Ankle swelling and shortness of breath

Q: I tend to get ankle swelling on hot days. But now it seems more constant. What might cause the change?

A: Lower leg and foot swelling is most often the result of an abnormal fluid buildup. Doctors call it edema. Because fluid flows downhill, it pools in the lowest parts of your body.

Excess fluid retention can be triggered by many things, including summer heat, eating too much salt, or standing for a long period of time.

The most common cause is leaky valves in your veins. Doctors call this venous insufficiency.

There are one-way valves in your veins that help keep the blood flowing in the right direction. Ordinarily, as you walk around, your leg muscles squeeze the veins, which pumps the blood through these valves up toward the heart. When the muscles relax, the valves prevent blood from draining back down the vessels.

If these valves become leaky, the blood gets propelled upward, but much of it drops down again when the leg muscles relax. The result is an accumulation of blood — and an increase in pressure — within the veins. The higher pressure pushes fluid out of the veins, causing leg swelling.

Because your swelling seems to be worse than ever before, you should make an appointment with your doctor to be sure it isn’t due to a new medical problem.

Your doctor will ask if you have shortness of breath, fatigue or pain in your legs, and whether one leg is more swollen than the other.

Depending on your symptoms and your doctor’s physical exam, he or she might order blood and urine tests to evaluate your kidney and liver health. It’s also possible you might need an echocardiogram to make sure your heart function is normal, or a leg ultrasound to look for blood clots.

Some medications also can cause fluid retention in your legs. This can happen with high doses of ibuprofen (Advil, Motrin), naproxen (Aleve), and other nonsteroidal anti-inflammatory drugs.

Leg swelling is also a common side effect of certain calcium-channel blockers, especially nifedipine (Procardia XL) and amlodipine (Norvasc).

Meanwhile to help reduce the swelling:

• Cut down on your salt intake. Sodium can cause your body to retain water, so focus on eating less of it.
• Put your feet up. If you have a few minutes, elevate your feet above your heart when you are seated or lying down.
• Wear support stockings. Wearing support stockings, which provide pressure to the veins in your legs to help move blood back up toward the heart, can help reduce swelling.
• Get moving. Exercises such as walking, moving your ankles, and stretching can also reduce swelling by helping to push blood back toward your heart.

Q: I had a chest cold about six weeks ago. I thought I was over it within five days, but I feel like I am still more short of breath than usual. Is it from the chest cold? What else might be causing it?

A: When considering what might have caused your shortness of breath, I like to consider four general categories: a lung issue, a heart problem, anemia (low red blood cell count), and deconditioning.

I suspect your “chest cold” was a case of viral bronchitis. Since the symptoms resolved within a week, deconditioning secondary to such a short illness is less likely, except if you were already more sedentary due to health issues. So, let’s put this cause aside for now.

Regarding the other three categories, knowing if you have other symptoms besides shortness of breath is also important.

For example, shortness of breath, coughing and wheezing usually suggests a lung problem. Even people who have never had asthma can develop asthma-like symptoms after a viral respiratory illness. Those symptoms can last many weeks before resolving.

Shortness of breath from a heart problem could be due to a weak or stiff heart, which can diminish the heart’s pumping ability, known as cardiomyopathy. With cardiomyopathy, people also can experience ankle swelling from fluid retention and difficulty breathing when lying down.

Also, most people with coronary artery disease — plaque buildup in the walls of arteries that supply blood to the heart — experience chest pain with exertion, but sometimes shortness of breath is the only symptom.

A low red blood cell count, especially anemia due to iron deficiency, would be less likely than the other causes mentioned. Besides shortness of breath, other signs of anemia are pale skin and weakness.

Since you’ve had shortness of breath for six weeks, you definitely want to arrange for medical evaluation to help determine the underlying problem. Then, your doctor will likely have enough information to suggest whether your chest cold was either a cause or contributing factor to your continuing symptoms.

Your doctor will take a detailed history of your symptoms and perform a physical exam focusing on the heart and lungs.

Initial diagnostic tests will likely include wearing a finger probe to measure your blood oxygen level, a blood test to check for anemia, and chest imaging with a chest x-ray or CT scan. Additional investigation might include an echocardiogram, which uses sound waves to assess heart function, and an evaluation of your breathing (called pulmonary function tests).

The good news is that you and your doctor can formulate a treatment plan to help improve your symptoms, even if you don’t discover the specific reason for the shortness of breath.

Howard LeWine, M.D., is an internist at Brigham and Women’s Hospital in Boston and assistant professor at Harvard Medical School. For additional consumer health information, see health.harvard.edu.

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