Case of leg swelling is likely due to chronic venous disease

Dear Dr. Roach: I am an 80-year-old obese woman with high blood pressure that is being controlled with nifedipine and losartan. Over a year ago, I noticed that my small toe on my left foot was becoming numb, and my left foot and ankle were swollen by the middle of the day. I told my physician, who checked on my lower left leg in the morning and said to elevate my legs.As the year went by, my foot/ankle became more swollen, and I had to stop wearing most of my shoes. About two months ago, I noticed my right foot starting to swell, but not my right leg yet. I wondered what was going on and asked my doctor to suggest something. He told me to elevate my legs every two hours and sleep with a pillow under my legs at night. Unfortunately, I am a sleeper who rolls from one side to the other several times during the night.I do have much less swelling when I wake up, and my foot looks almost normal. But by the end of the day, my left foot is so swollen and the skin is so tight that it is very painful. — G.K.Answer: The most common cause of leg swelling in older adults is venous insufficiency, also called chronic lower extremity venous disease. You have two risk factors for it: being obese and being in your 80s. In addition, you are on a medication (nifedipine) that can cause leg swelling, even in people who don't have chronic lower extremity venous disease.What makes your story a little bit more concerning is that, at least at first, only one leg was involved. This should make your doctor think about a blood clot or some other cause of leg swelling that only occurs on one side. However, most of the time, we worry enough about a blood clot to order a test (usually an ultrasound), and the result ends up negative. Plus, it seems your doctor was sure enough of the disease that he treated you for chronic lower extremity venous disease. It is not that uncommon for symptoms to begin on just one side.Raising the legs periodically during the day is part of the treatment for this condition. Unfortunately, it doesn't sound to me that this treatment alone is adequate, since you are having a painfully swollen leg later in the day. I ordinarily prescribe compression stockings, which many of my patients initially find uncomfortable because they are very tight. But if you put them on first thing in the morning when your legs are least affected, this will help.I have found many places that make compression stockings that are quite attractive. Regular exercise is also beneficial, as muscular action helps squeeze out fluid and return the leg to its normal circulation.If these are not effective, referral to an expert is appropriate. Vascular surgeons are the experts, and there are many new approaches (much better than the old "vein stripping") that can be done in the office and provide excellent results.Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.