Joachim Zuther, Lymphedema Specialist. The external support provided by compression garments are an essential component of lymphedema management. Without the benefits of compression therapy, the lymphatic fluid removed by successful treatments would re-accumulate, and long-term management of lymphedema would be impossible.
Compression garments for extremities such as sleeves, gauntlets, stockings, and pantyhose, or those manufactured for other parts of the body (vests, brassieres) are available in several sizes, variations, and compression classes. This article discusses the different compression classes suitable for patients affected by lymphedema.
What are Compression Classes?
The level of compression within the different classes is determined by the value of pressure the garments produce on the skin; these pressure values are measured in units of millimeters of mercury (mmHg). For a compression garment to work effectively, the pressure needs to gradually decrease from the most distant part of an extremity (ankle, wrist) to the nearest part (shoulder, hip). This gradient is necessary to avoid tourniquet effects and subsequent obstruction of lymph flow.
Most manufacturers in the United States use the following pressure values within the compression classes:
- Compression class 1: 20-30 mmHg
- Compression class 2: 30-40 mmHg
- Compression class 3: 40-50 mmHg
- Compression class 4: over 60 mmHg
In general, compression levels provided by class 2 garments will be sufficient to prevent swelling in most patients affected by lymphedema of the upper extremity; patients with involvement of the leg will usually require a garment of compression class 3.
However, there are a number of exceptions to this general rule. Some patients with lower extremity lymphedema may require garments of lower compression levels than those provided in class 3, or maybe a garment of a higher compression. Alternatively, patients with lymphedema of the arm may use a sleeve of compression class 1, or even class 3 in some cases.
Many factors must be considered by the physician and/or lymphedema therapist in order to determine the correct compression class for each individual patient. Tolerance to external compression, age, activity level, skin integrity and possible additional conditions, such as arterial insufficiencies or heart problems may influence the level of compression.
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After a year of wearing (fitted for 2 pair of stockings at the beginning and again after 6 months)–Class 2–Jobst–Elvarex Soft due to allergic reaction to the other material–am getting more and more discouraged and wonder if the garments are doing more harm than good as they continue to cut off my circulation in two areas of the ankle and do not stay up after a few wearings. You mention that there are some made in the U.S., which I would far prefer for a number of reasons, but I am wondering if I should be wearing them at all! And I don’t know which is worse for me–the lymphedema or possible getting blood cuts from the garments I am now wearing. Any advice, suggestions, etc.?
Dear Charlotte:
A compression stocking should never cut into the tissue and disrupt circulation, nor should it slide down. Common reasons why stockings tend to cause tourniquets are either sizing issues, or lack of garment material distribution over sensitive areas. The use of rubber gloves to distribute the garment material has proven to be very effective, and I think you should give it a try. There are also stocking manufacturers offering silicone borders on the upper borders of compression stockings, which prevents sliding.
I am finding it very difficult to even find a reliable company to provide the custom stockings, they won’t take my measurements and then they never do them right, they take up to 12 weeks for pt to get and generally cost more than 500.00
The companies find that the whole process is too complicated and not profitable enough so many in the new orleans area have quit doing customs completely.
Try Luna Medical on line. I have found very helpful, they bill most insurance companies and provide good service. Good luck.
Hallo Herr Zuther,
wir hatten uns letztes Jahr in Australien kennengelernt – ich war mit Herrn von Zimmermann da.
Gratulation zur Ihrem sehr gelungenen Blog!
Ein Kommentar – Class 1 ist in den USA 15-20 mmHg, Class 2 20-30 mmHg usw.
Viele Grüße
Manuela Gassner-Oser
BSN medical GmbH
Hallo Frau Gassner:
Schoen von Ihnen zu hoehren. Ich kann mich natuerlich gut an unser Treffen in Sydney erinnern, und hoffe Ihnen geht es gut.
Ich wuerde Sie gerne an die Wikipedia Seite fuer compression stocking values verweisen: http://en.wikipedia.org/wiki/Compression_stockings#Compression_classes
Auf dieser Seite sind die Kompressionsklassen folgenderweise aufgezeigt:
With the advice or prescription of a physician or medical professional and proper sizing from a trained fitter.
20-30 mmHg
30-40 mmHg
40-50 mmHg
50+ mmHg
Viele Gruesse,
Joachim Zuther
I was told that I had “idopathic edema” (+2-3) in my lower extremities since my late 20’s. (misdiagnosed). Went again to Vascular Surgeon and was diagnosed with Lymphedema…(age 39). Dr. RX 20/30 pantyhose. My question is this..If it affects the entire body…(if dx with lower) I feel I need compression therapy from the upper waist down…(which makes more sense)since the largest of your lymph nodes are in the tummy area…Where can I get (affordable custom made) 20/30 ?’s Thanks for your input !!!!
Dear Alexandra:
Most manufactureres offer a wide range of ready-made compression pantyhose, so you may want to check out sizes before you decide to order a custom-pantyhose. You can check sizing charts for various manufacturers on the Academy of Lymphatic Studies’ website at https://acols.com/ViewProducts.aspx?cid=27&Description=PANTYHOSE
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Hola,me interesa muchisimo todo lo referente a linfedema lo padesco desde hace dos años,por una diseccion de ganglios inguinales en la extremidad izquierda,uso las medias Juzo de 30-40 y me han dado magnificos resultados
I have been wearing Juzo compression sleeves and gloves on both arms for the past 2 months due to mild lymphedema after bilateral lumpectomies and sentinal node biopsies (5 and 2 nodes removed). I recently noticed the formation of blisters and irritation under a one inch segment of the upper arm band exactly the pattern of the silicone dots on the band. This has occurred twice, both times on my less affected arm and following exercise on the treadmill. Could this be blistering from the lymphedema or an allergic reaction to the silicone?
Dear Debbie:
I am pretty sure that the blisters are an adverse reaction to the silicone.
Talk to your doctor about silicone allergy; its supposed to be “rare” but I have it and got blisters that look like poison ivy from the silicone band. The nurse practitioner at my allergy doc had to change her specialty (she used to be an ER nurse) after developing silicone allergy due to wearing gloves. It’s no joke and it won’t get better until you avoid silicone. I tried wearing my compression stockings inside out (silicone was on outside) and used them like that until they wore out, which helped.
I am really thankful to this topic because it really gives great information
[…] Garments: The wearing of compression garments is essential to prevent lymphatic fluid from accumulating in the tissues and conserves the results […]
I am a C6/7 Incomplete Quad due to an automobile accident in October 2001. Incomplete meaning I have been very blessed to have decent(75%)use of my arms and hands. However, I really struggle with lymphedema from the knees down.. I use Huntleigh Air compression garments while I sleep, and Juzo 3512 AD ll 30 – 40 mmHg when I am up and working. ‘m up for ~17-18 hours daily.
Like Charlotte, my stockings migrate to my instep and create pressure wounds. I use adhesive at the top to keep them in place, and have gone so far as to place little oval foam pads under the paper footie before pulling the stockings on.
Any council would be appreciated.
Regards,
Steve
Dear Steve: The most important issue in your case is to keep the garment from sliding and subsequently creating secondary issues like pressure sores. I would recommend two things – JUZO has stockings with liners (silk/silver) which not only make donning easier, but acts antimicrobial. Secondly I would recommend a silicone border on the top of your knee high garment to prevent sliding.
Hope this helped.
I am always looking for help with my lymphedema even after 25 years. I haven’t found anyone in my northern Colorado area with answers.I had a couple of “kurs” in Hinterzarten, Germany at the Foeldi Kinik when I lived in Germany with great success. My edema is lower extremities due to removal of 21 nodes for cancer, followed by radiation and chemo. A couple of years ago I had a heart valve replacement. I have more peripheral neuropathy now than before. My compression pantyhose dig into my right leg in the thigh area now. Mediven changed their Elegance line that was wonderful. I haven’t found a brand that doesn’t do that or constrict my feet to keep them from going numb either. Any suggestions are welcome.
Dear Holly:
I would suggest to give the “JUZO Soft” a try. All patients I know who use this garment would not want to be without it anymore.
I just started trying to wear Juzo thigh-high, Silver, Made-to-Measure, 34-40 psi, custom leg garments following months of lymphedema treatment. “Trying” is the operative word here. The first time I tried them on, it took 4 hands to get the band to lay flat on my legs. Then I had them on for no more than 5 minutes. Since then I have been released from treatment. Now that I am putting them on by myself, the garments will not stay up. Even if I am successful in getting the silicone thigh band to lay flat within 15-30 minutes after moving around, the garment bands begin to roll and then the stockings either create a tournequette or rolls down my thighs. I use latex gloves to put them on because they allow me to grab the material much better. But that doesn’t help keep them up on my legs. I have already tried the ‘It Stays’ body glue and that doesn’t work for me. Any suggestions? Is it the shape of my legs or are the garments not sized properly? How ‘tight’ around the thighs should the garments be? After reading through other blog comments, I too am concerned about restricting the circulation at the top of my thighs. I have already ordered a pair of full panty hose but as of today, I feel like I have wasted my money on the thigh-highs and they are too expensive to not be able to use.
I have lymphedema after breast cancer. The sleeves ordered for me are always too long and uncomfortable, they also cut into my upper arm. I am told there is nothing they can do about this? Hard for me to believe. What do you suggest?
I am so discouraged with having to live with this condition, it’s embarrassing wearing the sleeve everyone always asks what’s wrong? Not to mention one arm is larger than the other.
Dear Mary: There is absolutely no excuse for comments like “there is nothing that can be done”! Compression sleeves come in a variety of lengths and sizes and should never cause discomfort or a tourniquet effect. I would strongly recommen to locate a lymphedema therapist in your area to get measured for a correctly fitting sleeve. Please use the “Find a Therapist” link on top of this page to locate a therapist close to you.
Good post over again!! I am looking forward for your next post:)
My 12 yr old daughter has mild lymphedema in her right foot and ankle. She has a very thin body, therefore the therapist/specialist was not sure what compression garment for her, claiming the socks and stocking would be too big around her upper leg near her knee(seemed as if she was not confident in her skills and knowledge when it came to treating a child). I wrap her every night with the compression bandages, but I need somthing for her during the day becuase she can’t wear the bandages to school (trying to have as close to normal life style for her. They told me i needed to find her 20-30mm compression garments. There are so many options, I am overwhelmed… any ideas or suggestions/ recommendations from you would be greatly appreciated.
Dear Erricka: It is certainly possible to locate an apprpriate compression garment for your daughter. Manufacturers like JUZO, Medi and Jobst have a large assortment of ready-made compression garments in various sizes and compression classes, and I would suggest comparing your daughter’s measurements with those published by the manufacturers. In the case of your daughter’s measurements not falling within the manufacturers ranges for ready-made garments, a custom made stocking can be obtained. Examples on sizing charts for ready-made garments can be found here: https://acols.com/ViewProducts.aspx?cid=65&Description=20-30mm/Hg CC I
After decongestive therapy I was measured for custom made sleeve. It was had a large gap at the top so a second sleeve was ordered. This one caused deep creases in my wrist area as well as tingling in fingers and change of skin color. I suggested another sleeve in a softer fabric as I have very thin arms. After four weeks I have heard nothing from the fitter. My therapist as suggested a ready made sleeve. I would appreciate some advice.
Ready-made sleeves come in a variety of styles and sizes. If your measurements fall within the manfuacturers measurement guide, I would recommend to order a ready-made sleeve. The measurements should be taken, and the compression class determined by a therapist.
I have acquired a Peripheral Neuropathy (non-diabetic). Recently the Sensory Nerves produced more numbness and pain. I have a long standing lymphedema now for over 25 years that I have maintained with Juzo compression stockings. I am very distressed because wearing these stockings now it is very painful to the point that it becomes unbearable and I can no longer wear them. I am lying in bed a lot now, not knowing what to do. Are there any other choices for me to keep my lymphedema from getting worse without compressing the nerves?
Dear Raizel:
First and foremost, interrupting, or discontinuing compression therapy will have negative effects on your lymphedema. So it is important that you (and your therapist) find a way for you to be able to continue by either wearing a compression garment with less compression, or trying alternative modalities, such as Solaris or CircAid products, or bandaging with added padding. I would also like to refer you to a very good resource on the topic: http://www.lymphedemapeople.com/wiki/doku.php?id=peripheral_neuropathy
[…] Compression Therapy […]
Hi Joachim,
I am a BC survivor, 23 nodes removed, right (dominant) arm. Am wearing a class 2, flat knit, custom Jobst. I am a housewife, mother of two school age kids. No other health issues. How much fluid should I have in my arm at the end of the day? None? I usually have some. Does that mean I need to go up to a class 3?
Thank you.
I would suggest you consult with your lymphedema therapist. She/he will be able to advise you regarding higher compression class or additional MLD treatments
All the information are really nice this is very valuable information for all. Thanks for sharing such amazing post.
instead of wearing all these contraptions wouldn’t it be better to try a plant based diet to help fix this health problem?
Hi, my aunt just got treated for thrombous, but her her leg ( lower ext) still pretty swollen what type of stockings do u recommend for her?
Generally a knee-high stocking is recommended in these cases. Your aunt’s physician will make the decision
After bladder cancer surgery and forty two lymphnodes removed, I have lymphedema in my legs, abdomen, hips, and bum. I’ve been measured three times for custom garments but I’m having a time getting ones the control well. I have medis at 30-40 compression that are custom but don’t contain well enough, and OTC Juzo dynamics that have bands at the top of the thigh where I need better compression. Any recommendation of an OTC brand without thigh bands to reduce bulging?
Have a lymphapress for my right arm. Use it every morning for 30 minutes, follow with a 30-40compression sleeve for the day. Arm still about 1.5 inches larger than left. Any way to get it down to size of left arm?
Without additional Complete Decongestive Therapy this will be very difficult to achieve. Here is a link to a number of articles on the subject: https://www.lymphedemablog.com/category/complete-decongestive-therapy-cdt/
Living with lower extremity lymphedema. Was wondering if there is any ready made compression garments that have compression in the groin and abdomen areas as well? I now have custom compression to address the groin and abdomen but they are very expensive and insurance is fighting me on coverage. I am also looking for a night garment that is not to expensive. Thank you for your help.
Jeannie: Compression pantyhose does provide a certain level of compression in these areas. Here is a link to night-time compression alternatives: https://www.lymphedemastore.com/ViewProducts.aspx?cid=133
I have mild lymphedema in my front bikini area, groin, volva, and upper thigh after a total hysterectomy and 5 lymph nodes being removed. I’m active, in good physical shape and not overweight, and want to work out in a gym without looking like a freak.
I can’t find any garments that are appropriate for my activity level that I can be seen in public in, as a standalone, or under workout garments. My favorite workout bottoms are Lucy Perfect Cor Capris, that offer compression everywhere except my groin/vulva area, which is where it is worst.
Any thoughts?
I would suggest to check on JOVI Pak’s products. They do have specific garments for that area
Thank you for the recommendation. However, I’d really like to have something that I don’t look like I’m wearing a diaper in the rear and can move freely in without overheating, which makes the lymphedema worse.
I’d like to be able to do yoga, abdominal crunches, squats, lunges, rowing, cardio, and Pilates type exercises, and cant figure out how the JoviPak products would let me do these activities without being uncomfortable, in the way, or overheating. And, it’s bad enough having cancer without looking like a freak….
Was there a particular product you had in mind? Or is there a more practical, functional, and attractive alternative?
Thank you very much – I’m feeling a bit desperate, and need to be exercising in something…
Was sent home from the lymphedema therapist with foam to “experiment”. This is ridiculous… and an unserved need.
Do we just get written off if we have lymphedema as needing attractive, functional garments that will let us participate in normal activities? Are we just supposed to sit around in these quilt like garments waiting to die?
There must be a better answer…
Sharon, I completely agree with you and am feeling your pain. I too have also have front bikini area, groin and bilateral thigh lymphedema after a hysterectomy and 20 nodes removed. I am also very active. I am also in good shape and love to work out and run. I have also been very discouraged with the products out there for us! We are expected to live in these things every day for the rest of our lives but the way they are made just make me want to stay inside and hide. I wish I had some advice for you but unfortunately am in the same boat as you. I am praying for more education, resources and support in our future. Good luck and please pass on anything you find that works.
I have le that started in my right arm after Breast surgery with node removal and now have le in my trunk. (Front and back) after trauma from a mammogram that ruptured my implant pocket. I am needing a compression device that covers my chest all the way to my hip area. My groin even has fluid pockets. I am back in mld again and have a wright therapy gradient pump. I use a jovi pack type busteau and need something that is not as hot and bulky and comes down further. At the moment I am using a spanx type garment from Wal Mart. Hangar has been less than helpful… Ideas?? Thanks in advanced!
I don’t know if this will help, but I have been using the UnderArmour compression shirts to help me. They make tights that might be helpful for the above mentioned problems. Check out this link – https://www.underarmour.com/en-us/womens/apparel/bottoms/leggings/compression
Thanks! I have one of those and it doesn’t work for every day
After reading your blog post about compression garments and the disheartening comments by patients, I felt compelled to write.
“In general, compression levels provided by class 2 garments will be sufficient to prevent swelling in most patients affected by lymphedema of the upper extremity; patients with involvement of the leg will usually require a garment of compression class 3.” (posted on your blog)
In your statement above, you mention the use of very high class 2 and class 3 compression garments as the primary management option when dealing with lymphedema. I strongly disagree that this is the right path for lymphedema patients who are able to remain active, that are in stage 0 – stage 1 resulting from cancer and/or surgical procedures.
I do agree there are patients whose lymphatic systems are so impaired or their lymphedema so far progressed that the only choice is very high compression. However, I also believe there is a very large population who can manage their lymphedema without high compression.
Before and after images (https://www.solideamedical.com/wp/wp-content/uploads/2015/04/ActiveMassge.png) of my affected arm after using the Solidea Active Massage™ garments and implementing a few lifestyle changes.
I am a breast cancer survivor who developed lymphedema as a result of cancer treatments and founder of Solidea Medical. Through my experience,for I discovered Solidea Active Massage™ compression garments, which are very different from the high compression you recommend above. These garments are more effective in managing my lymphedema than any traditional compression I have worn.
Solidea Active Massage™ garments work on a similar principle to Manual Lymphatic Drainage.
“The overall goal of MLD in the treatment of lymphedema is to re-route the flow of stagnated lymphatic fluid around blocked areas into more centrally located healthy lymphatic vessels, which eventually drain into the venous system.” (posted on your blog)
Solidea Active Massage™ garments combine low compression with a 3D wave knit pattern on the interior of the fabric. As the patient moves, the raised fabric creates a gentle massage effect on the skin. Like MLD, this massage helps to move stagnant fluid to areas where lymphatic vessels are still functioning. These garments are not meant to replace therapy but rather enhance the treatment and improve quality of life.
Those with secondary lymphedema often had normal lymphatic systems prior to surgery and/or radiation and can reroute fluid to functioning lymphatic vessels. Therefore, this particular patient population would benefit more from garments like Solidea Active Massage™ and other management options that focus on enhancing lymphatic function rather than high compression which is designed to contain the affected area.
Over the past five years I have spoken with countless patients who are struggling, discouraged and disheartened like I was about their management options. I think that we need to talk more about early intervention options that can significantly alter a patient’s quality of life and ultimately their lymphedema.
How can one measure compression when garments must be layered? Im my case, with lower limb lymphedema, I wear mefeven knee high stockings with toe caps in a class 2 and a class 2 capri. This combination has done exceedingly well with helping control swelling and maintain my baseline, but I’m certain that 2+2 doesn’t equal a level 4 compression. Can I expect to continue with this combination or will it need to increase over time? My lifestyle is fairly active and I am careful to keep a healthy body weight and am extremely compliant with my doctor’s care plan (daytime garments/night garments/ pump).
You are correct, compression class II plus compression class II does not equal compression class IV. The level of compression is somewhere between 30 and 40mm/Hg. You can continue with this form of compression as long as your garments are sufficient to manage your swelling.
Hi, I was diagnosed with chronic lower limb lymphoedema this year, the scan I had showed I have no lymphatic track at all on my left side and one large tract on my right side. (I don’t fully get the diagnosis and what it means) I wear a class 2 pair of tights (pantyhose) and a microfine toecap for this but I always find it impossible to prevent the toecap from cutting in as it ends up slipping and rolling up underneath my tights making it impossible to correct the problem! How would you suggest I manage this problem? My nurse said it’s important I wear it but couldn’t tell me how to stop the garment cutting in.
Hannah – a compression garment, including a toe cap must never cut into tissue. If this is the case, then the fit is insufficient and you need to be re-measured for a different size toe cap.
I just want to say thank you for all the nice comments. I have had lymphedema in my right leg since I was 16 I am now 32. When I first had the swelling in my leg I was told by numerous doctors that they did not know what it was. Eventually a vascular surgeon dx me with lymphedema I was told there was no cure and not enough info about it yet. I went 14 years without doing anything because of ill fitted stockings that hurt me. 2 years ago I noticed my leg was getting worse and that my left leg was starting to swell. I sought help at the lymphedema clinic at the Cleveland clinic. Was put into therapy and began wrapping my legs with bandages. I did not respond to MLD. I did however respond to the compression bag pump. I had to fight with my insurance company to get a pump in my home (as I was told it wasn’t medically necessary) finally the company I was working with for the pump just gave it to me free of charge. I am now in nursing school and have found that my legs are not responding anymore to the pump/stockings/or wraps. I just saw my dr about it yesterday. And left her office crying being told there really isn’t anything she can do “there is no magic pill” I had to fight to get a script to get custom stockings being told “am I sure I really want to go that route it’s expensive” I’m willing to try anything since the stockings I have tend to either bunch at my ankle or bunch under my knee since I’m so short. I’m sick of hearing I don’t know that there is nothing we can do. I feel so discouraged. I’m on 32 this should not be what defines me. Why do lymphedema patients just get pushed aside like its no big deal. It’s so frustrating.
Joe:
Can you write a column on the concept of “stiffness” and how this applies to lymphedema compression garments? This concept will also help to explain why layered garments are sometimes used instead of higher compression class.
Wow great article. I didn’t know much about compression wear and how it could help lymphedema. How do the higher graduated compression differ in results with lymphedema?
The level of compression is not generally an indicator for it’s effectiveness. The level of compression depends on the extremity affected and the stage of the lymphedema.
What garments do you recommend for the stomach area?
It depends on the case – we usually use abdominal binders or compression pantyhose.
I have lymphedema in by right hand and arm and cant wear compression garments this is because my hands get tiny pin prick spots on and then weep and get infected and end up in hospital with cellulitis same thing happens with bandaging. am now looking at getting a compression pump. will this help
It depends on your individual case
I have the compression pump for my legs, arms and mid section plus I wear compression stockings too.
The pump is relief but not permanent