Leg swelling: patient guide to management
Leg Swelling: Causes and Treatment
Complex Wound and Limb Salvage Center Department of Surgery
Walter Reed National Military Medical Center
Henry M. Jackson Foundation for the Advancement of Military Medicine
There are many causes of leg swelling. The reason for leg swelling (also referred to as leg edema) can either be intrinsic (within the leg itself) or extrinsic (from a cause away from the leg). A person may have both an intrinsic and extrinsic cause for their leg swelling. The therapy you receive at the Walter Reed/Bethesda Complex Wound and Limb Salvage Center (CWLSC) is designed to help control the swelling in your legs and the negative impact that may result from chronic swelling, such as skin breakdown, leg ulcers, infection (cellulitis), and other medical conditions. Our Complex Wound team is made up of Surgeons (COL Alexander Stojadinovic, Medical Director and founder of the CWLSC, and Professor Christian Paletta, with over 25 years of experience in wound care and academic medical leadership), Nurse Practitioners (Kara Couch NP and Mike Lucrezio NP), a Physical Therapist (Nicole Steffen PT), Wound Care/Ostomy Nurses (Sharon May RN, Marie Paz Aquino RN, and Leslie Cnossen RN), Healthcare Specialists (Lloyd Kingsbury, Zac Rowe, and Lorraine Williams), and an Administrative Assistant (Carmen Ferreira) who coordinates your appointments. Each member of the team has both a special interest and expert training in the causes and treatments of conditions that create both acute and chronic wounds. For an appointment or questions about your treatment, our office # is (301) 400-‐2188 and you may get further information on our website www.cwiprogram.org (select Complex Wound and Limb Salvage Center).
Regardless of whether your condition is due to an intrinsic (within the leg itself) or extrinsic (from a cause away from the leg) condition, our team of wound care specialists works with your primary medical physician/practitioner/surgeon in an attempt to provide for you the best coordinated care possible. We understand the profound impact your leg swelling can have on your quality of life. The purpose of this document is to help you further understand why legs swell and the best therapies available and currently in use. It is our hope that this knowledge will help you and us better manage your condition.
What is leg swelling (edema)?
Normally, fluid in our bodies remains within our blood (vascular) system. Our blood is made up of both blood cells (red blood cells, white blood cells and platelets) and serum. The blood test referred to as a Complete Blood Count (CBC) measures our red blood cells (Hematocrit and Hemoglobin), white blood cells (WBC) and platelets (platelet count). The chemical elements in our serum such as our glucose, sodium, potassium, blood urea nitrogen (BUN), creatinine (Cr), calcium, total protein, albumin, bilirubin, liver enzymes, and a few other elements are determined through a test referred to as a Comprehensive Metabolic Panel (CMP; formerly called an SMA 6, SMA 12 or SMA 20). The BUN and Cr are used to measure our kidney function. See: http://en.wikipedia.org/wiki/Comprehensive_metabolic_panel
The blood cells are made mostly in our bone marrow and most of the chemicals in our serum are made in our liver. Together our blood cells and serum make up our circulating blood, referred to medically as whole blood. Our heart pumps our blood to our organs via our arteries. The color of our oxygenated blood is red. Our blood delivers oxygen and nutrients to our organs. Once the blood passes through the organs, it is picked up by our veins. It is hence less oxygenated and appears blue. The veins return the blood to our heart, first passing through our lungs where it picks up more oxygen.
Under normal conditions, all of this blood fluid remains within our cardiovascular (heart-‐blood vessel) system. There are times, however, when this blood fluid escapes our blood vessels. When our blood cells escape outside the arteries and veins, it causes a bruise. When our serum escapes, it causes swelling or edema. Typically after trauma (broken bone, also referred to as a fracture, pulled muscle, soft tissue injury, sprained ankle, etc.), both blood cells and serum escape leading to both a bruise and swelling. If you are taking an anticoagulant (blood thinner) such as Aspirin, Coumadin, Lovenox, Plavix, or Pradaxa, you no doubt realize how easily you bleed and bruise from very minor trauma or even from having your blood drawn. That is because the normal clotting mechanism is altered and blood more easily escapes the vascular system.
If you have either acute or chronic leg swelling, your condition is typically due to an extrinsic cause (a medical condition outside your legs) but which secondarily affects your legs, or intrinsic cause (a medical condition that originates in your legs), or in some cases, you may have both an extrinsic and intrinsic component.
What are extrinsic causes of leg swelling?
- Heart failure (impaired ability of the heart muscle to function). There are many causes of heart failure. The most common cause is coronary artery disease (CAD) due to atherosclerosis of the coronary arteries (plaque buildup on the inner lining of the arteries supplying the heart), which provide oxygenated blood to our heart muscle. If the heart is not strong enough to pump out the blood coming into the heart, this leads to heart failure. Think of it as a bottleneck where blood backs up in the lungs, which is why one of the first clinical signs of heart failure is shortness of breath with exertion. Also typically the heart beats faster (referred to as tachycardia) in an attempt to keep up with the blood coming in. Think of it as running faster to get to a destination. We may not be able to detect tachycardia (defined as a heart rate over 100) as your doctor may have you on a Beta-‐blocker, which slows down our heart rate. Some Beta-‐blockers also relax our blood vessels causing a lowering of our blood pressure. Examples of Beta-‐blockers include: Inderal (Propanolol), Tenormin (Atenolol), Lopressor and Toprol (Metoprolol), and Corgard (Nadolol). As our entire system returning blood to the heart gets backed up (in our venous system), blood will pool in the periphery (legs) essentially awaiting its turn to get to the heart. Typically because our legs are both gravitationally dependent and make up 20% of our body surface, they usually swell as a result of heart failure. When the venous system of our legs cannot hold the capacity of blood that is backed up, blood and fluid leaks into our soft tissue of our legs creating the edema or leg swelling. Think of it as water continuing to flow in a bathtub and exceeding the overflow drain’s ability to drain the amount of incoming water. We all know what happens in that case. Usually as your heart failure improves, so does your shortness of breath and leg swelling. Conversely, if your heart failure worsens, you become more short of breath and fight it difficult to breathe while lying flat on your back, and your leg swelling gets more severe. If you are on a Beta-‐blocker and would like more information, see http://www.livestrong.com/article/103951-‐betablocker/.
- Kidney failure. As with heart failure, kidney failure is a very common medical condition. The most common causes of kidney failure are diabetes and hypertension (high blood pressure). It can present as either an acute (recent) or chronic (more long-‐term) condition. Once the kidneys cannot filter the blood of its toxic components or waste products, we cannot survive without either dialysis (dialysis machine or process used to replace the function of the failed kidneys) or a kidney transplant. Much like heart failure, kidney failure leads to a buildup of fluid in the body and is often most pronounced in the legs. Oftentimes patients can have both heart failure and kidney failure making the leg swelling even worse. See: http://www.webmd.com/a-‐to-‐z-‐guides/understanding-‐kidney-‐ disease-‐basic-‐information
- Liver failure. The liver is the largest solid organ in the body. The liver rests in the abdomen just beneath the diaphragm and above the stomach and intestines. Like the kidney, the liver functions to remove toxins or waste products from the body. The majority of the medications you are prescribed, are either metabolized (broken down and handled) by the liver, and/or removed (excreted) by your kidneys. Hence, whenever a patient has diminished liver or kidney function, his/her doctor must make adjustments in the doses of the medications so as to reduce the risk of overdose and prevent side effects. In addition to removing certain waste products from the body, the liver also serves to generate chemicals necessary for digestion, clotting, and other process essential to life. The most common causes of liver failure are hepatitis (mostly B and C) and chronic alcohol consumption. Acetaminophen (present in Tylenol and is also an ingredient in many over-‐ the-‐counter (OTC) medications and prescription pain medications) is also toxic to the liver if taken in high doses and can lead to liver failure. Both alcohol and other toxins can ultimately lead to scarring of the liver called cirrhosis. When the liver begins to fail, it loses its ability to produce many blood elements, such as proteins. When protein levels in the body diminish, fluid leaks out of our bloodstream and causes tissue swelling. And, as with both heart failure and kidney failure, this swelling can become most pronounced in the lower legs. See: http://en.wikipedia.org/wiki/Liver; http://www.webmd.com/digestive-‐disorders/digestive-‐diseases-‐liver-‐failure
- Venous or lymphatic blockage. As opposed to heart failure, kidney failure and liver failure, venous and/or lymphatic blockage is more of a mechanical factor as a cause of leg swelling. Think of it as a damn blocking a river with water backing up as a result. An example of venous blockage is clots in the legs, at or above the veins of the groin (commonly referred to as Deep Venous Thrombosis or DVT). A treatment used to prevent clots from migrating to the lungs, which can be life threatening (known as Pulmonary Embolus) is the placement of a filter into the inferior vena cava (IVC), , the large vein returning blood to the heart. Dr. Lazar Greenfield at the University of Michigan developed the IVC filter device. Importantly, an IVC filter is placed to prevent movement of clots from our legs and pelvic veins to our lungs, (Pulmonary Embolism). Sometimes, as with our wounded soldiers, these filters are placed as a precaution (prophylactic or preventive procedure) in those that are at very high risk for pulmonary embolism. Regardless of the reason for an IVC filter, an increased pressure often develops in the venous system of the lower legs leading to mild, moderate or severe swelling.
When the blockage is due to a disruption of the lymphatic drainage of the leg, a condition called lymphedema develops. The lymphatic system is designed to take fluid that leaves our vascular system and return it into our vascular system. The lymphatic drainage system is present throughout the body; the most prominent lymph channels are in the: 1. head and neck, 2. upper extremities, and 3. lower extremities. In these three regions, the lymphatic channels drain fluid or other matter like infected or cancerous cells to the lymph nodes for disposal by the immune system. When you get a thorough physical exam, the examiner usually feels carefully around your neck (cervical lymph nodes), under your arm (axillary lymph nodes), and in your groin (inguinal lymph nodes). Typically, we can hardly feel these small structures, which normally are the size of a large green pea and buried inside fatty tissue. In the diseased state (for example when there is an infection or tumor draining into these lymph nodes), they are often enlarged, firmer and easier to feel. Many of us remember growing up and getting a sore throat and having pain under our jaw in our upper neck. We were told we had “swollen glands.” These are actually inflamed lymph nodes that are enlarged in the body’s attempt to fight the infection. There are several causes of lymphedema. Some people are born with an abnormality of their lymphatic system, which cannot drain the fluid in the affected arm(s) or leg(s). This condition is called congenital or primary lymphedema. Most lymphedema however, occurs later in life and is referred to as secondary lymphedema, due other causes. The most common causes are: 1. Surgical removal of lymph nodes, referred to medically as a lymph node dissection. For example, if a woman has breast cancer, especially one that has recurred following an original surgery, she will often be treated with a mastectomy and removal of the lymph nodes under the respective arm (called axillary lymph node dissection). And, if she is also treated with radiation, then she is at very high risk to develop arm swelling or lymphedema. This is why it is recommended that no blood be drawn or blood pressure measurements taken from this arm as it might worsen the swelling. Similarly, surgeons remove lymph nodes in the groin area when treating certain types of cancer (referred to as an inguinal/femoral lymph node dissection). The groin lymph nodes are usually removed for some gynecologic cancer, prostate cancers, penile cancers, or any aggressive cancer of the leg such as melanoma. And, as with heart failure, kidney failure and liver failure, due to the dependent or gravitational effect on our legs, lymphedema of the legs often occurs following removal of the groin lymph nodes. Such cases can become quite severe very quickly following surgery. For more information regarding lymphedema, see http://en.wikipedia.org/wiki/Lymphedema
What are the intrinsic causes of leg swelling?
- Venous insufficiency. This condition is very common in the adult population. It is the primary cause of 70% of lower leg ulcers seen in the United States. It is often seen and can be a contributing cause of another common condition called varicose veins. The veins of our body have structures called valves. These valves help the flow of blood back to the heart. Looking at our arms and legs as an example, there are two sets of vein systems: a superficial system (close to the skin) and a deep system (within the muscles of the arms and legs). The superficial system is used for drawing blood and placing intravenous catheters or IVs. The deep system drains the blood from our arm and leg muscles. In patients with venous insufficiency, the valves within the veins fail to function properly. Instead of blood flowing one way back to the heart, it tends to pool or stagnate in the veins of the arms or legs. This occurs especially in the legs, which are dependent with gravity. While blood in the veins with improperly functioning valves will still return to the heart, it does so much less efficiently. We call this condition venous insufficiency because there is insufficient anatomy present within the veins to allow normal flow of blood in one direction, back to the heart. This then leads to an increased pressure pushing on the veins, as there is more blood stagnating within the veins. While not precisely the same, think of it as molasses flowing through a hose instead of water. Water will flow much quicker and easier. Or think what happens to a hose in the winter when the outside water faucet is not drained and turned off. When the weather warms, the pressure in the hose is increased often leading to a burst water pipe. When the venous pressure exceeds the ability of the thin wall of the vein to hold its blood flow, blood begins to leak out into the surrounding tissue. This then leads to swelling or edema. Compounding the problem with adequate efficient flow of blood back to the heart, blood in such a system tends to stagnate or flow more slowly. Stagnant blood is at high risk to form clots. Clots in the superficial system are called superficial thrombophlebiitis. While this can be painful, it is not typically dangerous and is treated with pain relievers and warm compresses. Clots in the deep system (DVT) can be dangerous as they can lead to a fatal pulmonary embolism. It is estimated that there are between 300,000-‐600,000 cases of pulmonary embolism in the United States each year. For more information on Pulmonary Embolus, see http://www.nhlbi.nih.gov/health/health-‐topics/topics/pe/. Patients with DVT are normally hospitalized and placed immediately on anticoagulation (blood thinner) therapy. There are certain medical conditions that are associated with venous insufficiency either as a contributing cause or that can act to worsen the severity of venous insufficiency. These conditions include: Obesity, Diabetes, Congestive heart failure, Chronic renal failure, Cancer; and, Smoking.
- Trauma. Any injury to an arm or a leg leads to immediate swelling. Normally, as the injury improves, so does the swelling. Examples of extremity trauma include: 1. A broken bone, also known as a fracture, 2. A severe sprain, 3. A soft tissue injury such as a laceration, 4. Surgery on the extremity, especially knee operations such as knee replacement surgery. In some cases, the injury is either so severe (such as is see in injured soldiers or patients involved in high velocity motor vehicle accidents or falls), that there is damage to the soft tissue that is required to maintain venous and lymphatic flow from the extremity back to the heart. Such patients often develop chronic swelling of the arm or leg affected by trauma. The trauma also places patients at an increased risk to develop deep venous thrombosis and venous insufficiency.
How do we treat leg swelling?
- If a medical condition is either the cause of a major contributing factor to the leg swelling, it is absolutely essential to improve that condition as much as possible. Let’s use the example of congestive heart failure. While it may not be possible to completely reverse this condition as it typically has progressed over a period of years, there are many ways to improve this condition. This is guided by a patient’s primary physician or cardiologist. The key with heart failure is to control the factors that make it harder for the heart to work. Examples include high blood pressure, excess weight, poorly controlled diabetes, too much fluid and salt in the body, elimination of external factors which affect the heart such as smoking, diet, etc. Important elements to improving the factors contributing to congestive heart failure are heart, blood pressure and other medications. It is essential that patients who come to the wound clinic for assistance with management of their leg swelling also regularly see their physician who manages their heart failure. The same applies for all patients who have been diagnosed with a chronic medical condition such as diabetes, high blood pressure, kidney and liver disease or any other chronic illness. In other words, for the most part,our wound care team is treating the symptoms of a disease…but not the disease itself.
- The cornerstone in the management of leg swelling is controlled compression therapy. For patients with early swelling from venous insufficiency or another cause, typically this entails compression stockings. There are two categories of compression stockings: 1. Low-‐pressure stockings that are often referred to as “anti-‐embolic stockings.” These stockings provide compression pressures of less than 20mm Hg. They do not require special fitting or a physician’s prescription. They are recommended for patients who will be bedridden for a period of time, such as during a hospitalization. The most common brand used is called TED stockings. The purpose of TED stockings is to prevent clots from forming in the legs dues to prolonged bed rest. Stockings such as TED hose are meant for temporary use, not for long-‐term control of leg swelling. 2. High pressure stockings are the most commonly prescribed stockings for patients with moderate to severe leg swelling. Because of the degree of pressure on the leg (greater than 20mm Hg), a physician’s order is required. This will ensure that a patient has adequate leg circulation to prevent any vascular compromise, especially in a diabetic patient. There are numerous companies that manufacture these stockings. Examples include Jobst. Mediven, Sigvaris, and Juzo. For some patients with mild disease, off-‐the-‐shelf compression garments may suffice. Other patients may have to be measured or fitted for their stockings. Lower extremity stockings are categorized by the amount of pressure the elastic exerts on the leg. There are five standard pressures beginning at the lowest of 8-‐15mm Hg to the highest of 40-‐50mm Hg. Most patients with a history of chronic leg swelling wear either 20-‐30mm Hg or 30-‐40mm Hg stockings. Needless to say, the higher the compression, oftentimes the more difficult it is for some patients to get the stocking on and to remove them. Compression varies depending upon the severity of the underlying cause and the degree of leg swelling. The Journal of Foot and Ankle Research has a good review article on compression hose and can be found at http://www.lowerextremityreview.com/article/compression-‐stockings-‐one-‐size-‐definitely-‐does-‐not-‐ fit-‐all. Another good review of compression stockings can be found at http://en.wikipedia.org/wiki/Compression_stockings, or an Facebook at http://www.facebook.com/note.php?note_id=10150119391127945
- For patients whose leg swelling is too severe for proper compression stockings, compression therapy may be provided at a Wound Clinic such as the Walter Reed/Bethesda Complex Wound and Limb Salvage Center. Many such patients have had long-‐standing leg swelling and often have associated leg ulcers and/or circulation impairment. Because of this, the compression therapy must be both carefully applied and monitored. Complications such as further skin breakdown, worsening of the leg edema due to the patient’s underlying medical condition, leg infection such as cellulitis, skin rashes referred to as dermatitis, and a host of other conditions can develop. If the leg swelling is associated with a leg ulcer with much drainage, often these patients require twice weekly or more frequent Wound Clinic visits. The goal of therapy is to reduce the edema and heal the leg ulcer if present, while preventing the complications that can occur with acute or chronic leg swelling. Most patients with this condition are also being seen regularly by their Primary Care Team or Cardiologist. Once the swelling has been reduced to a certain level, the patient can be fitted for a permanent compression stocking. The ultimate key to success is control of the leg swelling and prevention of the development of leg ulcers and leg infections (cellulitis).
- For a select group of patients, a device called a lymphedema pump may be recommended. This is more typically used in women who have developed arm lymphedema following surgery for breast cancer. Lymphedema pumps are normally used in conjunction with massage therapy by a qualified Physical Therapist. Patients undergoing home pump therapy must be closely monitored. Such a device is used at home twice a day. In the lower extremity, it is recommended for those patients whose edema will most likely be an ongoing, chronic condition where stockings alone are insufficient. It is not recommended for any patient with an ongoing large lower extremity ulcer. If not used properly or under close supervision, complications can arise. For patients with congestive heart failure, renal failure or liver failure, it can only be used with the approval of the patient’s Primary Care Team and/or Cardiologist. The reason for this is that by manually pumping the fluid back into the circulatory system, it could lead to a worsening of the heart failure, kidney failure or liver failure. Lymphedema pumps are not to be used in any patient with active deep venous thrombosis as it could lead to movement of the clot into the lungs. For more information on lymphedema pumps, see http://www.lymphnotes.com/article.php/id/406/