Leg Swelling

Leg swelling (edema) is a common problem that affects millions of Americans and can be disabling for many. There are various causes of leg swelling, including vascular problems in the legs and also build-up of fluid in the body as a result of kidney disease, liver disease or other conditions. Leg swelling can be caused by fluid back up due to heart disease, which is caused by heart failure. Leg swelling can also be caused by certain medications. A health care provider can determine the cause of leg swelling in most cases with a complete history and physical examination. In some cases, other tests are necessary.

The most common vascular causes of leg swelling are venous insufficiency and lymphedema. The body has two circulatory systems that carry fluid away from the limbs and organs and back towards the heart: the venous system and the lymphatic system. The venous system's purpose is to carry blood back to the heart and lungs to get oxygen. Veins have valves within their walls that open, close, and help push blood back to the heart and prevent it from going in the opposite direction due to gravity. The veins are helped by the muscles of the calf to pump blood back to the heart during each contraction, which occurs with walking. If there is a malfunctioning of the valves in the veins, such as after a blood clot (DVT) or with severe varicose veins, it can result in chronic venous insufficiency. The lymphatic system also works in getting blood and fluid from the tissues of the body back to the heart. If there is a disruption in the lymphatic system, such as that caused by surgery or infection, swelling can result. This lymphatic swelling is called lymphedema.

It is also important to know that a patient can have more than one cause of leg swelling. What type of information helps a health care provider figure out the cause of leg swelling?

Timing. Swelling that develops all of a sudden is more likely to be due to variables such as a blood clot (deep vein thrombosis or DVT) or a skin infection (called cellulitis). Swelling that occurs slowly over time is more likely to be due to a vascular problem, such as vein disease (called chronic venous insufficiency) or lymphedema.

Medical history. A history of DVT, a family history of varicose veins or leg swelling, a lifestyle which demands standing or sitting for a prolonged period of time, trauma, recent surgery or infection will help determine if the swelling is due to chronic venous insufficiency or lymphedema. Since medications are associated with swelling, they are also important to review. Any decrease in activity can result in swelling, given the inadequate use of the calf muscles as a pump. A history of heart or lung disease can also give clues to the cause.

Location of a prominent swelling. The location of the swelling helps the doctor to determine its cause. Swelling due to chronic venous insufficiency tends to result in swelling throughout the leg, sparing the feet. Lymphedema tends to have more foot involvement, although, as it progresses, it can also involve the entire leg.

Pain. The presence of pain can be a clue that the leg swelling may be due to deep vein thrombosis or infection (cellulitis).

Swelling in areas other than the legs. If swelling occurs in the arms, fingers, abdomen or buttocks, it is more likely to be due to a systemic health problem such as liver or kidney disease, heart disease or even poor nutrition (in severe cases).

Rashes and skin findings. There may be other skin problems that develop with leg swelling that can help the doctor figure out the cause of swelling. Patients with chronic venous insufficiency may also have varicose veins, a redness or bluish discoloration of the skin, dark discoloration of the skin (called hyperpigmentation) and ulcers (open sores). Patients with lymphedema can have wart-like changes in the skin.

What types of testing can be used to further evaluate the cause of leg swelling? After a thorough history and physical examination, evaluations for leg swelling can include:

Ultrasound of the legs to look for DVT. An ultrasound can also detect leakage of the valves of the veins and varicose veins, which suggests chronic venous insufficiency. An ultrasound cannot evaluate the lymphatic system.

CAT scan of the abdomen and pelvic area to look for any masses that may be compressing the veins or lymphatics of the legs or a blood clot (DVT) in the abdomen or pelvis that cannot be seen with ultrasound

Tests of kidney and liver function and also protein level. The urine can also be checked for protein.

Thyroid function tests. An abnormal thyroid level can also result in edema.

Echocardiogram of the heart to look at the heart pump function and heart valves.

How can leg swelling be treated?
The treatment of leg swelling is based on the cause of swelling. If the swelling is due to chronic venous insufficiency or lymphedema, compression therapy may be used to help pump blood out of the legs and back to the heart. Compression may be in the form of compression stockings or wraps similar to ACE bandages. In some cases, special compression pumps may be used to treat chronic venous insufficiency or lymphedema. There is no cure for chronic venous insufficiency or lymphedema, but compression therapy can help reduce swelling and prevent worsening swelling and leg ulcers (sores).

Walking and calf muscle exercises are helpful, along with elevating the legs above the level of the heart, to use gravity to help blood flow back to the heart. Diuretics (water pills) may be used if the cause of leg swelling is a heart problem (known as congestive heart failure), but usually not for leg swelling due to vein or lymphatic problems.

All patients with leg swelling, regardless of the cause, should take good care of the skin of the feet and legs by regularly washing the legs and applying a moisturizer daily.

All photos are provided courtesy of the Cleveland Clinic. About the Author: Carmel Celestin, MD, is a vascular medicine specialist at Cleveland Clinic Foundation, Cleveland, OH, and is involved in the diagnosis and treatment of a wide variety of vascular diseases.