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Key Clinical Updates in Lower Extremity Edema

The physical examination is usually inadequate to distinguish lymphedema from venous insufficiency. Only the Kaposi-Stemmer sign (the inability to pinch or pick up a fold of skin at the base of the second toe because of its thickness) is a significant predictor of lymphedema.

Duplex ultrasonography is the diagnostic study of choice to detect chronic venous insufficiency due to venous incompetence.

ESSENTIAL INQUIRIES

  • History of venous thromboembolism.

  • Symmetry of swelling.

  • Pain.

  • Change with dependence.

  • Skin findings: hyperpigmentation, stasis dermatitis, lipodermatosclerosis, atrophie blanche, ulceration.

GENERAL CONSIDERATIONS

Acute and chronic lower extremity edema present important diagnostic and treatment challenges. Chronic edema and lymphedema are underrecognized conditions. Lower extremities can swell in response to increased venous or lymphatic pressures, decreased intravascular oncotic pressure, increased capillary leak, and local injury or infection. Chronic venous insufficiency is by far the most common cause, affecting up to 2% of the population, and the incidence of venous insufficiency has not changed over the past 25 years. Venous insufficiency is a common complication of DVT; however, only a small number of patients with chronic venous insufficiency report a history of this disorder. Venous ulceration commonly affects patients with chronic venous insufficiency, and its management is labor-intensive and expensive. Normal lower extremity venous pressure (in the erect position: 80 mm Hg in deep veins, 20–30 mm Hg in superficial veins) and cephalad venous blood flow require competent bicuspid venous valves, effective muscle contractions, normal ankle range of motion, and normal respirations. When one or more of these components fail, venous hypertension may result. Chronic exposure to elevated venous pressure by the postcapillary venules in the legs leads to leakage of fibrinogen and growth factors into the interstitial space, leukocyte aggregation and activation, and obliteration of the cutaneous lymphatic network.

CLINICAL FINDINGS

A. Symptoms and Signs

1. Unilateral lower extremity edema

Among common causes of unilateral lower extremity swelling, DVT is the most life-threatening. Clues suggesting DVT include a history of cancer, recent limb immobilization, or confinement to bed for at least 3 days following major surgery within the past month (Table 2–4). Adults with varicose veins have a significantly increased risk of DVT. Lower extremity swelling and inflammation in a limb recently affected by DVT could represent anticoagulation failure and thrombus recurrence but more often are caused by postphlebitic syndrome with valvular incompetence. A search for alternative explanations is equally important in excluding DVT. Other causes of a painful, swollen calf include cellulitis, musculoskeletal disorders (Baker cyst rupture [“pseudothrombophlebitis”]), gastrocnemius tear or rupture, calf strain or trauma, and left common iliac vein compression (May-Thurner syndrome), as well as other sites of nonthrombotic venous outflow obstruction, such as the inguinal ligament, iliac bifurcation, and popliteal fossa. Swelling of the ankle can be a manifestation of Charcot neuropathic osteoarthropathy.

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