Swollen ankles, puffy legs - we've all experienced them at some point. There are dozens of possible causes. Most aren't serious, but some, like blood clots, are dangerous conditions that require immediate medical care. How can you tell the difference?
This week's guest expert is Ian Del Conde, M.D., a board-certified cardiologist and vascular medicine specialist with Baptist Health's Miami Cardiac & Vascular Institute. Dr. Del Conde joins host, Jonathan Fialkow, M.D., to explain what different swelling symptoms indicate and when swelling is concerning enough to seek immediate medical attention.
Swollen ankles, puffy legs - we've all experienced them at some point. There are dozens of possible causes. Most aren't serious, but some, like blood clots, are dangerous conditions that require immediate medical care. How can you tell the difference?
This week's guest expert is Ian Del Conde, M.D., a board-certified cardiologist and vascular medicine specialist with Baptist Health's Miami Cardiac & Vascular Institute. Dr. Del Conde joins host, Jonathan Fialkow, M.D., to explain what different swelling symptoms indicate and when swelling is concerning enough to seek immediate medical attention.
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Dr. Fialkow: Welcome Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular Institute, where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health. Many of us have experienced swelling or puffiness in our legs from time to time. When it comes to swollen legs, there are dozens of possible reasons that could be the culprit. Maybe we spent all day on our feet at work, or we spent hours stuck in a cramped seat on an airplane, or maybe it's a sign of something more serious, even something that could be deadly. How do you know the difference? Well, that's the question we're talking about today with my colleague, Dr. Ian Del Conde, Dr. Del Conde is a board certified cardiologist and vascular medicine specialist who holds several leadership roles at Miami Cardiac and Vascular Institute. It's great to have you back on the podcast, Ian.
Dr. Del Conde: Thank you for having me, John.
Dr. Fialkow: So, Ian. Let's start with some of the basics. We'll talk about the medical causes of swelling and when it's something that one should seek medical care for, but what actually causes the swelling, what causes that puffiness that we may feel and that we may see or feel in our feet?
Dr. Del Conde: There are many different causes for leg swelling. And that's the reason that when a patient comes to see us, we have to think of all the different possibilities, but to keep it simple, let's remind ourselves of the force of gravity. Fluid will fall to the lowest part of the body, which are the legs. So, any fluid retention in the body will present as swelling. That's number one. Number two, blood has to flow against gravity to reach the heart. And because we don't have a pump at the very lowest part of the legs, the only thing that can pump blood upwards is movement. When you contract your calf muscles, that effectively serves as a pump. And when you're not using your calf muscles, for example, because you've been sitting in a car for five hours on a trip or a long plane ride, then that also causes leg swelling.
Dr. Fialkow: I think that's well said. I tell a lot of patients that if we think about all the medical conditions, including lightheadedness and passing out, one of the most complex things we do as human beings actually walk on two feet and we have to get blood back to the heart and to the brain against gravity. And here's an example where things can go a little awry. When one has swelling, what do they generally see? What would people notice to say, wait a minute, what's what's going on here? I'm noticing some swelling. What are the more common symptoms some will see?
Dr. Del Conde: Most people know what their feet and ankles look like. So, when there's a change in the contour of the ankles and the feet, people notice it pretty quickly. You can lose the shape of the ankle. And you can also notice that the shoes that you normally wear and that normally fit well, no longer fit well. They're tight. And your socks, if you use them, can leave marks behind.
Dr. Fialkow: Is it more common that people don't notice it when they first wake up? And as you mentioned, they're upright, gravity pulls the fluid down, or is it something that's 24/7. They wake up with swelling, they go to sleep with swelling. What do you generally see and if there's any pattern there?
Dr. Del Conde: Absolutely. It tends to worsen as the day goes on. And I would almost say regardless of the cause of the swelling, swelling will worsen as the day goes on. The more upright you are, the more the gravity will have an effect on all the fluid and the swelling will get worse. And also it's best in the morning for obvious reasons.
Dr. Fialkow: Because you're lying down and the fluid redistributes when you're [crosstalk 00:03:49].
Dr. Del Conde: Exactly.
Dr. Fialkow: Okay. So, let's talk about some of the medical causes. Would you say pretty much anyone that has swelling has a serious medical condition, or if not, what's the frequency that you would say it's more commonly benign?
Dr. Del Conde: Yeah. The vast majority of people will have a completely benign cause of their swelling and should not be a major concern. However, there are different medical conditions that manifest themselves as leg swelling and to think mechanistically about this broadly. So, it's usually a plumbing issue and it's a plumbing issue that can originate in the heart, or it's a plumbing issue that has to do with the veins that take blood from the legs back to the heart. And lastly, some conditions that lead to just massive fluid retention, those are the few medical conditions that can cause pretty significant leg swelling, and that patients should be aware of.
Dr. Fialkow: So, what would be some of the more frequent benign conditions? Again, you're a specialist in vascular medicine. You get a lot of people sent to you specifically because of swelling of various levels of complexity. What are the more common things you would discuss with someone and you know they're going to walk out, they're going to be fine and it's not either a sign of a more major medical problem or they won't need more medical care? What would, the more common things you'll be seeing in the population that you would tell people?
Dr. Del Conde: I think one of the more common things that I see are people who have been on a trip, they've changed their diet, perhaps more salt intake, less physical activity. And then they notice that their legs are swollen. That's classical. You eat more, you do less, your legs may get swollen. People who have taken new jobs and are on their feet or sitting all day long, they can also experience that. That's typical with hairdressers and even police officers. They're on their feet all day long. Other common conditions are medications. There are some medications, for example, some of the medications that we use to treat high blood pressure, a family called calcium channel blockers. People may know specific medications, such as Amlodipine or Nifedipine. This sort of medication can also cause leg swelling.
Dr. Fialkow: So, the benign conditions might be people who are upright more, as we said, medications. Do you recommend changing the job or getting off the medication? Or are there levels where it's just a finding and as if it doesn't bother you, don't worry about it?
Dr. Del Conde: The best thing is to try and understand what has triggered and perpetuated the swelling. So for example, if you're a hairdresser and you're on your feet all day long, you're going to be immobile, not using your calf muscles, as we mentioned. So, fluid is going to go to the lowest part of your body. So, for people in that situation, use of compression stockings works great. They actually feel better. They're more comfortable. They're typically in South Florida, you need an air conditioned room to feel comfortable with compression stockings. So, that's a great solution. If you mostly work outdoors, what the heat and the humidity now in South Florida, compression stockings may not be a great option. So, sometimes we can use low doses of diuretics for some people.
Dr. Fialkow: And so, again, the point is, let's take the medications for example, if someone's on a medication for blood pressure and it's working and they have a little bit of swelling, in that situation, you could say, if the swelling doesn't really bother you and the medications working, stay on it, or would you then say, no, you should use compression stockings or get off the medication. In other words, how much is it if it bothers the person? And then how much is it, it could really become a medical problem?
Dr. Del Conde: This is a great point. Swelling by itself is not dangerous. And I spend most of my time reassuring patients. Once we have excluded the medical conditions that I mentioned that can be serious, once you've excluded that, you really need to reassure patients. Leg swelling by itself is not dangerous. If it's not bothering you and you're doing well, for example, on a medication that is causing the swelling, just continue the medication, why change it. We only make changes to medications when patients are frankly uncomfortable with the swelling.
Dr. Fialkow: That's great stuff. Let's talk about a couple of medical conditions that more disconcerting, as you mentioned. The big one that people are concerned about are blood clots. Are there any signs or experiences that if someone notices some swelling, we may think more likely related to a blood clot or versus things you could say, it's probably not a blood clot?
Dr. Del Conde: Right. So, the one thing that I think is a little bit more concerning is when somebody suddenly develops swelling in just one leg, this is what in medicine we would call, unilateral leg swelling. And if it happens quickly, you're obligated to make sure you're not dealing with a blood clot, which could be a serious condition. So, if that's the situation and there is no trauma could explain the swelling. You didn't trip. You didn't sprain your ankle. You just woke up with a swollen leg, just one leg. You need to rule out a blood clot. And we usually use an ultrasound to do that or blood tests. But when it's in both legs, we have more time. The likelihood of a blood clot is much lower. So, you can schedule a visit with your doctor and take it from there.
Dr. Fialkow: So, you just have slow gradual, mild swelling in both legs, no pain, no redness, not an emergency. Don't need to go to the emergency room, but do get checked out. What about the pain, do blood clots always ... Let me phrase that. If someone has swelling that's due to a blood clot a venous thrombosis, a blood clot in a vein, is it always associated with pain? And conversely, if someone has, say, medication related swelling, is it never associated with pain, where is pain in the spectrum of our assessment?
Dr. Del Conde: Pain is a tricky symptom. Because blood clots that are potentially dangerous, typically do not cause pain. Pain is not one of the typical symptoms that patients have. They may feel of pressure like feeling but not pain. Pain is not a word that is commonly thrown out. When somebody complains of pain, you'd have to think about trauma or something else. Swelling by itself is not painful.
Dr. Fialkow: So, the absence of pain does not mean it's not a blood clot. If you have relatively sudden unilateral one-sided like pain. I think that's [crosstalk 00:10:26]-
Dr. Del Conde: That's exactly right, that's exactly right.
Dr. Fialkow: A couple of other things that I think are pretty common that we see in our patients. Speak a little bit about the correlation between weight and lower extremity leg and ankle swelling.
Dr. Del Conde: We have to go back to the plumbing. So, blood is flowing from the feet up towards the heart. And the tubes are the veins. If you have excess weight around your abdomen, that's resistance for the blood to flow. It's the same reason why pregnant women late in the third trimester also develop leg swelling, because there's difficulty for blood to flow through. So, there's pooling in the legs. If you are overweight with a lot of excess weight around your midsection, the same principles apply. You're going to have resistance to flow with leg swelling. Lose some weight.
Dr. Fialkow: So, when should someone see a doctor? We don't want everyone that has swelling run to emergency rooms and doctor's offices, because it's so common and more commonly benign, but what would be the things that would make you say, no, you really should get checked out right away versus make an appointment at your convenience versus, hey, don't even need to do anything about it. Are there any kind of pearls you can give about those conditions?
Dr. Del Conde: When it's unilateral, definitely seek attention. If you wake up and you have one swollen leg and there was no trauma, you didn't twist your leg or anything, seek medical attention that same day, don't delay it. It could be a blood clot. When it's both legs. If it happened very quickly and it's significant. I mean, you've lost the contour of your ankles, for example. Yes. Let's figure out why this is happening. Let's rule out medical conditions. When it's very slow, very gradual, very painless and your instincts tells you that this is after a long trip that you took a cruise, when we were able to take cruises, but you took a cruise, you ate more et cetera, then I think it's okay to wait.
Dr. Fialkow: Okay. And again, if you're ever not sure, you could always call a doctor or do a care on demand virtual visit. There's always resources to get checked out. Let's switch over to a couple of things about what people can do. We mentioned a couple. Losing weight where appropriate. Is there a benefit in elevating your legs, if it's a gravity phenomenon? Could people control it with that? Or is that just a little bit of a short-term solution?
Dr. Del Conde: We're humans. We're upright and we can't live with our legs elevated. So, I generally never tell patients to just elevate their legs. I tell them to elevate their legs, for example, if they have an infection or if they have a sprained ankle and swelling, but if you have swelling, elevating your legs is not going to be a sustainable treatment. Compression stockings. That physically does the same thing as like elevation and it works great.
Dr. Fialkow: So, let's unpack the compression stockings a little bit more. People just go to a pharmacy and buy a pair of compression stockings and put them in and they're okay. Or are there nuances towards proper use of compression stockings?
Dr. Del Conde: There are many different types of compression stockings. Some are medical grade, typically require a prescription. Not because they're controlled in some way or another, but you need someone to tell you the length of it. Is it knee-high or a thigh high, the degree of compression, et cetera, et cetera. So, those are typically prescribed by doctors. But there are many off the counter stockings that you can purchase, small, medium, large, and they actually work great for most people.
Dr. Fialkow: Are there tips? Is there a time of day to put them on? Do you have to sleep with them? Since again, I think as you mentioned, quite clearly, the majority of these conditions are benign and support stockings can make the problem better as well as prevent it from getting worse. What are the recommendations in terms of timing and whatnot?
Dr. Del Conde: Very important question. You should put the stockings on when the leg is not swollen. So, in other words, early in the morning, as soon as you get out of bed, before they get swollen, put those stockings on. If you try to put a stocking on a swollen leg, it's not going to be easy and it's not going to do the job that it's meant to do.
Dr. Fialkow: Do you find, and again, you're a specialty practice. You see a lot of patients referred to you specifically for this. You did mention hot environment. You're working outside and Florida, support stockings, not the greatest things if you're in air conditioning. Do you find the majority of people, especially with the right education are able to use support stockings successfully?
Dr. Del Conde: Not in South Florida, sadly, not here. Unless you're in an air conditioned room most of the day.
Dr. Fialkow: It's still first line, still worth a shot. Last question on treatment then if we have a minute or two, just going through a couple of other things that maybe weren't clarification. What is venous ablation procedures? When are they appropriate? Where do you see them used? Where do they come into play?
Dr. Del Conde: Great question. There's been tremendous abuse of ablation procedures. And there's only a small subset of patients that benefit from them. An ablation procedure is a minimally invasive procedure that is done to close a vein that is not working properly. So, instead of carrying blood upwards towards the heart of valves within the vein are not working and blood is leaking down. So, if you close the vein, you prevent that leaking. And it's usually done for people who have reflux. That's the medical term, reflux, blood flowing down in specific veins. Generally should never be done for cosmetic reasons. It's done when people have advanced venous insufficiency, people typically have a brownie discoloration in their ankle areas and the inner part of the leg and sometimes with ulcers. But if you have some varicose veins and you want to get an ablation, that's not the way to go.
Dr. Fialkow: Yeah. I think you had mentioned, and that's one of the banes of us as cardiology leaders, cardiovascular leaders, it's very much abused and a lot of people are referred or get those procedures who really would not otherwise benefit actually those risk. But with the right indication it's a viable solution.
Dr. Del Conde: Yeah. And let's not forget that the veins that are typically treated are the veins that we could potentially use in the future if the patient needed bypass surgery. So, you don't want to just close a vein for no good reason. This vein could be a lifesaver for you in the future.
Dr. Fialkow: Right. And with those circumstances, we can't use, there's no veins left to bypass because these people have had these relatively unnecessary procedures, if that comes up. Two or three quick points, and then we'll wrap up. Difference between above the knee and below the knee venous thrombosis. Is there one? And if so, what's the difference?
Dr. Del Conde: Yeah. So, this has to do with anatomy. If the listeners can imagine veins as being trees, you have the tree trunk that then divides into branches and then those branches into smaller branches and so on and so forth. So our big branches, our main branch is actually in our torso within our belly. The first set of branches are in our legs and below the knee they split. So, we have six veins below the knee. If you get a blood clot in one of those small veins, you're okay. The likelihood of this dislodging and causing a serious issue is actually very low. But because of anatomy, if the blood clot happens at the level of the knee or above, it's going to be a big branch and it could be serious. So, there's a big difference between below the knee and above the knee.
Dr. Fialkow: So, when someone has a blood clot in the leg, in a vein, obviously the concern could be swelling and pain, but the concern is a piece could break off and go to your lungs and be life-threatening. And there are factors which can make that more or less likely based on how you present, as you're saying. Again, quickly to other diagnoses, which sometimes get confused, or at least related, talk a little bit about lymphedema versus what we're talking about here. And then I'm going to ask you the differences about arthritis, which I've certainly seen in my practice. People come in and they've got some tendonitis or bursitis and swelling, and they think it's a blood clot. What's your experience regarding those two conditions? And then, again, I'll let you go.
Dr. Del Conde: Lymphedema is incredibly common. And when we talk about the vascular system or the circulatory system, we typically think about arteries and veins. Well, there's a third type of vessel called the lymphatic, the lymphatics suck all the fluid around the tissues, and they return it to the general circulation. And when those vessels, those lymphatics, are damaged, for whatever reason, it can be surgery or a trauma or a bad infection, bad cellulitis, then your body's ability to reabsorb that fluid is impaired. And you develop a very special type of swelling called lymphedema that has its own set of features that is very commonly misdiagnosed. But the difference between the way lymphedema looks and general swelling looks is that in lymphedema, the toes of your feet will also get swollen. They get very thick to the point that you can't really lift the skin off the top of your toes. So, most of the time it's because of, I said, injury of some nature, occasionally this has a genetic basis. So, that's lymphedema for you.
Dr. Fialkow: And that's very helpful. And again, a vascular medicine specialist, cardiologist, such as yourself, very commonly see these patients and very comfortable in assessing and treating them. And then, I mean, self-evident 30 seconds on arthritis. When someone has a tendonitis bursitis of an ankle, what are the differentiators?
Dr. Del Conde: You're going to have to get a rheumatologist for this one.
Dr. Fialkow: I would look at it like as redness, and as warmth, but all right, fair enough. I don't know how hot a topic that will be. No pun intended. Anyway, this is great information for a real, real common findings that an individual might have, or loved one may have. And I'd like to think that you're clear both descriptions and recommendations will help people in their self-assessment to both recognize when something needs to be escalated to a medical provider and when things are the lower risk and should not warrant any kind of anxiety and concern. So, thanks again. And any final comments, anything else you want to add?
Dr. Del Conde: No, I think it's a great topic, perhaps not the sexiest of all topics, but it is super common. And when you have leg swelling, you want to taken care of. So, I think it's an important topic to discuss. Thank you so much for the invite. I enjoyed it.
Dr. Fialkow: Thanks again, and to our listeners as always, if you have any comments, thoughts, or ideas for future topics for the podcast, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks for listening. And until next time, stay safe.
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