You take your socks off at the end of the day and you’ve got a bloody great sock mark riveted into your ankles. You stare down at it and quietly wonder “Am I turning into my mother?”
Bad news: We are all slowly turning into our mothers.
Good news: You can slow the process and sometimes even divert to an alternative destination.
In this article we’re going to talk about the causes (and potential fixes) of pitting oedema - that kind of swelling that you can literally, put a dent in.
And, is that even a word?
It is in our house, but for the uninitiated - cankles are that depressing puffiness that banish the nobbly bits on either side of your ankles into the dark recesses of the past and put an end to your catwalk days.
There are lots of causes of swollen ankles but the most common is the fancily named ‘dependant oedema’. It simply means fluid has leaked out of your blood or lymphatic vessels and collected where gravity told it to… your ankles.
In dependent oedema, you can literally put a dent in it by pressing your thumb into the affected area for a few seconds and then releasing it. You have pushed the fluid out of those tissues with simple external pressure.
Aside from the very likely diagnosis of dependent oedema, there are other causes of swollen ankles that I have in the back of my mind when you come to see me with this puffy problem.
Let’s run through them first and, providing you don’t fall into one of these slightly tricker groups, we can get down to the important business of banishing your cankles.
There are a few medications that are notorious for causing ankle swelling so it’s both important to identify, and an easy win when it comes to the fix. The biggest culprits in my clinical experience are calcium channel blockers.
In the UK, Amlodipine is the most commonly prescribed of these and we use it to treat high blood pressure. It’s excellent and bringing blood pressure down and it is generally well tolerated, but in a proportion of people it can cause ankle swelling.
If this is you, often we can stop the drug, the ankle swelling vanishes and all that’s left is to find an alternative way of treating your blood pressure. Don’t go all rogue on me though and stop medication without the guidance of your own doctor - it’s one that needs an appointment.
Sounds scary but is not uncommon in older patients, particularly those with a history of hypertension, ischaemic heart disease (angina and hart attacks) or atrial fibrillation. We can usually exclude this with a combination of a good history, examination, a blood test and sometimes an echocardiogram. Here’s what I’m looking for:
Your previous medical history - anything cardiac, hypertension
Your story - do you wake up at night gasping for air, do you sleep propped up with 3 pillows because it makes your breathing easier.
Examination - are any other bits of you getting puffy? Are there crackles in your lungs when I listen, are your heart sounds normal?
Blood tests - a raised BNP (brain natriuretic peptide) tells me if your heart is under strain
Echocardiogram - an ultrasound scan of the heart that shows us how well the heart is pumping and highlights any issues with heart valves
Your kidneys are seriously impressive bits of kit. They filter out toxins, hold on to salts in just the right balance and dilute or concentrate your urine depending on your hydration level. But sometimes, their exquisite function can deteriorate over time - particularly with age, diabetes, hypertension, medications or inherent kidney disease. In some cases they can become leaky, and instead of holding on to protein as they should, they let it leak out into your urine. When the protein level in your blood drops, it makes it easier for fluid to leak out into the surrounding tissues. Here’s what I’m looking for:
History - any reason that your kidney function might have taken a hit?
Examination - are you puffy in places other than your ankles?
Urine test - Is there protein in your urine, and if so, how much. (The first question we can usually answer on the day with a dip test, the second question needs the sample to go to the laboratory for testing)
Blood tests - an eGFR (U&Es) gives us a headline figure of your kidney function, but is perhaps less important in this case than the urine test.
For any of you that have a diagnosis of lymphoedema, I know it’s a tough one and it leaves a lot of people feeling well and truly beaten.
Lymphoedema may be a consequence of other medical problems - commonly following removal of lymph nodes as part of cancer treatment, or it can be primary lymphoedema - meaning there is no other underlying cause - in which case there is often a significant genetic component.
We have blood vessels and a separate lymphatic system. In lymphoedema the normal drainage of the lymphatic system just doesn’t work well and the result is swelling. And the biggest bug-bear is that we have no cure.
It’s a big topic and that probably earns it own article, but we couldn’t talk about ankle swelling without mentioning it.
This puffy problem can have a few different drivers. You may have just one of them, or you might have a full house! Either way, there are steps you can take to improve things.
PROBLEM: Water retention - your body will hold on to extra water in an attempt to maintain a steady salt concentration in your blood. Add salt, and your body will add water.
FIX: Reduce salt in your diet. Not just what you add to food, but the salt you find in processed food as well - in fact these are often the biggest culprit.
PROBLEM: Gravity
FIX: Move to the moon. Avoid sitting with your feet as the lowest part of your body. For the fluid to make its way back up and into circulation, you are going to have to get your feet up above your heart. The more time you spend sitting with your feet on the floor, the more your ankles will fill with fluid.
PROBLEM: Reduced venous return - this a fancy way of saying that your veins are now less efficient at getting blood back up from your feet towards your heart.
FIX: For many of us in midlife and beyond, the valves that sit inside the veins become floppy. This is what gives rise to varicose veins. But long before that, they can be leaky and this means blood doesn’t get back from your feet as efficiently as it once did. You can give it a helping hand though, by activating your calf muscles. The calf muscles act as an outside pump, encouraging blood back up to the heart from the ankles. Regular walking breaks or even just calf raises while you’re sitting at your desk can all help. For some, compression stockings are a helpful, if not very stylish management option.
PROBLEM: Reduced mobility - this is one that means the assistance your calf muscles once provided may have dropped. Perhaps you’ve been unwell or injured and that’s left you less mobile than before. You may well see the impact in your ankles.
FIX: Get active again once you’re able.
PROBLEM: Heat - it’s been toasty in the UK this summer so perhaps this has been the first year you’ve noticed this puffy problem. Your body’s natural cooling mechanism, is to allow blood vessels to dilate close to the skin to allow heat from your body to escape more easily. It’s a good system but it can cause extra fluid to accumulate (courtesy of gravity) in your ankles.
FIX: Keep cool!
If your puffy ankles respond well to these simple measures, then that’s often very reassuring. But if that’s not the case, or if other symptoms start to pile in, then ask your GP.
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