Swelling of the lower extremities, often referred to as pedal edema, has a variety of causes. Most causes
of lower extremity edema are not due to a direct vascular problem; rather, the swelling is a sign of another process going on in the body. The most frequent causes of leg swelling, not caused by problems with the leg vessels, are due to congestive heart failure, kidney disease or infections.

What is Leg Swelling?

Leg swelling, simply defined, is an increase in the girth (circumference) of the leg as compared to the ``normal" state. Normal is defined as the size before the leg began to enlarge and, if the swelling is confined to only one leg (unilateral), the opposite leg can serve as a guide to ``normal."

What Causes Leg Swelling?

Swelling can be a sign of a very serious condition. Heart failure, as mentioned above, can cause leg swelling usually in both (bilateral) legs. Kidney problems (renal failure) can produce leg edema--
usually in both legs. These problems need medical attention since left unchecked, they can be life threatening.

Leg swelling may be due to a problem with the veins in the leg. The veins typically transport blood from
the leg to the heart. If there is a blockage (clot) in one of the veins, the outflow of blood from the leg can be impeded. This causes an increase in pressure in the leg veins and results in leg swelling. Additionally,
a blood clot in the deeper leg veins is a serious problem since these clots have the ability to travel (embolize) to other, more significant veins (heart) as a pulmonary embolus. This condition can be fatal
if it occurs.

A less dangerous cause of leg swelling is Lymphedema. This condition occurs when there is damage to small vessels in the leg call lymphatics. The function of the lymphatic vessels is to transport excess fluid from the legs that ``leaks out" of the arteries and veins back to the heart. If the lymphatic vessels are damaged, this ``clean-up process" is impaired and can result in Lymphedema.

How Can I Tell What The Cause of My Leg Swelling Is?

The most important part of determining the cause of leg swelling is the history taken by an astute physician. Specific questions can indicate the probable cause of leg swelling. Once a history has been taken and an appropriate physical examination conducted, the use of noninvasive tests mat be
indicated to assure that there is no blood clot present. Since this is the most immediately dangerous
of all the causes of leg swelling, it is appropriate to ``rule out" the presence of a blood clot in one of the deep veins of the leg.

The most appropriate test to assess the veins in the leg is the Duplex Ultrasound examination performed by a qualified vascular technologist.  This test, done in an accredited noninvasive vascular laboratory, is highly accurate and easily performed. There are no injections or needles and the test is pain-free and without risks.

What Treatments Are Available for Leg Swelling?

The appropriate treatment is based on the cause of the leg swelling. Swelling due to heart failure or kidney disease requires that those underlying conditions be treated primarily. This will, in most cases, reduce the swelling dramatically. Swelling caused by blood clots in the deep veins of the leg necessitate aggressive (and immediate) treatment with ``blood thinners" (anticoagulants: heparin and warfarin.) Failure to appreciate the significance of this problem can have fatal consequences if the blood clot (thrombus) in the leg were to travel to the lung.

The treatment of Lymphedema is distinct from that of vein disorders. Once the absence of a blood clot has been confirmed, appropriate therapy must be started. Simple treatments, such as leg elevation, restriction of dietary salt intake, and the use of appropriately fitted and supported compression stockings are valuable. However, perhaps the best results for Lymphedema have been obtained with the use of a sequential compression device. This machine acts to ``milk" the excess fluid from the leg by alternately inflating and deflating a stocking (with several `fillable' air cells) that is placed on the leg. The most important problem with this method is its prohibitive cost and the unwillingness of many third party payers to approve its use.

What About the Support Hose That I Buy at the Store?

While minimally helpful, these popular brands do little to truly improve the leg swelling that may develop from Lymphedema or a vein problem. Stockings should be at least 20-30 mm Hg in compression strength and the presence of normal arterial supply to the feet MUST be established.