The Epidemic of Leg Swelling

by Dean Wasserman MD, RVT, FACS

Some epidemics are obvious and sensational while others are subtle and insidious. The currently observed increase in the prevalence of leg swelling is of the latter type. At first glance, this trend seems paradoxical as so much attention and education to the venous system has occurred over the past decade.

We know, however, that public awareness in the venous field has historically been challenging. This truth has been evidenced by the fact that the incidents of venous thromboembolic events have not statistically lowered over several decades.

Our understanding of venous anatomy and physiology has been accompanied by the development of precision diagnostics such as du-plex ultrasonography and venous reflux analysis. During this period of “enlightenment,” we have seen an elevated appreciation towards the venous system in the United States. venous medicine has been formerly labeled a “second cous-in” to the arterial circulation. we are reaching a momentous evolution where venous conditions may be referred to as the “Cinderella” of the family.

Highlighting events include identifying the magnificent role of human veins in their capacitance performance, carrying 75% of total blood volume-and as such regulating homeostasis and stable thermal environment through vasoconstriction and dilatation.

We have also known that the impact of venous disorders on a socioeconomic level is staggering.

Further insights regarding venous pumping by the calf pumps has been elucidated. we know that this calf muscle pump is maximally activated by a specific quality of walking, which includes an unrestricted ankle range of motion, and a moderate pace on a relatively flat incline so as to allow adequate filling time and result in maximum venous ejection fraction. Thus, what could account for a system that defies gravity to succumb to the recent epidemic of lower extremity venous hypertension and leg edema?

The proposition of this author admittedly stems from the oldest “scientific method” in history. My observations result within an environment of academically oriented clinical phlebology practice over the past 15 years. My initial consultation for venous insufficiency occupies an average of 35 minutes and includes intense listening to the patient’s history. Our patient understanding and compliance with wearing hosiery and walking are also key to our sclerotherapy results.

Estimates compare the finding of “pitting” edema in perhaps 1 of 10 patients a decade ago to our current documentation of pitting edema in a range of 8 out of 10 otherwise healthy individuals at this time. This finding is observed in both thin as well as heavy patients. This clinical sign has become so common that i am accustomed to reassuring the patient that remedy is available.

See Figures: 1A (?? y/o healthy female with no visual edema) and 1B (same female after pitting challenge), 2A (29 y/o healthy female with no visual edema) and 2B (same female after pitting challenge).

The presence or degree of edema is furthermore detected in our patient group irrespective of patients with normal veins, those with large varicosities, as well as patients with abnormal diffuse reticular varicose and telangiectasias a very common finding is a malady in the neuro-muscular system or podiatric lesions. These conditions seem to cause asymmetry in gait and are suspected to interfere with calf muscle pump function.

The concluding theory results in part from my practice philosophy of minimizing edema prior to interventional methods. i am not aware that minimizing edema prior to interventions results in superior results or reduces complications with the one following exception. it is essential in the performance of large vein calf sclerotherapy, that edema be controlled in order to obtain maximum compression to the veins, not diminished by diffusion of compression by edematous tissues.

This practice philosophy stems from two sources. First, the logistics of time required to obtain precertification may delay procedures, yet the basics of swelling reduction can almost always begin immediately. Second, it has been my experience that once the patient’s focus is on a procedure, the compliance and drive to ambulate and appreciate compression benefit takes a secondary often forgotten role. i do feel that continued commitment to a life style which includes leg vein wellness does result in a long term benefit of outcomes and prognosis.

The ability of informed and thus compliant individuals to achieve elimination of gross edema by following a simple walking protocol for a relatively short period of time is routinely observed. The essentials of this protocol as described above require intentional characteristics of walking again stressing a moderate typically 2 miles a day walking regimen maximizing heel-to-toe activation of the gastrocnemius muscles. These patients are able to “walk off” their edema within 2 weeks, on average.

I thus share my beliefs that such walking has diminished over the past several years in the context of a rapid transit, increasing work, and obligation commitments. i believe that a restoration of walking to the activities of daily living is both essential and successful as a foundation of venous health and has the ability to reverse the epidemic of leg swelling. Additionally, the benefits of compression therapy for individuals with occupational risk bears merit to further promote venous health. I propose a call to action toward the above goal. we as phlebologists shall work to emphasize to our patients that much of their venous health is within their hands and responsibility. Furthermore, by promoting the patient’s active participation, we empower them with knowledge and tools that when once educated, will deliver results. it is also our duty to demonstrate this hidden health factor and recommendations toward preventive care are within their reach.

Dean Wasserman, MD, FACS is a Board Certified Vascular Surgeon (ABS) and member of the American Venous Forum as well as the ACP. He is a Clinical Assistant Professor of Surgery at UMDNJ, Newark. He founded and is Medical Director of the Vein Treatment Center of New Jersey where his practice has been exclusively dedicated to venous disorders.