep the swelling in check.

  • Karen Binder

    Joe, I was recently visited by a company called “flexitouch” introducing me to an automated MLD body suit to be used with patients at home for maintenance of their lymphedema swelling. Was wondering if you had a chance to see it, and what your opinion is on the product. I liked the idea of it, but felt there were some flaws that make me hesitate to use or recommend it with my patients. Would love your input on this!

    • Joachim Zuther

      Dear Karen:
      Advanced and newer compression pumps consist of multi-chambered inflatable sleeves that include trunk garments containing inflatable chambers designed to prepare drainage areas on the trunk prior to moving fluid from the extremities.
      Pneumatic compression used to treat extremity lymphedema without treatment of adjacent body quadrants and drainage areas using complete decongestive therapy bears a significant risk of moving lymphedemateous fluid from distal to proximal, where it accumulates. This may cause protein molecules to accumulate in this area, forming a fibrosclerotic ring, truncal quadrants previously not swollen to fill with fluid, or external genitalia to swell.
      Recent studies suggest that multi-chambered sequential compression devices that include trunk and extremity garments and deliver the pressurized air in individual patient-oriented patterns may be beneficial as an adjunct treatment to effectively control lymphedema in the self-administered maintenance phase (Phase II of CDT), especially in those cases when physical limitations of the patient may result in challenges controlling the lymphedema independently with self-MLD.

  • Anita

    So are you for the Flexi-Touch? I could not really tell from your reply above?

    • Joachim Zuther

      If I had to use a pneumatic device, I’d probably choose the Flexitouch. However, these devices should never be used without complete decongestive therapy.

  • Andrea F

    Is it possible to run a low grade fever while under going MLD and compression bandaging? I had my first session of MLD last Thurs and started running a low grade temp Saturday and it’s been that way everyday since then. I was concerned it might be cellulitis in my leg but when the therapist removed the bandages my leg was fine.
    Thanks for any advice.

  • Ruth

    hi Joe – do you recommend that we tell patients who have had lymph nodes removed during cancer trx and possible damage from radiation to not have regular massages even if they are not showing signs of lymphedema

    • Joachim Zuther

      That would be a definite “yes” -, however, massage is contraindicated only on the extremity at risk and the adjacent trunkal territory

  • Nancy Wisnieski

    I would like to know how Reflex Sympathetic Dystrophy influence the cycles of Lymphedema.
    I have all extremities involved and spinal with RSD, diagnosed 1988,
    Lymphedema was diagnosed after a sever fall Jan. 2011.
    Thank you in advance.
    Nancy Wisnieski

  • Peggy

    Where can I get the Manuel Lymph Drainage instruction’s?
    Thank you

    • Joachim Zuther

      Peggy: Please check the left side on this page. Under “Index” you will find links for self-Manual Lymph Drainage for the arm and the leg.

  • Good afternoon Doctor.

    1. I have a secondary lymphedema, grade I inferior members. I found the method is affected when one of the legs. What would be the method of lymphedema affecting both legs?

    Location N.Y. I’m Latina, professional nurse, I do not speak English. I have done translations for different sections of your blog. Documentation and readings I’ve done I can say that I am well informed and fully understand the pathophysiology of secondary lymphedema. I go to a hospital in this city, where I receive instructions for me massages and drains. I feel that the therapist is not sufficiently trained and safe or certified in massage and drainage for lymphedema, I do not see stranglehold on the subject, Translations in the hospital because they are short and not done during the whole process, so is not possible number of questions that come out as the sessions unfold.

    2. You could guide me on this?
    3. Options in N.Y. here?

    Thank you very much for your prompt and important information.

    • Joachim Zuther

      Dear Elsa: Bilateral lower extremity lymphedema is effectively treated with complete decongestive therapy. Please click on the “Find a Therapist” button on the menu bar at the top of the page to locate a therapist in your area.