Swollen Ankles After 60: Heart, Veins or Medicine? How Doctors Sort It

In this episode

Learn what doctors ask about swollen ankles, including whether one leg or both are affected and when swelling started. Call 911 if swelling comes with shortness of breath or chest pain. Contact your clinician right away for new or worsening swelling in one leg. Ask your prescriber about possible medicine side effects before making any changes. This episode is for general education.

Chapters

1. 0:00Three questions to sort swollen ankles
2. 0:49Is anything urgent?
3. 2:38Why ankles swell
4. 4:11One leg or both?
5. 5:30What comes along with it
6. 6:52Is it my heart? The honest picture
7. 8:14Inside a leg vein
8. 9:19Could a medicine be involved?
9. 11:14Never stop a prescribed medicine on your own
10. 12:16When one pill leads to another
11. 13:29What helps day to day
12. 14:40Compression, carefully
13. 15:35Three ideas to skip
14. 16:30What to bring to your appointment
15. 17:31Back to the three questions

Transcript

If your ankles swell, three quick questions can tell you a lot. Is anything here urgent? Is it one leg, or both? And did it start around the time of a new medicine? Those answers won't name the cause. That takes an exam, and often a few tests. But they tell you how fast to act, and what to bring when you go. And you're far from alone. A twenty twenty-six review of studies found that about one in four people over sixty, living at home, have long-lasting swelling in their lower legs. This is general education, not medical advice. And please don't stop or change any prescribed medicine on your own. Let's take them one at a time. First: is anything here urgent?

Call 911 if swelling comes with shortness of breath or chest pain. That includes chest pain that feels like pressure or tightness, or pain that gets worse when you take a deep breath. Also call if you cough up blood, or faint. Contact your doctor right away, not next week, if swelling comes on suddenly, in one leg or both. The same goes if one leg is newly swollen or getting worse. Or if a leg is red, warm to the touch, or painful. Or if you have a fever. Call right away, too, if you have heart or kidney disease and your swelling gets worse.

Or if you have liver disease and your legs or belly start to swell. If you can't reach your doctor, don't wait. Get seen right away. Why the hurry with one leg? A blood clot in a deep leg vein most often shows up on one side. That clot may break loose and travel to the lungs, which can be life-threatening. And a clot doesn't always hurt. Swelling alone can be a sign. And sometimes a clot causes no symptoms at all until serious problems develop. So a swollen leg that doesn't hurt still deserves a call.

These clots are most common after sixty. The chances go up after surgery, with bed rest, on a long trip sitting still, with cancer, or if you've had a clot before. A skin infection called cellulitis can also make a leg red, warm and swollen. You can't tell the two apart at home, and neither one should wait. Now, why the ankles?

Your blood travels through tiny vessels called capillaries. A little fluid seeps out of them into the tissue around them. That's normal. A second set of thin vessels, the lymph vessels, collects that extra fluid and carries it back. Swelling builds when more fluid seeps out than can be carried away. Higher vein pressure, leaky vessel walls, low protein in the blood, or slow lymph drainage can each tip that balance. Then add gravity. When you're up and about, extra fluid tends to settle at the lowest point, which is your feet and ankles.

Many middle-aged and older adults have a little swelling by the end of the day that's typically gone by morning. But swelling that keeps growing over days or weeks, or doesn't go down overnight, can be an early sign of fluid buildup from the heart, the liver or the kidneys. Don't wait for your next checkup. Book a visit soon. You may have pressed a thumb into a swollen ankle and seen a dent stay for a few seconds. That's called pitting. It tells you there's extra fluid. It doesn't tell you why.

Pitting can show up with vein problems, with a clot, with heart failure, and even with early lymphedema, which is swelling from damaged lymph vessels. A press test at home can't sort out the cause. Question two.

One leg, or both? When one leg swells suddenly, a clot is the first thing doctors want to rule out. A family medicine review marks it as the most common cause. Other possibilities include an infection, an injury, or a fluid-filled cyst behind the knee that bursts. That cyst can look just like a clot. When one leg has been swollen for a long time, worn vein valves are the cause doctors think of first. Lymphedema is another, for example after cancer surgery or radiation, sometimes years later. When both legs swell over time, the same review lists several common causes side by side, with no ranking.

Heart failure. Liver or kidney disease. Worn vein valves. Lymphedema. Medicines. And a lung pressure problem called pulmonary hypertension. Everyday things add to it too. Long car rides or flights. Standing a lot, especially in warm weather. Extra weight. A lot of salt. And if one leg suddenly gets bigger than the other, treat that as new, even if both legs were already a little swollen.

If both legs are swelling, pay attention to what comes along with it. Heart failure clues: getting short of breath with everyday activity like climbing stairs, or when lying flat. Not being able to sleep lying flat. Feeling unusually tired. And weight gain. And if you're not very active, you may not feel short of breath at all. The National Heart, Lung, and Blood Institute says older adults may feel tired, or confused, instead. Kidney clues: one kidney condition, called nephrotic syndrome, can bring puffy eyelids and foamy urine along with swollen legs.

Liver clues: with scarring of the liver, called cirrhosis, fluid can build up in the belly as well as the legs. None of these clues is a diagnosis by itself. But if any of them is new or getting worse, call your doctor soon. And if breathing suddenly gets hard, call 911. If you already have heart failure, follow the weight rule your doctor gives you. MedlinePlus, for example, says to weigh yourself each morning and call if you gain more than two to three pounds in a day, or five pounds in a week.

You may have seen a claim online that ankle swelling after sixty is mostly

a lymph problem, not a heart problem. Here's the honest picture. Part of that is fair. Plenty of swollen ankles have nothing to do with heart failure. Vein problems, medicines and lymphedema are all on the list of common causes. And the lymph system really is part of every swelling, because swelling means fluid is gathering faster than the lymph vessels can clear it. But that's where the evidence stops. We couldn't find any reliable study that says what share of swollen ankles after sixty comes from each cause.

So any percentage you hear about this has nothing solid behind it. And heart failure sits on that same list of common causes. Doctors check for it because missing it matters. In one small, older study of people with swelling in both legs, the first guess often changed once tests were done. Some swelling first blamed on the veins turned out to come from the heart or the lungs. That's why tests matter. Your doctor may check your blood and urine, and sometimes order a heart ultrasound.

Let's look inside a leg vein. Blood coming back from your feet has to travel uphill. Two things help. Inside your leg veins are small one-way valves that work like swinging doors. They open to let blood up, then swing shut so it can't slide back. And every time you take a step, the muscles in your lower leg squeeze those veins and push the blood upward. Over the years, valves can get damaged. Then blood slips back and pools, especially when you stand. That's called chronic venous insufficiency. More fluid seeps out, and the ankles swell, typically worse at the end of the day. Later, the skin near the ankle may darken or thicken. Age, a past clot, extra weight, and long hours on your feet or in a chair all raise the risk. Worn valves can also cause varicose veins. The good news: varicose veins are common, and for most people they don't cause problems.

Now question three. Did the swelling start, or get worse, after a new medicine or a higher dose? If you take a prescribed medicine on this list, don't stop it. We'll get to what to ask in a minute. MedlinePlus lists blood pressure pills called calcium channel blockers. Amlodipine is one of them. It also lists anti-inflammatory pain relievers, like ibuprofen and naproxen. Steroids, like prednisone. Hormones, like estrogen and testosterone. And some older antidepressants. The FDA labels for gabapentin and pregabalin, used for nerve pain, list swelling too.

So does the label for pioglitazone, a diabetes pill, which also warns it can cause or worsen heart failure in some people. If you take it and notice swelling with fast weight gain or shortness of breath, call your doctor promptly. Amlodipine's FDA label calls swelling its most common side effect, and it goes up with the dose. In the studies behind the label, about two in a hundred people had swelling on two and a half milligrams, three in a hundred on five milligrams, and about eleven in a hundred on ten milligrams.

On a dummy pill, it was fewer than one in a hundred. Women had it more often than men, though women on the dummy pill did too. Those amlodipine studies included few people over sixty-five. For gabapentin, in two studies of nerve pain after shingles, eight in a hundred people had swelling, compared with two in a hundred on a dummy pill. Most people in those studies were sixty-five or older, and the label says swelling tended to increase with age.

Here's the most important part of this whole video. Don't stop, skip or cut back a prescribed medicine on your own. MedlinePlus puts it plainly. Never stop a medicine you think may be causing swelling without first talking to your provider. Some of these medicines do important jobs, like controlling blood pressure or preventing seizures. And a few, like gabapentin, pregabalin and long-term prednisone, can cause real problems if they're stopped suddenly. Ask the person who prescribed it, or your pharmacist. Could my swelling be from this medicine? Over-the-counter pain relievers like ibuprofen are a little different. Their labels say to stop and ask a doctor if you get leg swelling. So follow the label, and tell your doctor which ones you take. And one exception for everyone. If your face, lips, tongue or throat swell, call 911. That's a different kind of swelling, and it's an emergency.

Sometimes swelling caused by one medicine is mistaken for a new problem, and it gets treated with a second medicine, often a water pill. Experts call this a prescribing cascade. A large study from Ontario, Canada, looked at adults sixty-six and older with high blood pressure. Those who had just started a calcium channel blocker were more likely to get a strong water pill within three months. About fourteen in a thousand did, compared with about seven in a thousand people starting two other common kinds of blood pressure pills.

That's fewer than one extra person in every hundred. It shows a link, not proof of cause. Water pills can have side effects of their own. But please hear the other half. A water pill can be exactly the right medicine. In heart failure, for example, it helps your body get rid of extra fluid, and you should take it the way you've been told. The point isn't to doubt your water pill. It's to make sure someone has asked where the swelling came from.

What can you do day to day? MedlinePlus lists some simple steps that may help. The research behind them is thin. Move your legs. Walking works that calf pump. A Cochrane review of exercise for vein problems found only five small trials, and the evidence was very low certainty. That's not proof it fails. It just hasn't been measured well. Raise your legs. MedlinePlus suggests lying down with your legs on pillows, above the level of your heart. There's little research on it. If lying flat makes you short of breath, don't push through it.

Sit up, and tell your doctor. Go easy on salt, which may reduce fluid buildup. Skip tight clothing or garters around your thighs. And if you need to lose some weight, that may help too. If you've been told to limit fluids or salt for your heart or kidneys, follow that plan, not general advice. And if these steps don't help, or the swelling gets worse, call your doctor. None of these replaces finding the cause.

What about compression stockings? Before you try them, ask your doctor to check the circulation in your legs. If the arteries in your legs are narrowed, squeezing them can do harm. A family medicine review says doctors should test leg circulation in people at risk, with a simple comparison of blood pressure at the ankle and the arm. An expert panel also advises against compression with severe heart failure, or with severe nerve damage from diabetes that leaves the feet numb. When it's okay, that review says compression helps with most causes of leg swelling. When the veins are the cause, it's one of the first things doctors try. And on flights longer than five hours, a Cochrane review found travel stockings reduced leg swelling, though that evidence was low certainty.

You'll see a few other ideas online. A vitamin that drains swollen ankles. We couldn't find a single trial of any vitamin for ordinary ankle swelling. A severe lack of vitamin B one can cause leg swelling. But in the U.S. that's rare, mostly seen with heavy drinking. Drinking lots of extra water to flush the swelling out. We found no evidence for it. If your doctor has told you to limit fluids, follow that. Otherwise, keep drinking as you normally do. A massage routine that drains your lymph. Trained therapists use a gentle drainage massage for lymphedema, as part of a full treatment plan. But it isn't proven to drain everyday ankle swelling. And if one leg is newly swollen, red, warm or sore, get checked before you try any routine.

Here's what to bring to your appointment. Write down which leg swells, or both, and when it started. Whether it's there all the time, or worse in the morning or the evening. What makes it better or worse, and whether raising your legs helps. Your doctor will likely ask. Write down what else you've noticed. Your breathing. Your sleep. Your weight. Your belly. Your urine. Note any past blood clots, and any varicose veins. Then list every medicine you take, including over-the-counter pain relievers, vitamins and supplements. Next to any new medicine, or any new dose, write the date it started. And if you can, bring someone with you, to help you listen and remember. Then ask your doctor. What do you think is causing my swelling? Could any of my medicines be part of it? And is compression safe for me?

So, three questions, in order. Is anything urgent? One leg, or both? Could a medicine be involved? Then let your doctor do the part only a doctor can do. If someone you love has swollen ankles, please share this with them. And tell me in the comments: what's one question about swelling you'd like answered?