Stemmer's Sign
Introduction
Stemmer's sign is used to assess lymphoedema. It evaluates the subcutaneous tissues and skin for fibrotic changes. A positive Stemmer's sign indicates thickness and reduced skin mobility at the dorsum of the foot or hand.
Background
Stemmer’s sign is a clinical diagnostic test used to identify lymphoedema. It assesses the ability to pinch and lift the skin fold at the base of the second toe or finger for upper extremity. [1]The test mechanically evaluates tissue thickness and fibrosis resulting from chronic lymphatic fluid accumulation. It has specific importance in detecting lymphoedema and differentiating it from other causes of limb swelling.[2]
This test is attributed to Dr. Robert Stemmer, who first described it in 1976 as a pathognomonic sign of lymphoedema. It evaluates the subcutaneous tissues and skin for fibrotic changes secondary to chronic protein-rich fluid accumulation in the interstitial spaces. A positive Stemmer’s sign indicates increased tissue thickness and fibrosis. This reduces skin mobility at the dorsum the foot or hand. The inability to pinch the skin reflects progressive tissue changes. Thickening and induration are often localised at the dorsum of the foot, particularly at the base of the second toe. [2][1][3]
Historical Context and Origin
The Stemmer sign was first described by Robert Stemmer in 1976 as a clinical symptom for the early and differential diagnosis of lymphoedema. It is also known as the Kaposi-Stemmer sign, acknowledging Kaposi’s initial description in 1887. [4]The sign gained clinical acceptance due to its simplicity and ability to differentiate lymphatic from non-lymphatic oedema. It has since been integrated into clinical practice guidelines and physiotherapy protocols for lymphoedema assessment.[5] [4]
Anatomical and Physiological Basis
The Stemmer's sign is based on the anatomical and physiological changes that occur in lymphoedema. The dorsal skin of the toes or fingers is normally pliable and can be easily pinched.[6] In lymphoedema, the accumulation of high-protein lymphatic fluid in the subcutaneous tissues leads to chronic inflammation, fibrosis, and adipose deposition. These changes result in thickened, fibrotic skin that cannot be easily pinched or lifted, producing a positive Stemmer's sign. [3]The underlying mechanism involves dysfunction of the lymphatic vessels, which impairs fluid drainage and leads to fluid stasis. This stasis triggers an inflammatory response and tissue remodelling, including fibrosis and skin thickening, which manifest clinically as the inability to pinch the skin.[3] [6]
Technique of the Stemmer's Sign
The Stemmer's sign is performed as follows:
- Patient Positioning: The patient is positioned comfortably with the affected limb exposed.
- Anatomical Location: The examiner focuses on the dorsal aspect of the proximal phalanx of the second or third toe or finger.
- Pinch Attempt: The examiner gently attempts to pinch or lift the skin between the thumb and index finger.
- The test is typically performed bilaterally to compare affected and unaffected limbs.
- Variations in technique include assessing different digits or locations, but the proximal phalanx of the second or third toe/finger is most commonly used.[5]
Interpretation:
- Positive Sign: Inability to pinch or lift the skin, indicating lymphoedema.
- Negative Sign: Skin can be pinched normally, suggesting no lymphoedema or early-stage disease.
The Stemmer sign can be graded based on severity:
- Stage I: Barely pronounced (skin fold width 0.5–1 cm)
- Stage II: Moderately pronounced (>1 cm)
- Stage III: Severely pronounced (skin fold cannot be lifted at all) [5] [7]
Clinical Relevance: Sensitivity, Specificity, and Diagnostic Accuracy
The Stemmer's sign is highly sensitive, with studies reporting sensitivity values of 92% and 88%.[3] This makes it an excellent screening tool for detecting lymphoedema. However, its specificity is moderate, ranging from 57% to 59%. The moderate specificity results in false-positive findings, particularly in patients with obesity, spinal muscle atrophy, or other conditions causing skin thickening or oedema. [8]False negatives can occur, especially in early-stage lymphoedema or in patients with normal body mass index (BMI). Therefore, while a positive Stemmer sign is strongly indicative of lymphoedema, a negative sign does not exclude it. Comparatively, lymphoscintigraphy remains the gold standard for lymphoedema diagnosis, with higher specificity and ability to visualise lymphatic function. The Stemmer's sign is best used as part of a comprehensive diagnostic workflow, including clinical history, physical examination, and imaging or other diagnostic tests.[3] [8]
Pathophysiological Explanation
The Stemmer's sign occurs due to the accumulation of protein-rich lymphatic fluid in the subcutaneous tissues, leading to chronic inflammation, fibrosis, and skin thickening. [9]This process is a hallmark of lymphedema pathology. The lymphatic system’s dysfunction results in impaired fluid drainage, causing fluid stasis and subsequent tissue remodeling. The inability to pinch the skin reflects the fibrotic and thickened nature of the subcutaneous tissues, which are less pliable than normal skin. These changes are specific to lymphoedema and differentiate it from other causes of oedema, where such fibrotic remodeling is less pronounced.[3] [9]
Clinical Application in Physiotherapy
The Stemmer's sign is a practical and rapid tool used in physiotherapy for:
Initial Assessment: Identifying potential lymphoedema cases early, prompting referral for further diagnostic testing.
Monitoring Progression: Tracking changes in skin thickness and fibrosis over time to assess disease severity.
Evaluating Treatment Efficacy: Assessing response to interventions such as manual lymphatic drainage, compression therapy, and exercise. The sign is integrated into clinical practice guidelines and is recommended by the International Society of Lymphology and other authoritative bodies as part of the diagnostic workup for lymphoedema. It aids in differentiating between lymphoedema and other conditions, guiding appropriate physiotherapy management.[2]
Limitations and Controversies
Despite its utility, the Stemmer's sign has several limitations:Subjectivity and Inter-Observer Variability: The test relies on the examiner’s tactile sensation and experience, which can vary.False Positives and Negatives: As noted, obesity, spinal muscle atrophy, and earlystage lymphoedema can lead to misleading results.Lack of Standardisation: While severity grading exists, there is no universally accepted protocol for performing and interpreting the sign.Dependence on Clinical Context: The sign must be interpreted alongside other clinical findings and diagnostic tests.Alternative and complementary diagnostic tools, such as lymphoscintigraphy, bioimpedance spectroscopy, and circumferential measurements, provide more objective and quantitative data but may not be as readily available or cost-effective.[3] [10]
References
- ↑ 1.0 1.1 Stemmer R. Stemmer's sign--possibilities and limits of clinical diagnosis of lymphedema. Wiener Medizinische Wochenschrift (1946). 1999 Jan 1;149(2-4):85-6. https://pubmed.ncbi.nlm.nih.gov/10378332/
- ↑ 2.0 2.1 2.2 Brauer WJ. Stemmer Sign Needs to be Recorded and Interpreted Correctly. Deutsches Ärzteblatt International. 2021 Jan 22;118(3):39. https://di.aerzteblatt.de/int/archive/article/217395
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Goss JA, Greene AK. Sensitivity and specificity of the stemmer sign for lymphedema: a clinical lymphoscintigraphic study. Plastic and Reconstructive Surgery–Global Open. 2019 Jun 1;7(6):e2295. https://pmc.ncbi.nlm.nih.gov/articles/PMC6635205/#:~:text=A%20positive%20Stemmer%20sign%20is,standard%20diagnostic%20test%20for%20lymphedema.
- ↑ 4.0 4.1 Brenner E, Putz D, Moriggl B. Stemmer's (Kaposi-Stemmer-) sign–30 years later. Phlebologie. 2007;36(06):320-4. https://www.researchgate.net/publication/200149435_Stemmer%27s_Kaposi-Stemmer-_sign_-_30_Years_later
- ↑ 5.0 5.1 5.2 Brauer WJ. Stemmer Sign Needs to be Recorded and Interpreted Correctly. Deutsches Ärzteblatt International. 2021 Jan 22;118(3):39. https://pmc.ncbi.nlm.nih.gov/articles/PMC8129060/
- ↑ 6.0 6.1 Rockson SG. Current concepts and future directions in the diagnosis and management of lymphatic vascular disease. Vascular Medicine. 2010 Jun;15(3):223-31. [1]
- ↑ Goss JA, Greene AK. Sensitivity and specificity of the stemmer sign for lymphedema: a clinical lymphoscintigraphic study. Plastic and Reconstructive Surgery–Global Open. 2019 Jun 1;7(6):e2295. https://pmc.ncbi.nlm.nih.gov/articles/PMC6635205/
- ↑ 8.0 8.1 Jayaraj A, Raju S, May C, Pace N. The diagnostic unreliability of classic physical signs of lymphedema. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2019 Nov 1;7(6):890-7. https://www.sciencedirect.com/science/article/pii/S2213333X1930318X
- ↑ 9.0 9.1 Rockson SG. Current concepts and future directions in the diagnosis and management of lymphatic vascular disease. Vascular Medicine. 2010 Jun;15(3):223-31. https://journals.sagepub.com/doi/10.1177/1358863X10364553?utm_source=researchgate.net&utm_medium=article
- ↑ Planinšeg Ručigaj T, Tlaker Žunter V. Lymphedema after breast and gynecological cancer–a frequent, chronic, disabling condition in cancer survivors. Acta Dermatovenerologica Croatica. 2015 Jul 21;23(2):101-.https://www.researchgate.net/publication/280582363_Lymphedema_after_Breast_and_Gynecological_Cancer_-_a_Frequent_Chronic_Disabling_Condition_in_Cancer_Survivors