Lymphedema: Leg Bandaging

M. D. Anderson Cancer Center
Date: December 2009

Lymphedema: Leg Bandaging

[ Music ]

Physical Therapist Sara Cleveland:

I have Pam with me, who has lymphedema in her left leg and we're going to demonstrate bandaging for the left leg. Pam is in the maintenance phase, meaning that she has already been fitted for a compression garment, which she is wearing along with her bike shorts to help hold up the stockings. For demonstration purposes, we're going to bandage over the stocking. This isn't something we would normally do unless, for example, the person is flying or needs extra compression.

Bandaging is one of the most important things we can do to help manage the lymphedema. The bandaging material is all laid out here. The first thing you want to do is get everything that you need in order so that you don't forget anything, and we're going to use a stockinette to protect the skin from the bandages.

We always begin with a clean stockinette, so you can go ahead and put this on, Pam. I've made it extra long because every time you change the bandages you should wash the stockinette, and they tend to shrink. So we want to have it extra long so that they won't be too short by the end of their millionth time of bandaging. And then you have two choices: you can either keep the toes covered, or you can have them uncovered. So we're going to go ahead and start with the stockinette, and the first layer is for the toes.

Some of our patients don't have swelling in their toes, and so frequently we don't need to wrap the toes. But in Pam's case, she does have some visible swelling in them so we do want to wrap the toes. I'm going to demonstrate and then Pam will do it. She's going to pull down her stocking so I can get to her toes. We have the toe bandages that have been folded over and rolled up, and it has a crease here where the fold is. We want the fold to be towards the toes. We're going to start around the base of the toes to anchor them, and then we're going to come around and wrap each toe individually. We're going to start with the big toe. We're going to start two times around the toe. Then wrap around the base of the foot to anchor it and then wrap around the next toe. Try to keep the bandages fairly taut and cover the whole toe. Then go around the base of the toes, and then to the next toe. You can either wrap the little toes separately or some patients wrap the little toe together. You can do either way using the same method. So I'm going to take this off and give you another one, and have you do it. Here's the toe bandages.

Begin by wrapping around the base of the toes two or three times and go around each toe twice. The toe bandages are 100 percent cotton, and they have just a little bit of stretch by the way they are woven. We want to wrap the toes if there is any swelling, because sometimes if you have pressure on the top part of the leg, it could possibly push fluid into the toes. Excellent job. I can tell you do this all the time.

Pam:

In my sleep.

SC:

It's a daunting technique, but the rewards are great. Bandaging is probably the most effective thing you can do to help manage lymphedema. Very good. So then you pull the stockinette over it. For someone at home, if they wanted to cover their toes they could simply take the stockinette and turn it, twist and then cover and start on the next layer. I'll let you fix it how you had it. [ Laughing ]

The next layer is the foam padding. We put a piece of foam padding at the top of the foot here. The foam padding gives some compression to the tissue. It helps even out the bandages, and the bandages do a good job of pumping the fluid out. Sometimes, the bandages become loose and the padding helps keep the bandages nice and firm up against the skin. We put this right at the top of the foot to give it some protection, and then we're going to start the roll at the ankle. We begin rolling it around the base of the ankle, and then we come up the leg... overlapping it half and half up the leg. Will have several pieces of foam, depending on how much we need. So I'll let you do that.

I'll hold your leg. OK, that's excellent. You want to make it nice and firm without pulling it so hard that you tear it, but with no gaps in it... so nice and taut.

OK, then we start the next piece. You want to slightly overlap it. So she's rolling it up half and half. Try to wrap as close as you can to the groin. Sometimes I just tuck the corner into the bandage...Great. Now we're going to wrap with the brown bandages. These are the special short stretch bandages that have a little bit of stretch due to the way they are woven. They are 100 percent cotton. I'm going to tuck this in here. I'm going to start with the bandage around the base of the toes, and I'm going to wrap around three or four times depending on how much swelling there is. That's three...and four. I'm rolling it on the foot, then I'm going to come around. It is best to have your foot in a neutral position, like a 90 degree angle. I wrap around to the base of the ankle... the very bottom of the heel here. Then, I make a basket weave, or fish bone pattern, making little crosses. All these lines are going to be about the width of my finger. It is very important that you get all of these even in the front and the back. I'm keeping the bandages nice and taut, coming around the base of the foot... until the bandage ends. We keep doing that until the bandage ends and we put a piece of tape there.

We wrap the next bandage around the base of the ankle to anchor it. Wrap the bandage around a couple times to anchor it. And then we're going to take it around the foot at a 90 degree angle. We're going to wrap around the very center of the heel. Then, we wrap around the back part of the heel... and then wrap around the front part of the heel. Next we make a basket weave pattern where we wrap up and then down, overlapping the bandage half and half. And then we're just going to come up your leg in that position.
So let's start with the next size bandage here. That was the smallest size and now we're going to use a medium size bandage. For some patients who have a larger foot, they frequently need the medium size bandage at the foot, and not the smaller size; but you have a little foot.

Pam:

Yes. [ Laughing ] Around twice right?

SC:

Right.

Pam:

And then I come back over the heel.

SC:

Yes, over the heel, in the center of the heel. Then around the ankle again, and then around the back part of the heel.

Pam:

This part?

SC:

In this portion right here.

Pam:

OK.

SC:

And then come around this portion of the heel.
Now you can start doing the basket weave. Most of the bandage layers are on your foot and ankle. And then you put the tape on the bandages. Make sure you don't put the tape on the foam, because that could cause the foam to tear. The bandages are putting a lot of pressure on the foot and the ankle. Next, start the basket weave pattern with the bandages where it feels soft right above your ankle. We will now use the larger bandages.

Pam:

OK.

SC:

How can I help you with your leg?

Pam:

If you could hold it.

SC:

OK.

Pam:

Is this correct?

SC:

That's fine, you can overlap it half and half and make the basket weave pattern.

Pam:

OK.

SC:

Here's a piece of tape. So you are feeling the leg to find where it feels soft, and that is where you will start the next bandage. [ Tearing tape ] I think we can move the stool out.

Pam:

This looks really good.

SC:

Let's continue to do the basket weave pattern, slightly pulling it here and here like you're doing. OK, another piece of tape here. You want to start the next bandage where it feels soft and start from that point, and come up your leg. Probably about there. The pressure is determined by how many layers of bandages you put on the leg, or how tight you pull the bandages. And generally we want to put on more layers as opposed to using only a couple of bandages. This is why we use so many bandages. And now the next bandage.

Pam:

Is there a certain way to wrap the knee?

SC:

No.

Pam:

OK.

SC:

You just start again where it feels soft.

Pam:

I usually cross the bandage here.

SC:

That is fine. That makes bending the knee a little bit easier. OK, here is the next bandage. Then start wrapping again where it feels soft. And this is the last bandage for the very top of the leg.

Pam:

OK. [ Tearing tape ]

SC:

We find that this basket weave pattern works really well to help hold up the bandages. Some patients might find it easier to do just the circular wrap, but this basket weave tends to cause the bandages to hold up better. Do you find that the case?

Pam:

Oh yes, because otherwise the bandages slip down...

SC:

It is also helpful to wear the bike shorts over the bandages, to help hold them up.

Pam:

Sometimes what I do on the top bandage is fold it over like this.

SC:

You just fold it over?

Pam:

Yes, because if it is back here, I canít reach it and the tape rolls off.

SC:

What a good point. Excellent suggestion.

Pam:

Thank you.

SC:

You could put more tape there and then you could fold over the stockinette if you wanted to. In your situation, you generally use the bandaging for night. For patients who have finished the initial phase of lymphedema treatment, they wear the garments during the day and then bandage at night. While patients are in treatment, we encourage them to keep the bandages on 23 hours a day, only taking them off to bath and do the self manual lymph drainage.

Once we finish with the bandaging and the lymphedema has gone down, they wear the stocking during the day and then continue to bandage at night. So the bandaging does the best job of helping to pump the fluid back to the heart, giving the muscles something firm to pump up against, and then keeping the tissue from filling with fluid. This feels really good Pam, excellent job, nice and firm here at the foot and ankle. With all this bandaging it will be impossible for you to wear regular shoes. In therapy, you will be issued a special shoe to wear so you'll be able to walk and use your regular shoe on your other foot. Thank you very much for helping demonstrate, Pam. You did a great job. I think you've been a real inspiration to all of our patients.

Pam:

Thank you for asking me. I'm glad I could help out.