Questions, answers on leg pain issues
Q: My legs used to swell occasionally. But now it’s happening every day. Should I be worried?
A:It sounds like you have “edema,” swelling in your legs due to fluid in the soft tissues beneath your skin. This usually occurs because the pressure of the fluid inside your veins is high, which forces water out of the blood vessels and into the surrounding tissues.
The most common cause is leaky valves in your veins. Doctors call it venous insufficiency.
There are one-way valves in your veins that help keep the blood flowing back toward your heart. Ordinarily, as you walk around, the muscles in your legs squeeze the veins, which pump the blood through these valves up toward the heart. When the muscles relax, the valves prevent blood from draining down the vessels.
If these valves become leaky, the blood gets propelled upward, but much of it drops down again when the leg muscles relax. The result is an accumulation of blood — and an increase in pressure — within the veins. The higher pressure pushes fluid out of the veins, causing leg swelling.
Check with your doctor
It’s less likely your edema is due to some other medical problem. But you should make an appointment with your doctor to be sure. Your doctor will ask if you have shortness of breath, fatigue, pain in your legs and whether one leg is more swollen than the other.
Depending on your symptoms and your doctor’s physical exam, he or she might order some tests. These could include an echocardiogram to look at how your heart is functioning, blood and urine tests to evaluate your kidney and liver health, and ultrasound testing of your legs to look for blood clots.
A number of medications can cause fluid retention in your legs, such as high doses of ibuprofen, naproxen and other non-steroidal anti-inflammatory drugs (NSAIDs).
Also, leg swelling is a common side effect of certain calcium channel blockers, especially nifedipine and amlodipine.
To help minimize the swelling, raise your legs whenever you sit down. Even better, try to schedule 20 or 30 minutes during the day when you can lie down with pillows under your feet to get your legs above the level of your heart. In doing so, gravity becomes your ally, not the enemy.
You might consider compression stockings that squeeze the legs. By resisting the pressure from within the veins, they help prevent fluid from seeping out of the blood vessels. Usually the knee-high versions are sufficient.
Q: I have peripheral artery disease. I try to walk as much as possible. But I stop frequently because of leg pain. What else can I do?
A: In peripheral artery disease (PAD), not enough blood flows to the legs. The condition usually is caused by fatty deposits called plaques that build up inside the artery walls.
This buildup shrinks the size of the passageway and reduces the amount of blood that can flow through. The result is cramping and pain in one or both legs, even on a short walk.
You likely are trying to follow your doctor’s advice to walk as much as possible. But with PAD, it’s common to need frequent stops to let the pain resolve.
People with PAD usually modify their walking. They slow down and stop often. They also tend to take smaller steps, and use their calf and ankle muscles more than thigh and hip muscles to push off with each step.
With PAD, circulation is slowest in the lower parts of the leg. Using calf and ankle muscles creates more oxygen demand. Not enough oxygen-rich blood gets to these muscles. That’s what causes the pain with walking.
So, it makes sense to do exercises that will strengthen thigh and hip muscles. The more those muscles take over when walking, the less pain you will have.
Specialized exercise training
One of the most effective therapies for leg pain due to PAD — an approach called supervised exercise training — has become more widely available and affordable. Medicare and some other insurance companies now cover supervised exercise training for PAD.
The therapy, which requires a doctor’s referral, also includes education and counseling about healthy lifestyle habits. But the main focus is on the exercise, which is typically done on a treadmill with coaching from an exercise therapist.
Meeting with a trained therapist to exercise several times a week tends to be more effective than home exercise because people are more motivated and tend to work harder.
Medicare will cover up to 36 sessions of 30 to 60 minutes each over a 12-week period, with the possibility of approval for an additional 36 sessions over time.
To help you walk longer distances, your doctor might prescribe a medication called cilostazol (Pletal). It doesn’t stop the blockages from getting worse. Instead, the drug helps increase blood flow to the muscles.
People with PAD almost always have blockages in other arteries, including those that supply blood to the heart and brain. So it’s important to reduce the risk of heart attack and stroke by not smoking and usually taking aspirin and a statin drug.
Howard LeWine, M.D., is an internist at Brigham and Women’s Hospital in Boston and assistant professor at Harvard Medical School. For additional consumer health information, visit health.harvard.edu.
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