Do you know how to deal with swollen legs (lower extremity edema)?

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Swelling in the legs is common, uncomfortable, and caused by a wide variety of different things.  Fortunately, there are some simple considerations that will help you know what to do about the potentially dangerous causes and which treatments to discuss with your doctors.  Carte Clinics developed this brief to give patients dealing with edema some peace of mind, tools to advocate for themselves, and ways to improve discomfort.  We hope this resource helps you to feel more informed and empowered with the tools and knowledge you need to work with your healthcare providers effectively and efficiently to maximize your quality of life.  

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First things first: When did the swelling start?

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Sudden leg swelling or leg swelling on one side

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If this is a new problem for you, that came up in the last few days and you have not had it before, it’s important you get evaluated by a healthcare provider promptly.  Even if it’s diffuse or in both legs, even if you have no pain nor other symptoms, new swelling can be a sign of a dangerous condition that needs a medical evaluation. 

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The good news is that nearly all the dangerous acute causes of new swelling can be evaluated with these tests:

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• A physical exam to assure good blood flow and assess for infection and trauma 
• Leg ultrasounds to check for blood clots ‍
• Blood and urine tests for liver, kidney, heart and thyroid function

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You may not need all of these, your healthcare provider will advise you, but it’s ok to ask politely if these tests are indicated. If you still feel confused or not heard, we can review your specific situation and advise the optimal way forward. Each of these conditions can change normal blood flow and increase pressure in the veins of the legs leading to edema. Their complete description is beyond the scope of this article. However, we want you to know about conditions that can cause edema and the kind of tests your doctor would consider ordering to diagnose or rule out these causes:

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• Heart failure - confirmed with an ultrasound of the heart (echocardiography)
• Obstructive Sleep apnea - confirmed with a sleep study‍
• Pelvic masses - confirmed with a CT scan of the abdomen

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These tests are unlikely to be performed urgently when you first notice edema in your legs. If your edema is due to heart failure, sleep apnea or a pelvic mass you are likely to have other signs of those conditions before you develop edema from them.

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Leg swelling that has been going on for a while (chronic swelling)

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Many things can cause swelling in the legs that aren't dangerous, and maybe your healthcare provider didn’t think it would bother you that much so they haven’t made enough suggestions about what you can do to improve the swelling.  Here’s a list of some of the more common contributors and what you can do about them:

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Is it a medication side effect? 

You can show this list to your healthcare provider and ask if you take any of these medications that can cause edema. Do not stop taking any of these medications without consulting your doctor first, you are on them for a reason and some of them should be gradually tapered off. You can ask if it’s possible you could try an alternative that might be less likely to cause swelling in your legs. Everybody is a bit different and some people will have more swelling than others, whereas some people have no swelling in their legs who went on these medications.

• Commonly used for heart problems and high blood pressure or hypertension - amlodipine, hydralazine, nifedipine
• Anti inflammatory - prednisone, celecoxib, ibuprofen 
• Neuropathy/pain - gabapentin, pregabalin
• Diabetes- pioglitazone, rosiglitazone
• Oral contraceptives with estrogen and/or progesterone 

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Is it weight, nutrition, or a sedentary lifestyle?

Maintaining a healthy weight, being active, and drinking water is common sense health advice but there are some specific ways that failing to do them can cause or worsen edema:

Being overweight can cause general whole body inflammation and that alone can cause edema.

However, the excess weight also can increase pressure in the veins of your legs which makes some excess fluid more likely to stay in your tissue (when excess fluid is in your tissues causing edema you will especially see how the top of your socks leaves a line on your leg or if you push your thumb in firmly and hold it there you will create a temporary pit). Too much pressure in the veins pushes fluid out into the tissues and causes edema.

Not enough protein in your blood can also cause fluid to leak out from inside your veins into the tissues and cause edema.

The level of protein in your blood is something your doctor checks for the blood test, and it’s regulated by many different body systems, but good nutrition is always a good place to start. People with kidney problems have to be careful about eating too much protein (ask your doctor if you are one of them if you’re not sure) but if your kidneys function normally you should check that you are getting enough protein!

When you are sitting with your legs down all the time both gravity and the position can increase the pressure causing some fluid to leak out

If you work at a job where you spend most of the day sitting at a desk, or for other reasons you are mostly in bed or a chair, it’s really helpful to force yourself to get up and be active even just walking around for a few minutes every hour. There are many different apps that can remind us hourly that we should be getting up and walking around to be active, or you can set a simple alarm on your phone to remind yourself. When you walk around, that act of contracting the muscles in the calves of your lower legs help to push the blood in your veins back up into the rest of your body. Good blood flow can help reduce edema in the lower extremities.

‍Eating too much salt can cause you to have some excess edema, but this is probably more rare than we think it is

That is because healthy, normally functioning kidneys and hearts do a very good job of regulating how much salt(sodium) is in our bloodstreams. Like most things, moderation is probably the right answer. Check labels because high levels of sodium can be hidden by high levels of sugar and other spices, but there’s no need to fail to enjoy your food because you’re trying to restrict your salt intake.

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Venous Insufficiency: A Common Cause & Lifelong Risk

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If you’ve ever had a blood clot, spent some years being overweight, had something else like a mass limiting the blood from being able to return from your legs back to your heart, or even have a family history of varicose veins there is a good chance you have venous insufficiency. 

All of these things can damage the inside of your veins, especially the valves that are designed to prevent blood from flowing in the wrong direction. It is diagnosed by your doctor after they have ruled out other causes of lower extremity edema and they have considered your risk based on your history and your exam.  The point is you can’t visit your doctor and have a test like an x-ray that will tell you you have venous insufficiency causing edema in your legs. The good news is there are lots of things you can do safely and simply at home that can help to limit discomfort due to venous insufficiency:

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External compression of the legs, especially below the knees, helps to support veins

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Compression makes it so veins do not become too distended even if they have been damaged, and it helps compress your tissues so that less fluid will leak from the veins into your tissues causing edema.

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There are different ways to apply this external compression, the most common being tight stockings. You can buy these online or at any pharmacy and do your own measurement of the circumference of the widest part of your calf in order to determine the proper size and amount of compression.

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If you get them too small they will be so difficult to put on and so uncomfortable you are unlikely to use them. Most people get a good effect from the compression stockings that only come up to the knees, but they do create them so that they go up onto the thighs. Your doctor can also do a more detailed measurement and assessment of your needs and write a prescription to order custom stockings for your legs, these are generally only different from the ones you get at any pharmacy without a prescription in that they may fit better and have stronger Compression pressure. 

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The best time to put these on is right away when you get out of bed in the morning.

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Most of us will have slept with our legs at the same level as the rest of our body, which allows the fluid that may have built up as edema to drain out of the legs. This is one of the reasons that people who have lots of problems with edema in their legs sometimes have trouble sleeping because they have to get up to urinate frequently, this is because the kidneys sense that more fluid is around the body than expected (just like if you drank a lot more water than you normally do).

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When you sleep, you can even put your legs up on a pillow or two so they are elevated above the rest of your body, to help them drain out even more. Right when you wake up your legs are as small as they will be, and wearing the compression stockings for the rest of the day will help them to stay that way and minimize Edema, especially if you have to sit all day or stand on your feet.

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You can also just use gravity, by laying on your bed and propping your legs up against the wall or on some cushions so that they are higher than the level of your heart. Especially if they are very swollen or feeling painful or itchy this can start to be helpful within a few minutes.

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Another form of compression to help remove edema from the legs can come from electric devices that mechanically massage the legs

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Often these devices include multiple different points of massage that function sequentially to try to help push the blood from the veins down in your feet and ankles all the way back up to your thighs. Some devices include heat that can feel soothing, think of them just like You would a massage chair, or a heated electric massager you drape over your shoulders. Sometimes you can use common health insurance benefits like funds put into a health savings account (HSA) to purchase or get reimbursed. Here’s an example on Amazon, we don’t know how good this particular device is and we would not get any commission if you ordered through this link, it’s just an example so you know what we mean.

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Manual massage by hands is another good option

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People who suffer from a condition called lymphedema will often see specialized massage therapists who can help get as much fluid out of the legs as possible. Check out this link for some tips on what these massages are like, and how you can try doing them on yourself at home. You can also talk to your doctor about whether your edema is lymphedema, and if you might qualify for visits to one of these specialized therapists to get massages.

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If your kidneys function normally you can try soaking your legs in warm water with Epsom salts.

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Many people report that this feels great, relaxing the muscles and the high concentration of magnesium in water with Epsom salts can even help to reduce edema by kind of drawing some of the fluid out of the skin. There is no definitive evidence that this helps reduce edema, but as long as you don’t have kidney problems it should not hurt, and it might help. Epsom is a brand, you can often find generic and less expensive versions at the pharmacy, it’s not necessary to get the particular brand but the name is very well-known.

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People with edema in their legs often find their skin is dry and itchy: using a good moisturizer can help with both problems.

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Additionally, you can try using topical hydrocortisone or diphenhydramine cream that you can get over the counter at any pharmacy on the especially itchy spots. 

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Do not use either cream on any open sores or wounds, but if the skin is intact they are likely to give you some relief. Remember that diphenhydramine is an antihistamine and can cause drowsiness. Especially if you applied the cream over most of the surface area of both of your legs your risk of absorbing a good amount of the medication, so make sure you don’t have to be alert to drive or go to work. Don’t combine the topical hydramine with taking a dose by mouth as well to prevent the very small risk of overdosing. Even if you do take too much of it, it’s unlikely to be dangerous, only small children have been reported to have been harmed by topical diphenhydramine and it’s very rare.

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Did you learn anything new in this article and have some new strategies you can try to reduce your discomfort? 

We would love your feedback to help us keep improving.  

What other topics are you interested in learning about from your doctors? Let us know and we’ll work on it.

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