This version of the article contains supplemental content.This clinical content conforms to AAFP criteria for continuing medical education (CME). Edema is an accumulation of fluid in the intercellular tissue that results from an abnormal expansion in interstitial fluid volume. Swelling of the legs is abnormal and should be evaluated by a physician if it occurs more than occasionally after a long day of sitting or standing.
Swelling may occur due to high pressure in the veins of the legs, local injury, inflammatory changes, obstruction of lymphatic fluid outflow, infection, low blood protein levels, obesity, pregnancy, fluid retention states, or drug effects. Failure of the calf muscles to pump venous blood out of the legs due to stroke, venous injury, arthritis limiting ankle motion, or inactivity. Localized swelling may be due to trauma, hematoma (collection of non-flowing blood in the soft tissue), infections, fracture, superficial thrombophlebitis (clots in veins of the fatty tissues), rupture of a tendon or muscle, cyst at a joint (such as a synovial cyst at the knee), and, sometimes, spontaneous bleeding into the tissue due to a ruptured blood vessel. Some of the most common medications which cause leg swelling are non-steroidal anti-inflammatory drugs taken for pain relief or for arthritic discomfort and calcium channel blockers taken for heart disease or hypertension.
Cellulitis, infection of the skin and fatty tissues of the leg may cause swelling with pain and tenderness. Swelling of the foot, especially if the skin does not pit with brief application of pressure, may be due to lymphedema, a failure of the microscopic network of channels which move tissue fluid from the extremity back to the blood stream at the level of the upper chest. After venous insufficiency, obesity is the next most common cause of lower extremity swelling in the United States.
Routine daily use of graduated compression support hose, often rated at a compression level of 20-30 or 30-40 mm Hg.
Lymphedema may require special treatments called manual lymphatic drainage to massage the legs over a period of time with wrapping of the legs in special “short-stretch” elastic wraps and, sometimes, compression pump therapy to mobilize lymphatic fluid from the legs back to the bloodstream in the chest by intermittent squeezing of the legs. Management of swelling of the legs often becomes a lifelong issue, but it is important because swelling will increase the risk of infection or leg ulcer and the underlying conditions may be associated with serious complications such as deep vein thrombosis or difficulty healing injuries or surgical incisions. The most common causes of leg swelling or soft tissue pain or tenderness in North America are venous insufficiency and obesity. The rapid development of generalized pitting edema associated with systemic disease requires timely diagnosis and management.
Acute swelling of a limb over a period of less than 72 hours is more characteristic of deep venous thrombosis (DVT), cellulitis, ruptured popliteal cyst, acute compartment syndrome from trauma, or recent initiation of calcium channel blockers (Figures 1 and 2). Mechanical therapies, including leg elevation and compression stockings with 20 to 30 mm Hg for mild edema and 30 to 40 mm Hg for severe edema complicated by ulceration, are recommended.1,4,5,8,29 Compression therapy is contraindicated in patients with peripheral arterial disease.
Pain or tenderness in the legs associated with swelling is an especially important reason to seek evaluation. Further testing is based upon the clinical assessment and may include ultrasound, X-ray,CT, or MRI imaging in the legs or evaluation of the heart or blood vessels in the abdomen or pelvis.
The causes of swelling in one leg may be similar to the other leg, but it is not unusual for different factors to cause the swelling in each leg.
High pressure in the veins of the legs results in fluid, proteins, and blood cells leaking through the wall of small veins into the soft tissues, especially near the ankles.
Pain from cellulitis may be very severe or may manifest as tenderness and mild pain with faintly pink to bright red skin. Frequently, conservative measures are helpful and these often are started before the cause of the swelling is fully evaluated.


Resolving lower extremity swelling, if possible, prior to extremity surgery is an important means of reducing the chances of wound healing complications including bleeding, hematoma, wound breakdown, or infection. STUDDIFORD, MD, Thomas Jefferson University Hospital, Philadelphia, PennsylvaniaSARAH PICKLE, MD, Rutgers Robert Wood Johnson Medical School, New Brunswick, New JerseyAMBER S. The chronic accumulation of edema in one or both lower extremities often indicates venous insufficiency, especially in the presence of dependent edema and hemosiderin deposition. A study of 120 patients with venous ulcers showed that 6% had mixed arterial-venous ulcers.30 In another study, a higher prevalence of peripheral arterial disease was found in women with symptoms of chronic venous insufficiency vs.
While some of the causes of leg swelling may be minor self-limiting conditions, others require very urgent medical care to reduce the likelihood of major complications or death. The most common failure of diagnosis occurs due to a venous ultrasound study which is performed in a manner to rule out clots, known as deep vein thrombosis, in the deep veins of the legs and does not evaluate for failure of one-way valves in the leg veins (venous insufficiency). Frequently, leg swelling is caused by more than one factor such as venous insufficiency, obesity, and previous saphenous vein harvest for heart bypass surgery. This causes pitting edema, swelling which will leave a temporary indentation in the skin with pressure from a shoe, sock, or intentional pressure such as a squeeze with a finger. Obesity also accelerates the stretching of the leg veins due to the effects of gravity, thus contributing to the progression of venous insufficiency.
Chronic swelling of the legs with discomfort or a heavy feeling to the legs often contributes to inactivity which worsens the problem since the calf muscle pumping of blood out of the legs with walking is an important means of getting venous blood back to the heart.
Untreated leg swelling may lead to other complications such as infection, poorly-healing wounds, or clots in leg veins.
It is common for patients with chronic leg swelling to be told that the ultrasound is “normal” or “was negative for clot” while failing to test for treatable venous insufficiency.
For mild to moderate chronic venous insufficiency, oral horse chestnut seed extract may be an alternative or adjunctive treatment to compression therapy.33,34Local skin and wound care of venous ulcers is essential in preventing secondary cellulitis and dermatitis. Patients who have had deep venous thrombosis should wear compression stockings to prevent postthrombotic syndrome. The mechanism often includes the retention of salt and water with increased capillary hydrostatic pressure.
If clinical suspicion for deep venous thrombosis remains high after negative results are noted on duplex ultrasonography, further investigation may include magnetic resonance venography to rule out pelvic or thigh proximal venous thrombosis or compression. The initial goal is to improve fluid resorption until a maximum therapeutic response is reached.
Obstructive sleep apnea may cause bilateral leg edema even in the absence of pulmonary hypertension. Graves disease can lead to pretibial myxedema, whereas hypothyroidism can cause generalized myxedema. The maintenance phase of treatment includes compression stockings at 30 to 40 mm Hg.11,37,38 Pneumatic compression devices have been shown to augment standard therapies.
Brawny, nonpitting skin with edema characterizes lymphedema, which can present in one or both lower extremities.
Although considered a diagnosis of exclusion, obstructive sleep apnea has been shown to cause edema. Possible secondary causes of lymphedema include tumor, trauma, previous pelvic surgery, inguinal lymphadenectomy, and previous radiation therapy.


Use of pneumatic compression devices or compression stockings may be helpful in these cases.
Edema should also be evaluated for pitting, tenderness, and skin changes.Pitting describes an indentation that remains in the edematous area after pressure is applied (Figure 3).
Lower extremity examination should focus on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot. Key search terms were edema, oedema, peripheral edema, lower extremity edema, venous insufficiency, deep vein thrombosis, lymphedema, obstructive sleep apnea, and iliac vein syndrome. Also reviewed were the Cochrane database, National Guideline Clearinghouse, Essential Evidence Plus, UpToDate, and the U.S. For example, acute DVT and cellulitis (Figure 4) may produce increased warmth over the affected area. Because of the deposition of hemosiderin, chronic venous insufficiency is often associated with skin that has a brawny, reddish hue and commonly involves the medial malleolus4,5,8 (eFigure A).
As venous insufficiency progresses, it can result in lipodermatosclerosis (Figure 5), which is associated with marked sclerotic and hyperpigmented tissue, and characterized by fibrosis and hemosiderin deposition that can lead to venous ulcers over the medial malleolus.
Myxedema from hypothyroidism presents with a generalized dry, thick skin with nonpitting periorbital edema and yellow to orange skin discoloration over the knees, elbows, palms, and soles. In the late stages of complex regional pain syndrome, the skin may appear shiny with atrophic changes. Pretibial myxedema causing a peau d'orange appearance in a patient with Graves disease.eFigure B. Long-standing lymphedema with thickened, verrucous skin.Examination of the feet is important in lower extremity edema. In patients with lymphedema, there is an inability to tent the skin of the dorsum of the second toe using a pincer grasp (Kaposi-Stemmer sign)7,9–11 (eFigure D). Failure to tent the skin overlying the dorsum of the second toe using a pincer grasp (Kaposi-Stemmer sign) in a patient with lymphedema.eFigure D. Failure to tent the skin overlying the dorsum of the second toe using a pincer grasp (Kaposi-Stemmer sign) in a patient with lymphedema.DIAGNOSTIC TESTINGRecommendations for diagnostic testing are listed in Table 2. The following laboratory tests are useful for diagnosing systemic causes of edema: brain natriuretic peptide measurement (for CHF), creatinine measurement and urinalysis (for renal disease), and hepatic enzyme and albumin measurement (for hepatic disease). In patients who present with acute onset of unilateral upper or lower extremity swelling, a d-dimer enzyme-linked immunosorbent assay can rule out DVT in low-risk patients.
However, this test has a low specificity, and d-dimer concentrations may be elevated in the absence of thrombosis.13,17,18ULTRASONOGRAPHYVenous ultrasonography is the imaging modality of choice in the evaluation of suspected DVT. Therefore, indirect radionuclide lymphoscintigraphy, which shows absent or delayed filling of lymphatic channels, is the method of choice for evaluating lymphedema when the diagnosis cannot be made clinically.11,21MAGNETIC RESONANCE IMAGINGPatients with unilateral lower extremity edema who do not demonstrate a proximal thrombosis on duplex ultrasonography may require additional imaging to diagnose the cause of edema if clinical suspicion for DVT remains high.




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