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EBMG

Leg Oedema

Essentials

  • Causes of leg oedema that require prompt treatment must be identified, e.g. deep vein thrombosis and heart failure.
  • The most common cause of leg oedema in patients over 50 years of age is insufficiency of the superficial or deep leg veins.
    • Mildly symptomatic oedema caused by insufficiency of the veins can be treated with compression therapy (graduated compression stockings); in more severe symptoms also invasive therapies are applicable, see Venous Insufficiency of the Lower Limbs.
  • In women under the age of 50 years, the most likely cause is idiopathic oedema and non-drug therapy is the first-line treatment approach.
  • Oedema caused by medication (particularly calcium-channel blockers) must be recognised.
  • Excessive use of diuretics must be avoided when oedema results from immobilisation, venous stasis or an obstruction to the lymph flow.
  • In many cases, oedema is caused by a multitude of factors.

Causes

Examination of the patient

  • Was the onset of leg oedema acute or chronic (more than or less than 3 days)? If the onset was sudden, the possibility of deep vein thrombosis must be borne in mind.
  • Current medication
  • Systemic diseases (heart, liver and kidney disease)
  • Does the patient have a history of pelvic or abdominal cancer, surgical treatment or radiotherapy (lymphoedema)?
  • Does the swelling reduce during the night (reduction occurs in venous insufficiency, but not in lymphoedema)?

Clinical findings

  • Does the patient have pitting oedema evidenced by an indent in the skin following finger pressure, most marked over the tibia?
    • Pitting oedema may be caused by deep vein thrombosis, venous insufficiency and early stages of lymphoedema.
    • Non-pitting oedema (no skin indent) that remains unchanged overnight is rare, and a disturbance in the lymph flow should be considered as a possible cause.
  • Does the oedema cause pain?
    • Deep vein thrombosis and reflex sympathetic dystrophy Complex Regional Pain Syndrome (CRPS) are painful conditions.
    • Lymphoedema (picture ) is usually painless.
    • Chronic venous insufficiency may cause some aching.
  • Any asymmetry of the oedema should be determined by measuring the circumference of both calves at their thickest point.
  • Skin discoloration (stasis dermatitis; pictures ) may be noted as well as visible varicose veins.
  • In erysipelas (picture ), local oedema is often present in addition to skin redness and tenderness.

Differential diagnosis and principles of care

  • Unilateral oedema indicates a local cause. A sudden onset of oedema may be indicative of venous thrombosis, whereas in chronic oedema deep venous insufficiency should be suspected. The possibility of a ruptured Baker's cyst should also be borne in mind.
  • If deep vein thrombosis is suspected, the patient should be referred early to compression ultrasonography.
  • Bilateral oedema is often caused by heart failure, deep vein insufficiency or prolonged standing.
    • Leg oedema of cardiac origin is always accompanied by other symptoms or findings of heart failure Chronic Heart Failure.
    • Venous leg oedema may be associated with stasis dermatitis or varicose veins.
    • Obesity and work involving standing predispose to pitting oedema in the evenings.
  • If no heart or venous problem appears to be causing the oedema, the possibility of kidney or liver disease should be considered.
  • When a patient presents with bilateral leg oedema, and heart failure or venous stasis are not likely causes, the following laboratory investigations are recommended:
    • Basic blood count with platelet count
    • Urinary protein and plasma creatinine
    • Plasma potassium and sodium
    • ALT (oedema due to liver disease is common in alcoholics)
    • TSH, particularly if oedema is present elsewhere than in the legs and the swollen area does not reduce under pressure.
    • Fasting blood glucose
    • Serum albumin (less than 20 g/l will often give rise to oedema).
  • Bilateral pitting oedema in a woman less than 50 years of age, mainly occurring in the evenings, may be considered to be benign provided that there are no signs of venous insufficiency or systemic illness.
  • Abdominal ultrasonography as well as the consultation of a specialist physician (and CT scanning of the abdominal/pelvic region) should be considered for patients over 50 years of age if no aetiology can be confirmed for leg oedema and for younger patients in the presence of suspicious findings (unilateral leg oedema, signs and symptoms at the pelvic region, weight loss), particularly if the clinical picture is suggestive of lymphoedema of unknown cause. The cancers that most frequently are associated with limb oedema are prostate cancer, ovarian cancer, lymphoma and kidney cancer.

Clinical picture and treatment guidelines

Venous thrombosis

  • See Deep Vein Thrombosis.
  • Leg oedema is usually unilateral and the onset is relatively rapid (rarely more than a week before seeking medical help).
  • The calf is often tender when walking and when pressed. There may also be some pain.
  • The absence of calf pain at passive dorsiflexion of the ankle (positive Homans' sign) does not rule out thrombosis.
  • Increased skin temperature on the side of the thrombosis is a typical finding. It may be observed best by feeling each calf alternately with the back of the fingers.
  • The most important factors in the patient's history to confirm the suspicion of thrombosis are previous deep vein thrombosis, an illness requiring bed rest and recent limb immobilisation (the patient must be asked about recent flight travel).
  • Deep vein thrombosis in a patient confined to bed is usually not painful and the swelling is less intense.
  • Useful tools in the diagnosis of venous thrombosis are the determination of plasma D-dimer and compression ultrasonography.

Ruptured Baker's cyst

  • See Baker's Cyst.
  • Possible to diagnose clinically, if the patient describes having had a lump behind the knee and having developed sudden pain.
  • The diagnosis can usually be confirmed with ultrasonography.

Heart failure

  • See Chronic Heart Failure.
  • Bilateral oedema of the legs with a relatively rapid onset (days-weeks)
  • The patient is often known to have heart disease
  • Heart failure that causes oedema is almost invariably accompanied by exertional dyspnoea and also often orthopnoea during the night.
  • The patient should be asked about rapid weight gain.
  • Tachycardia is common.
  • The liver may be swollen and tender.
  • ECG is often pathological.
  • BNP concentration will help in differential diagnosis
    • Normal serum BNP concentration rules out uncontrolled heart failure.
  • Chest x-ray may reveal cardiomegaly.
  • Heart failure is frequently exacerbated by the patient not taking the prescribed medicines, a change in medication (such as adding a calcium-channel blocker) or new-onset atrial fibrillation.

Venous insufficiency of the lower limbs Interventions for Varicose Veins and Leg Oedema in Pregnancy

  • See Venous Insufficiency of the Lower Limbs.
  • The best diagnostic indicator is stasis dermatitis - browning of the skin on the inner side of the ankle and loss of skin hair.
  • Varicose veins are also often visible.
  • Swelling of the legs usually develops more slowly than in heart failure and may be accompanied by pain, particularly in the evenings.
  • Diagnosis is often clinical, but it may be confirmed with a Doppler study if indicated.
  • Insufficiency of the deep leg veins that is confined to one side can be seen in post-thrombotic syndrome. The patient's long term history will include deep vein thrombosis or a fracture that required plaster casting.
  • In elderly individuals and paralysed patients, who sit for prolonged periods with their knees bent, venous emptying may diminish to such an extent that pitting oedema develops. A relevant history and the lack of symptoms suggesting heart failure or venous insufficiency suffice for diagnosis.

Treatment principles

  • Compression therapy reduces the symptoms of venous insufficiency and is beneficial to some patients, but it will not prevent the varices getting worse.
  • Regular exercises to improve the calf muscle pump function and elevating the legs whenever feasible may alleviate symptoms.
  • Intermittent pneumatic compression devices Compression Therapy for Treating Post-Thrombotic Syndrome are an effective means of treatment, even if the swelling is severe. A district nurse, for example, may carry out the treatment, and it is also suitable for patients with open leg ulcers.
  • Leg oedema of venous origin should generally not be treated with diuretics because the results are poor and the adverse effects of the medication may exceed its benefits, especially in older individuals. In some cases, a short course of diuretics is warranted if the swelling of the legs is particularly severe. Diuretics should be stopped if weight loss or a clear reduction in the swelling is not observed.
  • Invasive treatment is planned individually, based on clinical assessment and colour Doppler ultrasonography.

Idiopathic leg oedema

  • Most frequently seen in women aged between 20 and 30 years. It is also known as orthostatic oedema, cyclic oedema, periodic oedema and fluid retention oedema.
    • The patient's weight increases a kilogram or more during the day.
  • Leg oedema is present throughout the entire menstrual cycle which differentiates it from premenstrual oedema.
    • Most women experience generalised swelling and weight increase a few days before the start of menstruation (premenstrual oedema Premenstrual Syndrome (Pms)).
  • In addition to oedema of the lower limbs, the patient may complain of oedema affecting the face and hands.
  • History and physical examination of the patient are usually sufficient to exclude systemic illnesses.

Treatment principles

  • Non-drug treatment
    • Rest and elevation of the limbs
    • Avoidance of warm atmospheres
    • Restriction of salt intake and excessive fluids
    • Weight loss (if the patient is overweight)
    • Compression stockings are rarely beneficial, and these patients do not generally tolerate them.
  • If the swelling is severe, spironolactone 50 mg daily may be tried combined, if necessary, with a small dose (12.5-25 mg) of hydrochlorothiazide. Loop diuretics should be avoided.

Lymphoedema

  • Lymphoedema is caused by a compromised lymphatic system. Primary lymphoedema is rare and occurs due to poorly-developed or missing lymph vessels. Symptoms usually become evident in childhood or adolescence but in some cases not until the patient is over 35 years old, and he/she develops oedema of the lower legs (lymphedema tarda).
  • Secondary lymphoedema is more common than primary lymphoedema.
    • The most common causes are a tumour (lymphoma, prostate cancer, ovarian cancer, renal cancer), surgery, radiotherapy and infection (bacterial infection or filariasis).
    • Can be differentiated from venous insufficiency by skin changes, the type of oedema (non-pitting) and history (a known reason for compromised lymphatic flow). It might be difficult to differentiate between early lymphoedema with pitting oedema and leg oedema of venous origin.
    • It is not possible to pinch the loose skin at the base of the fingers or toes (positive Stemmer's sign) in lymphoedema.

Treatment approach

  • Exercise, elevation of the limbs, compression, manual lymph drainage, intermittent pneumatic compression. In very severe cases of lymphoedema the patient may be referred to a plastic surgeon for assessment.
  • Tinea pedis (athlete's foot), if present, must be treated.
  • In cases of recurrent cellulitis, antibiotic prophylaxis should be considered.
  • Diuretics are usually of no benefit.

Medications causing oedema

  • It should be checked whether the patient is using medication with the potential of causing oedema. The most common culprits include
    • calcium-channel blockers (particularly vascular selective dihydropyridines)
      • Including an ACE inhibitor or angiotensin receptor blocker to the drug regime may reduce the oedema
    • anti-inflammatory drugs
    • pioglitazone and rosiglitazone
    • corticosteroids
    • sex hormones.

Principles of non-drug treatment

  • Compression therapy with stockings or (at the early stages) multilayer bandaging.
  • Exercise therapy, increased physical activity and postural therapy can all be used to enhance lymphatic drainage and venous return.
  • Manual lymph drainage
    • In chronic lymphoedema, the treatment is carried out once (or twice) a week in a series of 10-15 sessions, and the series is repeated every 2-3 months (physiotherapist, lymph therapist).
  • In some cases, intermittent pneumatic compression or mechanical lymph drainage massage devices
  • Proper foot care must not be neglected.
    • Cleanliness, moisturising, nail care, appropriate foot wear and socks

Compression therapy Compression for Venous Leg Ulcers, Graduated Compression Stockings in the Prevention of Postoperative Venous Thromboembolism

  • Compression therapy reduces the symptoms of venous insufficiency and is beneficial to some patients, but it will not prevent the varices getting worse. Low level of compliance is common, and compression therapy provides only to few patients a sufficient amount of symptom relief.
  • Compression bandages or stockings must be worn during waking hours, and if arterial pressure is sufficient they can also be left in situ overnight.

Compression bandages

  • The management of leg oedema in, for example, venous thrombosis and leg ulcers is usually started with compression bandages.
  • The choice of bandage is based on the patient's general health, mobility, the size of the limb, how expedient and economical the bandage is, the person applying the bandage and the technique used (Pütter technique, i.e. using the natural contours of the leg, spiral technique, figure of eight technique).
  • The bandage is applied to the leg in the morning before getting out of bed.
  • The ankle is kept at an angle of 90 degrees. The bandaging is started at the base of the toes; toes are left free. The heel should be carefully covered. Padding is added to all bony prominences and tapering parts of the limb.

Graduated compression stockings

  • The stockings are classified from Class I to IV according to the pressure exerted at the level of the ankle. The pressure decreases progressively from the ankle upwards.
  • The stockings are put on in the morning before getting out of bed.
  • The stockings are chosen individually for each patient by measuring the length and circumference of the leg and by determining the pressure class required (in venous insufficiency a Class II stocking is usually chosen; a Class I stocking may be used if the patient cannot tolerate the tighter stocking) as well as the length of the stocking needed (knee length, thigh length, tights).
    • A physiotherapist, lymph therapist or appropriately trained nurse will usually do the measuring and obtain the stockings.
  • The oedema reducing effect is based on continuous pressure that is maximal at the foot and gradually decreases proximally. Problems encountered include stretching of the stockings (a stocking will last just over six months of continuous use) and the difficulty of putting the stockings on.
  • Compression stockings may be reimbursable when prescribed for certain indications.

Selection criteria

  • Class I (light pressure, 15-23 mmHg)
    • Mild venous insufficiency or in cases where higher pressure cannot be used due to other existing conditions
    • Prevention of venous thrombosis
    • Prevention of varicose veins, e.g. during pregnancy
  • Class II (24-34 mmHg)
    • Venous insufficiency
    • Varicose eczema and venous leg ulcers
    • Mild lymphatic oedema and oedema post cancer surgery
    • Follow-up care after varicose vein surgery and erysipelas
    • Treatment and prevention of deep vein thrombosis and superficial venous thrombophlebitis.
  • Class III (35-49 mmHg)
    • Severe oedema not managed with lower pressure
  • Class IV (50+ mmHg)
    • Very severe lymphatic oedema or severe venous insufficiency.

Exercise and positional therapy

  • The patient is advised to move his/her feet and walk occasionally during long flights and car or train travel.
  • Walking and physical exercise improve the muscle pump action and strengthen leg muscles.
  • The patient is advised to stand alternately on tiptoes and on the heels. The exercise is repeated 15 times, a few times every day.
  • The patient should lie down a few times daily with the legs elevated and knees slightly bent.

    References

    • Webb E, Neeman T, Bowden FJ, et al. Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med 2020;383(7):630-639. [PubMed]
    • Sachdeva A, Dalton M, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev 2018;(11):CD001484. [PubMed]
    • Smyth RM, Aflaifel N, Bamigboye AA. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev 2015(10):CD001066. [PubMed]
    • Makani H, Bangalore S, Romero J, et al. Effect of renin-angiotensin system blockade on calcium channel blocker-associated peripheral edema. Am J Med 2011;124(2):128-35. [PubMed]