Swollen legs is a common presentation to primary care providers (PCPs). Most patients start the conversation with “I need a water pill.” Despite what might seem intuitively obvious, a “water pill” (diuretic) is often not at all what’s needed.
Diuretics act by increasing the amount of water removed from the bloodstream by the kidneys. Thus they can only remove water if it is actually in the bloodstream. Most of the time when people notice swelling in the legs, the water is actually outside the bloodstream, in the tissues. Before this water can be removed, it has to get back into the blood. Legs can be swollen for many reasons; today we’ll cover a few of the most common and their treatments.
Congestive heart failure — This is an unfortunately common condition in which the heart is unable to handle the load of fluid in the bloodstream. In the most common scenario, fluid backs up in the venous system, and fluid leaks out into surrounding tissues. Common problem areas include the legs (swelling) and the lungs (shortness of breath). Other sites can include the liver and scrotum. This situation is the one many people have heard about in which a diuretic is often helpful to clear excess fluid from the overloaded system and provide relief for the heart. Tests for congestive heart failure include the common chest x-ray and certain blood tests. There can be exceptions, but fluid excess in the lungs and/or legs due to congestive heart failure is usually bilateral (present on both sides).
Venous insufficiency — Veins are the blood vessels that return blood to the heart. The veins of the leg have valves that help “hold” the blood column between heartbeats until the next beat pushes the column of blood farther up the leg towards the heart. As we age, these valves tend to fail and allow blood to reflux or flow backwards between heartbeats. Increased pressure in these veins allows fluid to leak into the surrounding tissues. A diuretic is not indicated for this common condition. In fact, diuretics are contraindicated unless another condition like congestive heart failure is also present. Treatment for venous insufficiency may simply require elevating your legs to the level of your heart when resting at home (think recliner!). Swelling is usually least in the morning after the legs have been elevated in bed all night, and at its worst late in the day, especially after a lot of standing. Swelling usually starts later in life and can involve one or both legs. Obesity is rampant in the United States, and this complicates and contributes significantly to venous insufficiency. Extra weight in the abdomen amounts to “damming up the river” by compressing veins that are returning blood from the legs, causing back pressure and resultant leaking of fluid into the tissues of the legs. Therefore, weight loss can be an important treatment for leg swelling. (Pregnancy and obesity can both cause leg swelling by this mechanism.) One of the most common and effective rapid treatments is the use of compression stockings. These are best custom fitted and can be knee-high or full-length stockings available by prescription.
Blood clots (DVT, deep venous thrombosis) — Blood clots can arise in the deep veins due to inactivity (e.g. a long car or plane ride) and many other reasons. Like obesity, the clot provides a blockage to the return of blood to the heart, and the resultant back pressure causes fluid to leak from the veins into the tissues. Clots cause swelling in only the leg with the clot and can be associated with some pain and redness. DVTs are dangerous, as a portion of the clot can break off and travel to and through the heart, lodging in the lungs. If you suspect a DVT, please seek help immediately in your PCP’s office or emergency room.
Some medications can cause leg swelling. These include anti-inflammatory drugs like Celebrex and even ibuprofen. Other possible culprits include steroids, some antivirals (acyclovir), blood pressure medications (beta-clockers, calcium blockers, clonidine, minoxidil, others), and some antidepressants including trazodone. Your PCP is in the best position to discuss your medications with you to determine if one might be the cause of your swelling.
Lymphedema — The lymphatic system returns fluid from the tissues (outside the bloodstream) to the venous system. Anything that blocks this system can also cause swelling in the limbs. Tumors are a concern, but other causes are possible. Special imaging may be required for exact diagnosis. Treatment often involves specialized mechanical massage and compression techniques.
Swelling sometimes results from a problem with the nerves in the affected area. One such scenario is the complex regional pain syndrome (reflex sympathetic dystrophy). This is an unfortunate syndrome in which trauma can result in nerve malfunction with pain and swelling in the region served by the injured nerve.
So if you are puffed up, a visit to your PCP is in order. You do have one, right? If your leg swelling is new and you’re short of breath and/or having chest pain, you should proceed to the emergency room.
Dr. Fleming is the Medical Director of The Jane Pauley Community Health Center (part of Community Health Network). Ideas for this column can be e-mailed to Dr. Fleming at AskDrFleming@gmail.com