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Swelling of the lower legs without redness or fever is a common entity seen in medical practice. It is much more common amongst older adults. If one or both of your legs tend to swell, there is a greater tendency to develop ulcers or skin infections called cellulitis. When we see swollen ankles, we first try to decide whether it is acute or chronic. Acute refers to a sudden new swelling that appears within a few hours. It is also important to decide whether it affects one or both legs. Leg edema tends to fall into two broad types. Oxygen rich blood flows down to our legs in arteries, but returns two ways. It can travel through capillary beds and then into veins, or it can flow through spaces between tissues called lymph flow. When the capillaries cannot filter and return fluid fast enough, it seeps into the areas around them. It contains little protein, and pushing on the area can cause an indentation by squeezing fluid to the side. We call this “pitting edema.” Lymphedema is generally due to a problem with some sort of blockage preventing lymph from draining out of the legs and tends to be more serious. Cancer needs to be ruled out in these cases.
The veins in our legs carry blood back to the heart in an uphill fashion. They contain little valves that resemble saloon-doors, and allow blood to flow in one direction only. hen we are active, our calf muscles also help the blood flow. This whole mechanism tends to function less efficiently as we age. Some people are more prone to varicose veins. This is a condition in which the veins enlarge due to poorly functioning valves. Varicose veins should not be confused with leg edema.
Venous stasis is a chronic type of vein insufficiency that tends to bother older folk. It can be totally harmless or can be an indicator of heart failure. It tends to get worse through the day and is helped with elevation or compression stockings. There tends to be no shortness of breath or chest pain. If the swelling is chronic, you may notice a browning of the skin caused by hemosiderin deposits. In simple terms, this is the result of our body doing a chronic cleanup of debris that has accumulated in the area.
The one emergency situation that we are always on the look out for is a sudden painful unilateral leg swelling suggesting a blood clot. Technically, it is called a DVT (Deep Vein Thrombosis). It requires urgent diagnosis and treatment to avoid the rare complication of a pulmonary embolism. These clots can break off their footings and travel to the lungs. Blood is a very responsive medium. It tends to clot when smooth flow stops. This can occur at the side of a cut or during long periods of leg inactivity such as on plane or car rides. The standard treatment was to prevent further clot formation by injecting heparin, but this has been replaced by newer more efficient drugs such as Lovenox.
Sometimes leg edema is the result of medication. Some drugs, particularly calcium channel blockers, can modify the response of blood vessels to changes in posture. One way to control hypertension is to move fluid “away from the heart.” For this reason, I often caution patients who feel “water pills” are a quick solution for all types of leg swelling. The concern I sometimes harbor is that when the infamous “water pill” helps one person they sometimes cannot help but advocate it to anyone encountering with swollen legs. Some people even offer free samples. Other people turn to herbal preparations with known mild diuretic effects such as horse chestnut. Self-treatment is not defined by the source in my mind.
As our population ages, we are diagnosing more people with sleep apnea. In this group of patients who also develop leg swelling, it is vital to rule out a potentially serious condition called pulmonary hypertension.
Elevating the legs as much as possible, wearing compression stockings and regular walking can relieve chronic leg edema. If you notice new leg swelling it is best to get it checked by a medical professional. Sudden onset of swelling deserves urgent assessment. Lovenox (Enoxaparin) is a newer blood thinning drug that is being used to prevent blood clots not only in surgical patients, but is also starting to be used in cancer patients. Snowbirds engaging on those southern migrations in cramped cars may also consider discussing its use during travel. I would be very cautious about water pills. They often help many types of swelling but without an appropriate diagnosis can mask a more serious problem. It is dangerous to share or sell any prescription dispensed to you.
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