Divergent lymphatic drainage routes from the heel to the inguinal region: Anatomic study and clinical implications

Purpose: To determine routes of lymphatic drainage from the heel to the inguinal lymph nodes to assist in the clinical management of lower limb lymphatic disorders. Methods: Six lower limbs from three unembalmed human cadavers were studied. Under a surgical microscope, 6% hydrogen peroxide was used to detect lymphatic vessels on the medial and lateral sides of the heel. The lymphatic vessel on either side was then injected with a radio-opaque mixture. The lymphatic vessels were traced, photographed, and radiographed to demonstrate the lymphatic pathways from the heel to the inguinal lymph nodes. The final results were transferred to computer for digital image analysis. Results: Two groups of lymph collecting vessels were identified. The medial group, arising from the skin between the medial malleolus and the Achilles tendon, coursed along the medial side of the leg and thigh to the inguinal lymph nodes. The lateral group, arising from the skin between the lateral malleolus and the Achilles tendon, coursed along the postero-lateral side of the leg to the popliteal fossa. Alternative routes were then identified from the popliteal fossa to the inguinal lymph nodes. The number, size, type, and distribution of lymph vessels and nodes were variable from person to person. Conclusion: Two different lymphatic routes from the heel to the inguinal lymph nodes have been described. This information upgrades current anatomical knowledge and the results will be of benefit for the clinical management of lower limb trauma and malignancy.