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Leg Swelling is Not Normal

Posted: March 5, 2014   |   Revised: October 19, 2016

It is easy to ignore subtle swelling near the ankle, but what starts as minimal swelling usually will get worse with time. Leg Swelling is Not Normal and often provides a clue to more serious underlying problems. Undiagnosed and untreated leg swelling may lead to pain, tenderness, recurrent infections, skin ulcers, clotting in the leg veins, and even death.  For these reasons, it is important to seek a professional assessment of leg or ankle swelling.

Leg Swelling is Not Normal Your physician should ask about your medical history and about symptoms that might reveal the nature of the leg swelling.  A history and physical exam that takes into consideration the heart, lung, brain and nerve function, muscles, and blood vessels helps to sort out the possible causes of leg swelling.  It is not uncommon for the swelling to be due to more than one problem and clinical knowledge and experience are key to differentiating causes of the problem.

Although more expensive testing such as X-ray, CT, or MRI scans may be helpful on occasion, a thorough lower extremity venous ultrasound exam often is the first and only necessary diagnostic test.  Venous ultrasound studies are used to rule out clotting of the deep veins of the leg (deep vein thrombosis, DVT), but, unfortunately, many laboratories do not perform the other venous ultrasound studies which are essential to diagnose the cause of swelling if DVT is not found.  Too often, patients are told that the ultrasound exam did not show any DVT and the evaluation is stopped without answering why the legs are swelling.

A detailed venous color duplex ultrasound exam is required to evaluate leg swelling to determine whether or not there is failure of one-way valves in the veins of the leg or obstruction of the veins limiting venous blood flow out of the legs.  Failure of the one-way valves causes venous insufficiency with backward flow down the veins toward the feet resulting in very high pressures in the veins of the legs (venous hypertension).  Venous insufficiency is the most common cause of leg swelling in North America.  It is treated initially with periodic elevation of the legs above the level of the heart, exercise especially of the calf muscles, avoidance of prolonged sitting or standing when feasible, and elastic support stockings.  Eventually many patients develop venous insufficiency severe enough that they require treatment with minimally-invasive office procedures to close or remove the veins with the worst valve leakage.

Obesity is the second most common cause of leg swelling in North America.  Extra fatty tissue in the abdomen and pelvis compresses the veins and lymphatic channels which are the pathways for blood and lymphatic fluid to get from the legs back to the heart.  Inactivity of the legs such as prolonged sitting or standing, or an abnormal flat-footed walk, commonly contributes to leg swelling, especially among the elderly due to arthritis or nerve problems.

Patients with leg swelling often are placed on diuretic tablets, often called “water pills” which frequently fail to resolve the swelling and may cause dehydration, dizziness, or fainting spells.  Diuretics are appropriate for leg swelling only if there is evidence of retention of fluid in the legs because of congestive heart failure (poor pumping by the heart) or failure of the kidneys to rid the body of excessive fluid.  Unfortunately, physicians have been trained for many decades to treat leg swelling with diuretics while ignoring the most common causes of leg swelling.

One of the feared causes of leg swelling is clotting in the deep veins of the legs (the large ones inside the muscles).  Deep vein thrombosis may result in leg pain, swelling, a purple leg, or may present with a potentially fatal migration of the large clots from the leg veins to the lungs (pulmonary embolism).  For this reason, it is important to diagnose DVT with venous ultrasound studies and to institute anticoagulation with medications to prevent formation of additional clot.  In some cases involving a large amount of fresh clot in the veins of the abdomen, pelvis, or large veins of the thighs, drugs delivered directly into the clot by small catheters may be used to dissolve the clots (catheter-directed thrombolysis).

Leg swelling, often with pain in the leg or pelvis with exercise is due to compression of a vein in the pelvis by other organs or by old clot in the veins of the abdomen or pelvis.  This problem may be treated by placement of a metal stent into the narrowed vein by means of a needle stick approach in order to hold the vein open.

Some patients develop leg or foot swelling due to collection of a clear fluid within the tissues; this lymphatic fluid normally travels through microscopic pathways up the legs and eventually reaches the bloodstream in the chest.  Some patients are born with obstructions in the lymphatic tissues and may have leg swelling as children.  Others develop obstructions due to infection, surgery, or injuries resulting in lymphatic fluid building up in the calf or foot.  Some patients produce an abnormally high volume of lymphatic fluid which overwhelms the capacity of the lymphatics to move the fluid back to the chest.  This build up of fluid, lymphedema, if untreated, usually will get worse and much more difficult to manage with severe lifelong disability.  Treatment may include massage, elastic wraps or compression devices, compression pumps, and, rarely, surgery.

Finally, lower extremity swelling may occur as a side effect of medication and these side effects may not be very predictable.  Swelling shortly after starting a new medication is a hint that a drug may be part of the problem.

Leg swelling is an important clue to potentially serious complications in the future and most of these complications can be avoided by proper diagnosis and treatment.  It is important to see a physician with the knowledge and a very specialized venous ultrasound laboratory to identify your particular problem and needs.  It is also important that you have access to the right devices to control the swelling and the teaching about how to control the swelling.  This is very special expertise which the team of experts at VeinCare Centers of Tennessee provides daily to our patients.  Our credentials and experience to care for these problems are unrivalled in Middle Tennessee.

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