“Why are my legs swollen?” In this blurb I’m going to hopefully give you the big picture on a very common complaint, leg swelling (edema) that tends to go right along with venous disease.
When I give talks on venous disease of the legs, I emphasize that I believe one of the most important things I am trying to accomplish is educating patients on the importance of recognizing signs and symptoms of problems early when treatment can produce rapid recovery and return to function. Doing this can prevent progression to advanced stages when recovery and improvement can be lengthy. In addition to explaining the possible health consequences that could result from ignoring serious signs of developing vein disease in their legs, I like to focus on just how effective, well tolerated and elegant that modern vein procedures really are.
In most advertising for vein clinics (mine included!), you will see some version of “leg swelling?” being asked. The typical pattern of swelling that is associated with what I treat (venous insufficiency) usually begins around the ankle and progresses up the leg. Usually, this swelling tends to increase during the work day and decreases overnight or with simple maneuvers such as leg elevation. Over time, swelling is noted to occur on top of the foot as well.
From here, keeping an eye on the big picture is challenging to say the least. Figuring out the cause of swollen legs can be a complicated affair and frustrating for patients and physicians. It’s very much like that scary forest right outside the Emerald City on the Wizard of Oz. The second you walk into the trees it gets dark. And thick. So off we go.
First of all, when I see a patient for evaluation of a swollen leg, it is usually after studies searching for urgent situations such as acute deep venous thrombosis (DVT) have already been performed. This is not always the case however. Sudden swelling that occurs over hours to days is termed “acute” and if from a venous cause, is usually due to either a DVT in the leg or other obstruction higher up the venous circulation in the abdomen or pelvis. These problems are usually managed in the hospital setting.
Leg swelling that occurs over a longer period of time, weeks to months, is termed “chronic” and when a patient comes for treatment, early investigation should start. The most important thing to remember is that the longer swelling is allowed to continue without treatment, the more likely it will potentially become permanent.
My focus at Precision Vein Therapeutics is sorting out whether or not a swollen leg is the result of a vein that is not doing its job. I perform a thorough venous ultrasound of both deep and superficial leg veins to determine this. This exam is noninvasive and done right in our clinic on Watermelon Road. The amount of information about the venous circulation that can be obtained from this elegant test is truly amazing.
In the setting of saphenous vein reflux, which I detail on the vein disorders and treatment pages of this website, mild to moderate swelling that follows the pattern I mentioned above, (gets better overnight), after treatment with endovenous laser ablation, typically resolves. Longer standing or more extensive swelling that tends to remain unchanged over night on average may improve after correction of saphenous reflux, but in a percentage of patients, will need further management to deal with. This is where the woods get dark and deep. In medicine, we like to blame a set of conditions on one cause. The swollen leg is a big ugly example of the situation where there can be multiple contributing causes. It’s very important in cases of severe edema and venous insufficiency to help patients set realistic expectations.
The lymphatic system of the body is an extremely important little machine and it doesn’t get much air play. For all practical purposes, it is microscopic, but it is the hardest working system in the body for its’ size. It is responsible for collecting the plasma portion of the blood that is filtered out between arteries and veins at the cellular level. Okay, there it is, we just lost the sun. Walk with me in the dark for just a second.
There are many different medical and structural issues that can affect the load on the lymphatic system’s fluid transport ability and when it can’t keep up, you guessed it, edema happens. The lymphatic system itself can have abnormalities that affect its ability to function correctly. There’s even a little roundworm that is transmitted to humans by mosquitos mostly in tropical countries that has an appetite for human lymphatic vessels and basically destroys them. Outside of developed countries, this is the #1 cause of lymphedema in the world. 120 million people have this. 120 million. There are effective treatments but I’d still take some Deep Woods Off if you plan to go down there. Here’s a classic example.
In developed countries, the #1 cause of lymphedema is obesity. There are even some medications that can cause lymphedema.
I mention all of this mainly because of what I mentioned earlier. Expectations. There is no question that venous insufficiency can cause or contribute to leg edema. If I’m asking in my advertising if you have swollen legs then you might have venous disease, I better know what your next stop needs to be if you don’t.
The good news is that for patients clinically diagnosed with lymphedema, there are treatments available to help manage the disease. There are lymphedema clinics that specialize in this very issue.
This brings us right back around to what I mentioned at the beginning of this. Job #1 for me is providing education and awareness of the resource that Precision Vein Therapeutics can offer patients in terms of thorough evaluation for the presence of treatable venous disease, and then offering those definitive, effective outpatient treatments in the same office-based setting. For those patients with a family history of venous disease, living with chronic leg and ankle edema, thinking it is just a sign of aging, working too hard or it’s something that just “runs in my family”, understand that waiting can be a very bad thing. Make an appointment and get treatment.
That’s the big picture.
Michael R. Barlow MD, RPhS
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