Swollen legs

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“Doctor, I have swollen legs!” It is not uncommon to hear this statement.

There are several degrees of swelling. It is very likely that most people who work standing up can see the outline of their socks when they take them off in the evening.

Rest assured! The presence of a small outline is completely normal. However, the degree of swelling can vary significantly, sometimes making it difficult to wear shoes, which is not normal.”

Worried? You must talk about it

If you are concerned about swollen legs, present the problem to your doctor. There are several possible causes for this issue. Your doctor can perform some checks to determine the cause.

Possible causes

The most common cause of swollen legs, sometimes of unequal sizes, is related to poor functioning of the leg veins, called venous insufficiency.

Other causes can be related to blood diseases, kidney diseases, liver diseases, and certain intestinal diseases, to name just the most common ones.

The heart can also be the cause of this problem. In this case, leg swelling is accompanied by other symptoms, such as extreme fatigue requiring a change in daily activities, shortness of breath, and difficulty sleeping in a usual manner in bed, to name just a few.

Review of how circulation works

Veins are vessels, or tubes, that return used blood to the heart. It should be noted that blood reaches the legs through arteries. These arteries divide into smaller arteries, then into arterioles, allowing oxygen to be delivered to the muscles and other structures of the leg.

Everything takes place in the capillaries

The delivery of oxygen and nutrients occurs at the level of the systemic capillaries, as it does throughout the rest of the human body.

Systemic capillaries are the junction points between the arteries and veins in the human body. These are microscopic vessels in which blood cells pass in single file.

What is a capillary?

Capillaries are like perforated drains covered with a thin membrane that prevents proteins and blood cells from exiting, but allows blood fluids to escape and/or re-enter the bloodstream.

It’s a bit like your sink where you use water. It arrives through the faucets, you use it, and then it goes down the drain. On both sides, the pipes are sealed.

Stability point

Normally, the balance between what exits and what enters is maintained.

There is no accumulation of fluid at the capillary level. But where does this balance between the water that exits the capillaries and the water that returns come from?

Human body cells are in water

It is important to know that the cells of the human body must be immersed in a liquid to ensure their proper functioning and to allow the exchange of oxygen (O₂) to the cells and carbon dioxide (CO₂) to the capillaries, then to the veins of the human body.

Three factors control the water

Three factors influence the entry and exit of water from the capillary: one tries to keep it inside, and the other two allow it to escape.

“Oncotic” factor

Let’s call the first factor the oncotic factor or oncotic pressure. ‘Oncotic’ to help us remember ‘on’ for ‘in’ in English, meaning ‘inside.’

The retention of water in the capillary is exerted by the blood cells and blood proteins that cannot cross the capillary membrane and therefore remain inside.

“Osmotic” factor

The second factor that influences the entry and exit of water from the capillaries is the osmotic factor or osmotic pressure. 

The term ‘osmotic’ comes from the word ‘osmosis,’ which means the free passage of water to balance the concentrations inside and outside the capillaries. 

This way, the cells are immersed, but there is no overflow.

The veins in the legs are special

The blood exits the capillaries, pushed by the pressure from the heart. This push is transmitted through the veins to move the used blood back towards the heart. Gravity forces the weight of the blood to fall back down when standing up.

To counter this problem, the veins are equipped with small valves that prevent the blood from flowing backward, that is, downward. In other words, the role of the valves in the veins is to hold the blood in place until the next push from the heart.

The contraction of the calf muscles also helps to circulate the blood in the veins upwards through the legs.

The veins in the legs can dilate

Over time, certain factors cause the dilation of the veins in the legs and give rise to varicose veins:

  • The number of pregnancies in women;
  • People who are always standing.

The dilation of the veins impairs the sealing of the valves in the veins, which then causes blood to flow back downward, creating stagnation.

The accumulation of blood in the dilated veins increases the weight of the blood, which leads to an increase in pressure in the veins.

This stagnation extends to the capillaries, causing fluid to leak into the space where the cells are immersed… it’s a flood!

“Blood pressure in the capillaries” factor

This brings us to the 3rd factor that governs the entry and exit of fluid in the systemic capillaries.

Blood pressure is generated by the contraction of the heart to move blood throughout the human body. Normal blood pressure at the level of the systemic capillaries is on the order of a few millimeters of mercury.

An increase in pressure in the veins, as described here, is automatically transmitted to the capillaries. This will result in creating congestion in these capillaries.

An ice jam in the river

Let’s take the example of a river in which an obstruction has formed. The water rises in front of this obstruction, the river overflows its banks, and floods the surrounding lands.

The water floods the surroundings

In the legs, the stagnation caused by the malfunctioning veins and their small valves results in water accumulating in the ‘bathtub’ of the cells, like a river that floods the surrounding lands.

Vicious circle

Once the veins are dilated and their small valves can no longer prevent the blood from flowing back down, a vicious cycle sets in.

The more distension there is, the more pronounced the effect of gravity, and the larger the column of blood becomes. The pressure in these stagnant veins increases, with repercussions at the capillary level. This is known as “venous obstruction.”

Worse at the end of the day

People with venous insufficiency in the legs wake up in the morning with little swelling. The problem appears as the day progresses and is more pronounced in the evening.

In severe cases of venous insufficiency, the situation is already well established just a few hours after getting up.

Fingerprints can be seen in the swelling

If you apply light pressure with your fingers on the ankle, the imprint remains and you can see the shape of the fingers on the skin.

The situation is more pronounced in people who stand for long periods during the day, and it is even worse in hot weather.

Laying down stops the gravity effect

Once lying down, the effect of gravity is no longer present.

The drainage of the veins improves and, consequently, the capillaries as well. The excess fluid is then reabsorbed by the capillaries.

Upon rising, the swelling (edema) of the ankles is greatly or completely resolved.

Deceiving treatment

Treatment begins with a change in habits, namely:

  • Trying to keep the legs elevated as much as possible when sitting;
  • Adopting a low-salt diet;
  • Using diuretics to eliminate excess water, although the results are often disappointing;
  • Wearing graduated compression stockings, which can be very effective, especially when leg edema is accompanied by pain. They should be put on as soon as you get up, as it might be difficult to put them on later in the day.

Graduated pressure supportive stockings

Custom-made graduated compression stockings are often expensive, uncomfortable, and hot, especially in summer. They can also be difficult to put on; some people need assistance to wear them

Other causes of venous congestion

Certain interventions on the veins of the legs can result in swollen legs.

Esthetic therapies for varicose veins

The problem of leg swelling is also found in patients who have undergone an aesthetic procedure, such as sclerotherapy for varicose veins, which was once popular but is still available today.

The main vein in the lower leg, the saphenous vein, has been damaged by these treatments and is minimally or non-functional. This causes congestion in the smaller veins, similar to a traffic jam on side roads after the closure of a highway.

Using the veins in the legs for bypasses

Finally, the same congestion problem described during saphenous vein sclerotherapy can be found in people who have undergone coronary artery bypass surgery.

For the creation of the bypasses, the saphenous vein from the leg is harvested, sometimes from one leg, sometimes from both.

Leg edema in these patients will be asymmetrical, being more pronounced on the side where the saphenous vein was harvested.

Swelling of only one leg

Other causes of localized edema in one leg are mostly related to issues other than venous insufficiency.

If this is the case and there is also associated redness and pain, consult a healthcare professional without delay.