Doctor my Legs are swollen? –
Written by Dr Harold Gunatillake-Health writer

Swelling of legs and feet are quite visible among women who wear sandals, especially among the seniors. It is not visible to men as they wear longs and shoes.

Most women are not aware of this swelling, as it is a slow process of collection of fluid in most situations, and do not bother until finding difficult to walk due to the heaviness. In certain situations, especially travelling, seated for long hours as in a flight you might get sudden swelling of feet and a concern to consult a doctor soon. This sort of swelling lasts for a few days, even at ground level, and should resolve within a few days. To prevent such quick swelling- start moving your feet around your ankles and walk down the aisle, a few times.

Swelling on the upper aspect (dorsum) of the feet and around ankles is due to too much fluid in the extracellular spaces. In most situations, there is too much of extra-cellular fluid in the whole body but is only visible in most dependent areas –below the knee extending to the feet. If neglected you may feel breathless on walking due to fluid collection in the lungs- we call, “pulmonary oedema”

In situations where the cause is central, as in heart failure, or liver and kidney disease, both legs will swell. If one leg swells, obviously the cause is local. Sometimes, sleeping on one side continuously may gravitate the fluid to one leg and may appear unilateral masking the diagnosis.
You may be lacking proteins in your blood due to being on certain diets. Normally the sodium and water are kept within the blood vessels, and if you don’t have enough of a blood protein albumin, the fluids tend to leak out and collect in the extra-cellular spaces. In liver, kidney diseases the fluid will collect in these spaces due to lack of protein in these conditions.

In chronic kidney failure towards the ‘end-stages’ legs seem to swell due to retention of fluids, an early sign needing dialysis to rid the excess fluid accumulations.

A liver disease like cirrhosis can cause swelling of your tummy due to collection of fluid; we call it, ‘Ascites’ and swelling of legs and feet, too. The collection of fluid in your abdominal cavity is due to the obstruction to the veins (portal veins) that drains venous blood from the liver. The term, ’Portal hypertension’ is used to describe in such a situation.

The excess extra-cellular fluid is normally got rid of in the kidneys by using sodium and potassium. But having too much salt in your body retains that fluid and the kidneys may fail to rid the extra fluid. In this situation, you need to go on a salt reduced diet by cutting back on foods high in sodium. You need to lay off the salt-shaker on your dining table, and avoid eating treats like fried dry-fish with your rice and curry.

The normally functioning kidneys excrete about 100-120 quarts of fluid from the blood stream. With kidney disease protein will be lost, causing a situation called, ’Proteinuria’ meaning proteins in the urine that should not be there.

Retention of fluids and loss of protein through the kidneys can lead to oedema of legs due to both situations.

When you pass your 60th year, become breathless on walking with leg swelling, and racing heart, confusion and fatigue, the most likely condition the doctors will suspect would be heart failure. The heart muscles become weak and the pumping action is slowed.

Heart failure could be as a result of neglected high blood pressure, or a previous heart attack, or heart valvular disease, and irregular heart beating (arrhythmias).
In this situation in addition to swelling in your feet, ankles, legs, fluid collects in your lungs and abdomen, your heart will beat faster.

You need to see your doctor soon with such symptoms.

You could get localised swelling limited to one ankle after strains and fractures of ankle bones. In such an eventuality, you need to go to the out-patients casualty unit in your closest hospital for x rays and plaster immobilization. In a neglected situation, the strain could become recurrent, and the fractured bone surfaces may lead to arthritis.

When you stand or sit for long hours, gravity may pull down the fluid towards your dependant legs and ankles. This is exactly what happens during a long flight as mentioned earlier.

Hot weather also makes your ankles and feet swell mainly more due to dilatation of the minute blood vessels.

In bed-ridden patients lying down without much leg movements, a clot can form in the deep veins of your calves. Under normal circumstances with activities like brisk walking, the calf muscles work like the peripheral hearts to pump venous blood towards the heart. Clot formation in the deep veins of your leg is called ‘Deep Vein Thrombosis’ (DVT) quite a serious condition. Your doctor may strap your legs with crepe bandages or make you wear firm socks and give you intravenous heparin after admission to the hospital.

DVT can give you swelling of legs and ankles.

Several kinds of drugs can bring about leg and ankle swelling as a side effect. They include pain relievers, called non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen and aspirin. High blood pressure medications can give rise to leg swelling, especially the calcium inhibitor medication for the heart like amlodipine and peripheral vaso-dilators like vasopressin.

Long-term steroids and oestrogens also can give rise to legs swellings.

There are diabetes drugs and antidepressants that can make your body hold on to extra fluid, which can cause leg swelling.

During pregnancy, it is common to retain excess body fluids. This is mainly due to the changes in hormones, a temporary phenomenon that resolves after pregnancy. Such swelling may be due to a dangerous condition called preeclampsia. Alert your doctor immediately, if sudden swelling develops during pregnancy.

Lymphedema

So far the conditions mentioned for the cause of leg and feet swelling is due to the fluid collection with an excess of salt.
In this condition, if you press firmly with your thumb on oedematous area under the skin, an imprint or a dent is created. We use the word ’pitting’ to describe this sign. So the general term ‘pitting oedema’ is used.

Fluid may accumulate in your dependant areas due to stasis of lymph, too.

In addition to the blood vessels including arteries and veins, there is another circulatory system called the lymphatics. These are the invisible string like strands under your skin and deeply approximating the main blood vessels. These lymphatic paths are interrupted by glands called ‘lymphatic glands’. They are like railway stations and the lymphatic streams are like the railway lines.

These lymphatics participate in the conduction of nutrients and mainly in the defensive function of safeguarding against enemies. It forms part of the immune system in your body.

So, in lymphedema there is a build-up of lymph due to blockage or damage to the lymph system, i.e. the railway lines.

In cancer these lymphatic streams can get blocked. After surgical ablation of organs and tissues, too these lymphatic streams can get damaged and block the lymph drainage.

A good example is breast cancer where there is lymphatic blockage in the armpit, causing the many lymph nodes to become swollen and palpable. This blockage causes lymph in your arms to get blocked also, as they all drain into the lymph system in the arm-pit.

So now you can understand why women get big arms due to blockage of lymphatics after surgery.

A similar situation in the lower limbs too causes swelling of feet and legs. We call this ‘lymphedema’ of the legs. In Sri Lanka, this was quite common along the coastal regions due to a chronic inflammatory condition of the lymph caused by the filarial germ.

The legs become massive, and even the scrotal skin can get affected in men, and they become huge to sometimes the size of a football.
Swelling of legs and feet in this situation does not show signs of pitting, and hence called brawny swelling.

Treatment

Swelling of feet and ankles may be painful, limits your joint movements, feel heavy to walk.

Initially, for any such swellings there are home remedies. RICE is an acronym that stands for rest, ice, compression, and elevation. These strategies are useful in case of an injury.

For fluid retention due to medical conditions mentioned earlier, you need to take a diuretic like Lasix to get rid of the fluid fast to feel comfortable.
Your doctor will do the necessary investigations to find the cause of swelling, and you may need life-long specialist treatment for chronic swelling of legs and feet.

Conclusions: Hope this article benefits those who suffer from chronic or recurrent swelling of your legs, and the need to see a doctor is explained.