Cause & Prevention of Swelling of Feet & Legs
Note: Although the information here is useful for anyone with swollen feet, it is intended for people with an ongoing problem
with swelling of feet and legs due to being unable to walk. If this is not your situation, please consult your doctor to
determine the cause and treatment of your swelling. If there is swelling or puffiness of your fingers or around your eyes,
see your doctor promptly.
The Cause of the Swelling
The heart pumps blood through the arteries under high pressure. As the arteries branch out into smaller arteries and then
into tiny capillaries, pressure decreases. Oxygen is removed from the blood in the capillaries and then the "used"
blood flows into veins for the trip back to the lungs for another load of oxygen. Unfortunately, the pressure generated by
the heartbeat has been lost by then and the blood relies on simple back pressure to move back up to the heart. This is aided
by muscle activity. Ordinary muscle movement "squeezes" the veins and pushes the blood along. The veins have little
one-way valves all along the way that keep blood from draining backward as it is pushed upwards.
When muscle movement is lost, it becomes much harder to get the blood back up from the legs. It pools in the veins and causes
them to get distended. Water seeps from distended veins out into the surrounding tissue and your legs and feet swell (edema).
With repeated episodes of swelling, the little veins become damaged and leaky so that water seeps into the tissues even more
easily. At the same time, the valves are collapsing under the heavy weight of all that blood that is pooled on top of them.
That damage to the valves is permanent. Without the valves, the blood pools in the feet even worse than before and
remaining valves are under even more pressure and more likely to fail.
Doctors aren't very good about helping with swelling. They will offer prescriptions for TED hose (somewhat
helpful) and "water pills" (which should be used as a last resort only). And the first thing they will say is to put your legs up to minimize
the swelling but they don't tell you how to do that effectively!
Don't be fooled by an adjustable bed or hospital bed. The gismo that lifts your legs actually only lifts your knees. Your feet
are left hanging down on the far side of your knees. That is actually worse for circulation to them than lying flat. Put pillows
under the foot of the mattress to get the feet back up to the level of your heart.
Look at is the chairs you sit in. A recliner may seem like the ideal way to keep your feet up
and swelling down but it is NOT! There are two big problems with most recliners. First, the foot rest section is made
in such a way that all the weight of your legs rests on the calves. That is really bad for circulation. Second, putting your
feet up - even way, way up - without "unfolding" at the hips is minimally helpful
as that bend interferes with the already difficult job of moving blood upward to your heart. Lift chairs are wonderful and
most of them are recliners, but if you spend most of your time in a recliner, I strongly recommend that you bring the foot
rest up only when you lower the back rest. Rather than spending all your time sitting up with the foot rest up, you will
probably have better results if you leave the footrest down but take several breaks during the day to recline as flat as
possible with the footrests up as far as possible. This self discipline is so easy to advise but such a nuisance to stick with!
All too often I see PALS and other people in wheelchairs whose footdrop has been allowed to progress to the point where
their feet cannot rest flat on the footrest. This guarantees that the feet and lower legs will swell badly and the valves will
collapse like dominos! Don't let this happen! As soon as foot drop droops its ugly head, start using a footrest or positioning
boots in bed whenever you are on your back. A footrest can be as simple as a plywood or plexiglass piece between the mattress
and foot board and pillows in front of it to keep the ankles at a normal angle. While up during the day, wear your AFOs (Ankle
Foot Orthotics. Below the knee braces the keep the foot at a right angle to the ankle to prevent tripping.).
Once you quit walking you don't need the AFOs but you do need to keep your feet flat on your footrests. People complain
that the footrests are hard and cold. Slippers solve that but aren't as good as wearing shoes for correct possitioning of your
feet. All too often PALS quit wearing shoes because their toes curl under when they try to get them on. Unless your spasticity
is bad, here is how to keep wearing shoes.
- Buy lace up shoes a full size larger than your normal and extra wide (W) or WW wide.
- Remove the lining of the shoes if it is spongy or soft. The inside has to allow your foot to slide in easily.
- Find socks that are thin and smooth for easy sliding. Compression hose work very well. (Don't buy the kind with
open toes. They are for hospital use to check for circulation after leg surgery or a cast is first put on.)
- When putting the shoes on, pull the tongue forward to loosen the laces as wide as possible. The toes will still
want to curl under but unless your spasticity is bad, they should relax after a minute and slide into place. Twisting
the toe of the shoe side to side will help get the toes comfortably positioned.
Whether you sit in a regular chair, recliner, or a wheel chair, it must be properly fitted to you. You need to make sure that
your leg to floor/foot rest distance is short enough that there is minimal pressure at the back of the lower thigh and knee.
Having your feet "dangle" is a sure-fire way to cause swelling! Put a box/platform under your feet (an old
hard side suitcase worked great for me - lightweight and had a handle) or raise your wheelchair foot rest an inch or so. The objective
is to make certain there is minimal pressure on the back of your knees/thighs. If you add a ROHO or other cushion you
need to adjust your platform/foot rest upward to make up for the height of the cushion. A note of caution: If your feet
are too high, your weight will be shifted back on your tail bone and cause a pressure problem there. It is a balancing act to
find the happy medium for footrest height!
Standard power wheelchair leg lifts are fine for adjusting your legs while sitting up, but when you lie back in your chair and
raise the footrests, the footrests are suddenly too short! Your knees have to bend or you need a big pillow to get your heels
above the footrests. Very inconvenient and hard to get comfortable! The solution is to order "articulating" legrests. These
lengthen as they lift so that your legs aren't scrunched even with the legs all the way up. Comfortable for elevating your feet
to reduce swelling or just catching a nap!
The best treatment for leg swelling that I have found is something that I discovered entirely by accident: More time in
bed.When my husband was working, I spent about seven hours in bed at night and then would lie back in my recliner for
another two or three hours in the afternoon. Even with that, my legs were swollen by noon, miserably uncomfortable by evening
and absolutely painful by bedtime. When my husband retired, I was able to go to bed at the usual time, listen to books on
tape for an hour or two, and then sleep late in the morning. Instead of spending 10 hours lying with my feet up in two
separate sessions, I began spending 10 hours or more in bed all at one stretch. Within a matter of days after starting this
routine, I noticed that the swelling was minimal. Now I don't even have to lie down in the afternoon in order to be
comfortable in the evening! I don't know if this is due to spending more time lying down at one stretch, spending all my
lying down time in a bed rather than a recliner, getting more sleep, or some combination of the three. All I know is that in
this has made an incredible difference for me. Not only has it made my problems with swelling minimal, I feel better in
Another thing that helps is muscle activity. Granny's old rocking chair served a real purpose beside putting
babies to sleep! I find that the swelling is minimized on days when I am most active. (Interpret that as days when I am
frequently hauled in and out of my chair and forced to stagger a few steps, whining all the way!) I guess I have some muscles
left in my legs, even though I sure can't feel 'em! Even passive range of motion exercises help.
Keep cool. A few minutes of being too warm, toasting my feet by the fire,or just sitting in the summer sun is all
it takes to turn my feet into balloons. (Blood vessels dilate when we are warm.) Simply keeping my legs in
the shade makes a difference, but I have also been known to pour cold water over my feet on hot days when I need
to be outside. Wet socks and tennis shoes are still more comfortable than that miserable burning sensation of swollen
Sometimes I also have problems with a burning sensation in my feet in bed at night. It doesn't start until my feet began
to warm up. It can get really bad in the middle of the night if I have the electric blanket on and my feet get really warm.
That is a real nuisance because the rest of my body gets really chilled and I can't move at all if I pile on extra
blankets. So, in cold weather I end up sleeping with the electric blanket on, but my feet sticking out!
For some people, this burning pain becomes severe and doesn't seem to be relieved by getting the swelling down.
This might be the end result of long term or severe swelling. Some people find that aspirin (not tylenol) helps. Do not
take aspirin if you are on anticoagulants (medications to thin the blood). If burning pain is felt when swelling has not been
a problem, discuss it with your neurologist.
Limiting salt intake used to be high on the list of things to do to minimize swelling, and your doctor may suggest it,
but the need for that is questioned these days. I guess it is enough to say don't over-indulge with salty foods.
Hospitals often use devices to improve blood flowto the feet of patients who are going to be stuck in bed for a while
in order to reduce the risk of blood clots. TED (elastic or compression) stockings are by far the most common. By
simply squeezing the legs and feet a little, they help keep the veins from getting distended. You can ask your
doctor for a prescription for these stockings, but unless you have strong hands and arms, you will need help getting them on.
Hospitals also use types of "boots" that inflate and deflate to help pump the blood along. One study showed that
simple alternating pressure on the soles of the feet greatly improves flow, so some brands of boots simply apply waves of
pressure to the bottom of the foot. With help from your doctor you may be able to get your insurance to cover the cost of
this equipment. It is not complicated to use, but you must be very careful to make sure that it is not rubbing anywhere and
causing breakdown of the skin.
If you complain about swollen ankles and feet to your doctor, odds are he will whip out the old prescription pad and put you
on diuretics. I have real reservations about this because many of us are borderline dehydrated half the time anyway.
(Another contributing factor for the development of blood clots.) It gets hard to reach a drink, or hard to swallow, or it is
simply too hard to get to the bathroom so we don't drink as much as we should. Diuretics cause your kidneys to remove
more water from your blood stream. The "thicker" blood is then able to "sponge up" more water on its
travels through the body so it does reduce the edema. It does nothing about the cause of the edema -- poor blood flow –
however. Using diuretics for swollen legs is kind of like taking a diuretic to lose weight - sure it "works", but
it doesn't really solve the problem.
I certainly won't say diuretics should never be used -- if nothing else works well enough to keep the swelling under
control, they need to be used because the swelling further damages the veins and valves and the situation just gets worse.
But all the things described above should be implemented first before diuretics are even considered.