My Journey with a Chronic Leg Ulcer (Part 2)

 

I wrote an article on my first journey with dates of my admission to hospital and a private wound care centre for my leg ulcers here: 

https://scientificlogic.blogspot.com/search?q=leg+ulcers

This is my second journey for an ulcer that has never healed. 

I have this chronic leg ulcer for 10 years now that never healed despite all efforts by countless medical and vascular surgical specialists. 

Chronic leg ulcers that resist healing despite standard venous treatments, and with imaging confirming lymphatic compromise, suggesting a more complex pathology, possibly involving combined venous and lymphatic insufficiency (phlebolymphedema). 

My situation is indeed medically challenging.

Let me summarize my case systematically as a clinician myself

Chronic non-healing leg ulcers.

Treated with radiofrequency ablation (RFA) → likely to address varicose veins or venous reflux.

Later treated with GLUE (cyanoacrylate) ablation → another modality for venous closure.

No healing occurred.

A lymphoscintigraphy showed impaired lymphatic return, indicating lymphatic dysfunction, perhaps secondary lymphedema.

Chronic leg ulcers that resist healing despite standard venous treatments, and with imaging confirming lymphatic compromise, suggesting a more complex pathology, possibly involving combined venous and lymphatic insufficiency (phlebolymphedema). 

The question I ask myself is, would Hyperbaric Oxygen Therapy (HBOT) useful in my case? Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized environment, which:

1. Increases oxygen delivery to hypoxic tissues.
2. Promotes angiogenesis (formation of new capillaries).
3. Stimulates fibroblast activity and collagen production.
4. Enhances leukocyte killing of bacteria and improves immunity.

Reduces edema, particularly in areas with compromised microcirculation.

These effects can support wound healing, especially in cases where tissue oxygenation is poor.

 Evidence in Lymphatic/Venous Ulcers:

1. For Venous Ulcers Alone:
HBOT has modest evidence.

Cochrane Review (2015): Some studies suggest short-term benefit in accelerating ulcer healing, but not conclusive for long-term outcomes.

Best when used as adjunct therapy, not standalone.

2. For Lymphatic Compromise / Lymphedema:
Evidence is less robust, but there are case reports and small studies showing:

Reduced inflammation and swelling.

Improved microvascular perfusion.

Enhanced lymphangiogenesis in animal models.

 Interpretation for my case given that I have exhausted standard venous treatments. I now have documented lymphatic insufficiency., and the ulcers remain chronic and resistant. It is reasonable and worthwhile to consider HBOT as adjunct therapy, especially if there is no arterial insufficiency (i.e., ABI > 0.8). The ulcer base is not heavily infected or necrotic (or infection is controlled). However, the cost and availability of HBOT is expensive and not always accessible. HBOT is not a miracle, at best used alongside compression therapy, nutrition optimization, infection control, and lymphatic management (manual drainage, elevation, etc.). The risks with HBOT is  barotrauma, oxygen toxicity, claustrophobia. However, there are complementary strategies I  might also consider such as, complete decongestive therapy (CDT) for lymphedema. Low-level laser therapy (LLLT)  which I read is an emerging evidence for lymphatic stimulation.

Nutritional support with a protein-rich diet, vitamin C, zinc which are all critical for wound healing. Topical growth factors (under specialist supervision), and avoiding local trauma, tight garments, infections.

In my complex and multifactorial case, venous + lymphatic ulceration, HBOT is not a guaranteed cure, but it can provide real benefit by enhancing tissue oxygenation and promoting healing. It may be especially useful now that conventional interventions have failed.

Even if I go for HBOT the increased in  oxygen in the blood and lymph is only temporary for the duration of the HBOT and will drop back to low levels after that since circulations whether blood or lymph flow is a continuously  24 hours day cycle.  So in my mind it may not help unless the oxygen content is continuously high with good venous and lymphatic returns continuously. We can't be on HBOT continuously as this will damage the lungs. I think one of the best approaches is leg elevations as much as possible to facilitate fluid returns against gravity. I tried compression bandage but this does not seem to work well. In fact there is oedema on the feet possibly due to compression by the dressing bandage itself over the wounds.  

Peddling on a stationary bicycle may help together with using a mechanical leg massager to help pump the fluid back to the heart is another option. There is a rational critique of HBOT’s limitations. Indeed, by physiological reasoning it is entirely correct: oxygen diffusion from HBOT is transient, and unless the underlying circulatory and lymphatic dynamics are improved, the long-term benefits may be marginal. I need to focus on sustained strategies, including gravity assistance, muscular pumping, and mechanical augmentation. This approach is not only sensible but in line with current best practices in complex wound and lymphatic management.

Let me now offer myself  a carefully structured, evidence-informed integrated treatment plan tailored for myself for my own case:

1. Precise Diagnosis: Classify the Ulcer Type - 

Since both venous reflux and lymphatic dysfunction were identified, I believe it is likely I  have phlebolymphedema, or mixed etiology ulcers. In that case, I need rule out arterial insufficiency (via Ankle-Brachial Index (ABI) and Toe Pressures if ABI >1.3 from calcification). Rule out infection or malignancy in chronic ulcers.

 2. Core Therapeutic Philosophy: 
“Sustain tissue oxygenation and interstitial fluid balance not by spikes (like HBOT alone), but by continuous venous and lymphatic unloading, microcirculation optimization, and mechanical facilitation of return flow.”

3. Foundational Treatments

Leg Elevation,  as much as possible. This is the best strategy for passive fluid return. Elevate above heart level at night and during rest. Use wedge pillows or recliners with foot lift.

Duration matters more than angle: 4–6 hours per day minimum improves outcomes.

4.  Compression, but with caution if there is worsening pedal edema, which suggests:

Bandages may be too tight distally, blocking lymph flow. Or compression not well graded (graduated pressure,  higher at ankle, tapering upwards).

5. Optimizing Compression by avoiding  elastic bandages over ulcers that are exudative or inflamed. Consider in-elastic or “short-stretch” bandages like Unna boots or multi-layer wraps designed for mixed pathology. Custom compression stockings (class 2 or 3) fitted after edema stabilizes.

Perhaps I may also trial adjustable Velcro wraps (like Circaid or Juxta Lite) which allow pressure adjustment and comfort.

6. . Muscular Pump Activation: Dynamic Therapies such as  a stationary bicycle or ankle peddling.  Logically, I believe this is an excellent choice for  enhancing calf-muscle pump, which is the primary venous return engine. Stimulating lymphatic drainage via muscle contractions. 10–15 minutes 3× daily, increasing as tolerated.

 7. Mechanical leg massager that simulates sequential compression, like, intermittent pneumatic compression (IPC) devices.. This can be effective in augmenting lymphatic flow and reducing edema. Use  this device for 30–60 min/day but I must be careful with ulcers to avoid direct pressure over wounds.

 8. Lymphatic-Focused Therapies. A. Manual Lymphatic Drainage (MLD) with the help of  trained therapists. Gentle massage techniques in proximal-to-distal-to-proximal sequence to clear lymph pathways. This to be followed by compression wrapping if tolerated.

Complete Decongestive Therapy (CDT). This includes, MLD, compression therapy, skin care, and exercises. I believe this is the best for advanced lymphatic involvement. Long-term maintenance needed to prevent rebound swelling.

9. Adjuncts to Improve Healing - A. tropical therapy that uses non-adherent dressings (e.g., silicone mesh) + moist wound environment with hydrogels or alginate if exudative.

10. I shall consider topical growth factors (e.g., PDGF) or honey-based dressings for chronic ulcers.

If biofilm/infection is suspected: iodine, silver, or PHMB-based dressings.

There are also systemic support with serum albumin, vitamin C, zinc, B12. I may consider Arginine + Glutamine supplements (e.g., Juven), shown to aid chronic wound healing.

I am not diabetic, but need to check for microvascular dysfunction. HBOT  as  a targeted adjunct, but should not be a primary therapy, but to:

Kickstart granulation tissue in hypoxic, refractory wounds, especially if signs of osteomyelitis, ischemia, or biofilm. Use in short bursts: e.g., 20–30 sessions over 6 weeks. I need to monitor for benefits, then withdraw.

Surgical Re-Evaluation (if non-healing persists). Consider referral to a multidisciplinary wound center.

Evaluate for:

1. Skin grafting (e.g., STSG) or bioengineered skin substitutes (e.g., Apligraf, Dermagraft).
2. Lymphovenous bypass or VEIN-LYMPH anastomoses if lymphatic anatomy allows (experimental).
3. Debridement of fibrotic or infected tissue. Static elevation is good; dynamic muscle work is better.
4. Avoid compression that does not breathe with the limb, fluid return needs gradient, not a tourniquet.

My opinion about HBOT's oxygen being transient is not wrong. Its true benefit is stimulating healing cascades, not maintaining oxygenation. I should not underestimate the power of routine gentle exercise and calf pump activation, that is my biological heart for the legs.

My closing opinion as a senior research medical scientist and clinician is: 

“Healing comes not from a single tool but from the orchestration of pressure, motion, oxygen, and rest, like a symphony for circulation.

 However, mastering that orchestration can be daunting and difficult, but I can try these therapeutic strategies that several vascular surgeons have not explained them to me so far, except they merely use radio frequency ablation and  cyanoacrylate (glue) method - both have failed me miserably. 

However, a overly complex, multi-modal regimens often become impractical and can lead to non-compliance, frustration, or even harm if not precisely managed. What I need  is to  balance efficacy, simplicity, and sustainability. Let me affirm some simple and more practical therapeutic approaches once again:  

1. Leg Elevation — Foundation of Success
Keeping the legs above heart level whenever possible reduces venous and lymphatic hydrostatic pressures dramatically.

Crucial Detail: Combine with deep breathing exercises to create thoracic negative pressure, this further enhances venous return.

2. Toe Flexing and Ankle Pumping
Absolutely excellent. The calf muscle pump and foot arch pump are the most powerful "venous hearts" for the lower limbs.

Regular pumping, every 15–30 minutes during elevation, is more effective than static elevation alone.
 

3. Leg Massager (Mechanical Aid)
Excellent adjunct.

I need to choose sequential compression models over random massage units, if possible.

Proximal-to-distal then distal-to-proximal sequences help “clear the highway” before pushing fluid upward.

4. Stationary Bicycle Pedaling - 
One of the most effective low-impact therapies.

Encourages sustained calf and thigh muscle activation.

Try for 2–3 short sessions daily (10–15 min), gradually increasing to 30–45 min as tolerated.

5. Nutritional Support
Absolutely foundational. As I am not just merely a clinician, a doctor and a medical researcher, but I am also a nutritionist. Thus, I believed I have nailed the essentials using these: 

High-quality protein (≥1.2 g/kg/day if no renal issues).

Vitamin C: 500–1000 mg/day (collagen synthesis).

Zinc: 15–40 mg/day (but beware of copper depletion if used >1 month). I may consider adding:

L-Arginine + Glutamine mix (e.g., Juven) to stimulate healing (optional but evidence-based).  These are nutritionally supportive to tissue repair. 

I need to focus on the mechanics of circulation and drainage, not just temporary biochemical fixes.  Manual Lymphatic Drainage (MLD) once or twice weekly

Gentle technique. No equipment. No risk. Facilitates drainage especially where scarred or fibrotic lymphatics exist. 

“Healing is not about doing everything, it is about doing the right things, persistently, in harmony with the body's wisdom.”

There is one final thought I missed out, and that is weight reduction. Excessive body weight presses over all the veins in the pelvic cavity preventing or slowing down all venous and lymphatic returns. This is not not just physiology but it is  physics - this is actually my favourite subject as well as mathematics. This just struck at the heart of a physical law that is too often overlooked in clinical practice. This is not just physiology, it is physics, and beautifully so. 

Weight Reduction is  the unseen mechanical lever. This is physiological truth. Adipose tissue isn’t passive, it’s metabolically active, pro-inflammatory, and compressive. Central obesity especially exerts mechanical pressure on:

Inferior vena cava, iliac veins and pelvic lymphatic trunks. This results in stasis, increased venous pressures, and lymphatic congestion in the lower limbs. This is physics applied in medicine.  According to Pascal’s Law, pressure applied to an enclosed fluid is transmitted undiminished throughout the fluid. Therefore, central pressure (from abdominal fat) translates directly into:

1. Hydrostatic resistance in lower limb venous return
2. Increased interstitial filtration → oedema
3. Impeded lymph return due to collapse of low-pressure vessels

Imagine the venous system as a garden hose:

Pelvic adiposity = someone stepping on the hose near its origin.

Downstream (i.e., legs), pressure builds, return flow stalls.

The same applies to lymphatics, which are even more delicate.

Hence I need to consider weight reduction as a decompression strategy. Even a 5–10% reduction in body weight has been shown to:

Decrease venous hypertension

Improve ankle-brachial index (ABI)

Reduce chronic oedema

Improve healing rates of venous ulcers

Improve insulin sensitivity and systemic inflammation, which indirectly supports tissue repair

Strategic Summary: 

Now I  have given myself  the 7 Pillars of treatment 

 1. Leg Elevation

2, Toe/Ankle Pumping

3. Mechanical Massage

4. Stationary Bicycle

5. Nutritional Support

6. Optional: Manual Lymphatic Drainage

7. Weight Reduction (Mechanical + Metabolic Benefit).  

 All  the essential levers to restore circulation, reduce oedema, and promote healing, through insight, not just interventions. I hope this medical intuition continues to shine like a diamond for my chronic leg problem no medical or surgical specialist has ever told, explained, or discussed with me. Maybe they are not familiar? They merely asked me to go for wound dressing twice a week after their RFA and glue failed me miserably. 

I believe I have given myself a masterclass in applied clinical physics and physiology. All  the essential levers to restore circulation, reduce oedema, and promote healing, through insight, not just interventions. I hope this medical intuition continues to shine like a diamond for my chronic leg problem no medical or surgical specialist has ever told or discussed with me. Remove the upstream resistance, and the downstream flow will follow.

 I think medical doctors need to seriously integrate medicine with physics, engineering, biochemistry, physiology, nutrition, rehabilitation, psychology, and even philosophy - not just give the chemical medicine that does not cure anything. This  final point completes my equation. 

It is very unfortunate that as a patient I cannot treat myself as a doctor. I need another doctor to treat me. It is  is very unfortunate, none of them - all senior medical and surgical specialists have been unable to cure me of my leg problem - let alone explain to me the dynamics of these pathologies 

(I shall write about my personal hobbies in my next article - despite my leg problem) - jb lim