Healthy circulation includes upward blood flow in the veins from the legs to the heart. Unfortunately, the force of gravity works against this normal circulation. Prolonged sitting and standing can lead to swelling as weakened leg veins struggle. After a long day, puffy feet and ankles appear. This edema — a buildup of fluid in the feet and lower legs — is common. Often benign, you can take simple steps to prevent or at least ease day-to-day leg swelling.
Sometimes, however, lower-leg swelling can indicate serious medical conditions. “Heart failure, kidney failure, liver failure: All of those are systemic causes, the more whole-body problems that lead to leg swelling,” says Dr. Elizabeth Ratchford, director of the Johns Hopkins Center for Vascular Medicine and an associate professor of medicine at Johns Hopkins University. “That’s separate from having a leg vein issue.” Pregnancy can also bring lower-leg bloating.
Harmful blood clots and heart conditions can cause swelling requiring urgent diagnosis and treatment. “It’s that sudden onset that occurs with no apparent reason, that occurs with one leg that’s painful, or it’s associated with chest pain, shortness of breath or difficulty breathing, especially when you’re lying flat or exerting yourself,” says Dr. Rachel Bond, a cardiologist with Dignity Health in Arizona. Dizziness or fainting episodes that accompany swelling are also cause for greater concern, she says. “That’s when medical care needs to be looked at immediately and urgently. Because the likelihood is that it’s something coming from the heart, or even as dangerous as something coming from a blood clot.”
Here’s what you can do on your own to manage foot and ankle swelling or when you need to seek medical advice.
Easing Everyday Swelling
“The treatment for swelling — no matter what the cause — is usually compression, elevation, exercise and weight loss,” Ratchford says. These simple tips can help keep swelling under control:
— Elevate your feet in bed. Put a pillow under your legs to prop them and put gravity to good use, Bond suggests. This promotes venous blood flow back to the heart.
— Wear compression socks. Knee-high compression socks, available over the counter or by prescription, can be really helpful to wear during the day when standing or sitting for long periods, Ratchford says. “You can get them in sporting goods stores to improve venous blood flow to the heart to improve endurance,” she says. “You can also get them in medical supply stores, where they’ll measure you to ensure proper fit.” Learn more about compression therapy in the vascular disease patient information page in the June 2021 issue of the journal Vascular Medicine.
— Avoid prolonged standing. If your job includes standing in one spot most of the day, for instance working behind a register, ask for a stool so you can sit at least part of the time, and move about when you can.
— Take breaks from sitting. Conversely, if you’re parked behind a computer for hours on end, use a small stool to elevate your feet and stretch your legs, and also, take breaks whenever possible. Consider using a standing desk intermittently. While traveling by plane, stand and stretch or take a short walk when the seatbelt sign goes off.
— Exercise. “Thirty minutes of exercise, seven days a week is key because of the calf muscle pump,” Ratchford says. “That’s something in the calf that pushes 70% of the blood out of the calf every time you walk. Sometimes people have neurological issues or spine problems that cause the calf muscle to shrink. That leads to swelling because you’re not getting that pump pushing the blood back.” Being in an orthopedic boot, where you can’t move your ankle to point or flex your foot, is another culprit. “So, exercise like biking, walking, swimming or elliptical — anything where you’re pointing or flexing your foot a lot, or toe raises, calf raises, that kind of thing — will help push the blood back to the heart.”
— Lose weight if needed. Eliminating excess weight can help reduce the pressure on your leg veins. That’s another good reason to exercise regularly. You may also want to speak with a dietitian about healthy eating plans.
— Reduce salt in your diet. Americans eat too much salt, which is why the Food and Drug Administration just recommended sodium-reduction guidelines for commercial food manufacturers. You can also take independent steps to consume less salt. “Cutting back on sodium can definitely help with the swelling,” Ratchford says.
— Talk to your doctor. Don’t hesitate to ask your health care provider about symptoms like swelling, particularly if it doesn’t improve despite all your efforts.
COVID-19 and Swelling
“The biggest change that has happened in the past couple of years is that there’s been an epidemic or pandemic of swelling because of COVID-19,” Ratchford says. “People are so much more sedentary than they were before, especially with being on Zoom meetings.”
With doctors appointments largely restricted to telehealth at one point, Ratchford experienced leg edema firsthand. “Even as a doctor doing video visits at the beginning of the pandemic, when our office was only open for emergencies, I would be sitting in front of my computer for hours on end and my feet would be swollen at the end of the day,” she says. For herself or patients, doing all the right things — exercising daily and maintaining a normal weight — wasn’t always enough to counteract gravity’s effect.
Actually developing COVID-19 infection can bring up a more direct cause of swelling. “Having COVID-19 significantly increases your risk of blood clots,” Ratchford says. “The most concerning cause of swelling — especially if it’s just in one leg — is a blood clot in the leg veins, or DVT, deep vein thrombosis.”
Most Likely to Experience Swelling
While anyone can have occasional leg swelling, certain groups are more vulnerable:
— People with obesity.
— Patients with chronic heart, liver or kidney conditions.
— Workers in sedentary occupations.
— Older adults.
— Women during their periods.
— Pregnant women.
— Surgical patients during prolonged recovery.
Getting Down to Causes
“The first part of management will be to figure out what the cause of the swelling is,” Bond says. Heart-related causes include the heart muscle not pumping well, blocked veins in the leg or venous insufficiency — problems with the vein that prevent the blood from circulating as it should through the body. “So, once we figure out the underlying cause, then we can delve into fixing the problem.”
Swelling and Testing
With potentially serious swelling, your doctors will do a medical history and order a number of tests that may include:
— Leg vein ultrasound. This noninvasive test can show the presence of a blood clot.
— Echocardiogram. This sonogram lets doctors visualize the heart muscle’s squeezing action, and can uncover heart valve or structural problems.
— Blood tests. Blood tests can reveal kidney problems or imbalances in electrolytes like sodium and potassium.
Your health history, medical evaluation and test results can lead to diagnoses and treatment for conditions including:
— Venous insufficiency. Weakness or damage in your leg vein valves can lead to chronic venous insufficiency. That allows blood to pool in your veins and cause swelling.
— Varicose veins. These enlarged, twisted varicose veins, which most often occur in the legs, are due to weakened or damaged valves.
— Heart failure. With congestive heart failure, the lower heart chambers can’t pump blood as well as they should, leading to backup and pooling in the lower extremities. Heart failure can also lead to abdominal swelling and fluid buildup in the lungs may cause shortness of breath — other symptoms to watch for.
— Iliac vein compression syndrome. In this condition, also known as May-Thurner syndrome, compression of the left iliac vein hinders circulation in the left leg. Mostly affecting young women, this syndrome may lead to development of a deep vein thrombosis.
— Kidney disease. As the kidney’s ability to filter blood is reduced, extra fluid and sodium in your circulation may cause edema, typically in your legs or around your eyes.
— Liver disease. Cirrhosis of the liver can cause fluid to accumulate in your abdominal cavity (ascites) and in your legs.
— Pregnancy. In pregnancy, pressure from the belly weighs down the leg veins as they try to work against gravity. “There’s also dilation of the blood vessels just related to the hormones,” Ratchford explains. In addition, pregnant women are at higher risk of varicose veins.
— Lymphedema. Problems in the body’s lymphatic system, which helps to fight infection and drains excess fluid from the body’s tissues, can lead to swelling in the feet and legs. “It has a very characteristic appearance that you can tell just from looking at the toes,” Ratchford says.
— Medication side effects. Swelling can be a side effect of prescription medications like amlodipine (Norvasc) used to treat high blood pressure. Nerve pain medications, nonsteroidal anti-inflammatory drugs, birth control pills, oral steroids like prednisone and certain medications for Type 2 diabetes can also cause leg swelling.
— Surgical recovery. When you’re hospitalized after surgery, nurses encourage you to get up and move as soon as possible to avoid complications including swelling. “After surgery, a lot of times patients are more prone to this, because they are more sedentary, therefore prone to having blood clots form in their leg,” Bond explains.
Once the cause of leg swelling is determined, you and your doctors can discuss the range of treatments.
[Read: The Best Diets for Your Heart]
“You should seek medical care when the swelling is associated with other signs that may indicate a more serious condition,” Bond says, “such as: chest pain, difficulty breathing, shortness of breath — especially when you’re walking or exerting yourself, or even more notably when you’re lying flat in bed — and absolutely if it’s associated with fainting or dizziness. Because that may imply that there is an active cardiac cause for that swelling.”
Leg swelling with these characteristics may be caused by a dangerous blood clot and needs to be evaluated immediately:
— Single-leg swelling.
— Sudden leg swelling for no apparent reason.
— Redness, heat or warmth to the touch in an extremity.
— Pain that worsens on bending the foot.
— Skin discoloration.
— Leg cramps.
— Chest pain.
— Difficulty breathing/shortness of breath.
— Faintness or dizziness.
“Once we figure out the underlying cause, we can delve into fixing the problem,” Bond says. Your doctor may discuss a range of procedures and treatments including:
— Medications like diuretics. Diuretics or ‘water pills’ like furosemide (Lasix) help the body get rid of excess fluid.
— Heart medications. If a heart condition is diagnosed, medications to treat it will reduce complications like swelling.
— Deprescribing or swapping meds. Your doctor may determine that you no longer need a medication that causes swelling. That drug then could be deprescribed or a different one could be substituted.
— Vein ablation procedure. Usually done as an outpatient procedure, vein ablation is performed to cauterize and close varicose veins.
— Stent insertion. With a stent-insertion procedure, a small tube is inserted into a leg vein to clear any blockage, prop open the vein and keep blood flowing in the right direction.
“With peripheral edema, or swelling in the legs and ankles, it’s rarely just a one, unified cause,” Bond says. “It could be because the heart muscle isn’t pumping well. Is it because there’s a blocked heart artery? At which point we would do additional testing and we’d get patients on an appropriate medication regimen.”
If heart valves aren’t working appropriately because they’re tight or leaky, Bond says, “In that situation, we may suggest having a conversation with what we call a heart team. We have a cardiologist, a general cardiologist like myself, an interventional cardiologist and a cardiothoracic surgeon to determine what would be the best treatment for that particular patient, depending on the severity of their heart valve condition.”
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