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Why do my ankles and feet swell?
Sooner or later, it happens to almost everyone: you reach the end of the day and notice that your ankles, and perhaps even your feet, have become quite swollen, sometimes even a bit painful to the touch.
Your doctor would describe this as peripheral edema, a somewhat cryptic medical term that simply refers to:
- swelling caused by an accumulation of fluid (edema),
- which develops in the extremities of the body, meaning in the periphery, farthest from the heart.
If this happens to you only occasionally, and in the absence of any other noticeable symptoms, there is usually nothing to worry about. However, since in some cases this swelling can be an early warning sign of more serious underlying conditions affecting the heart and/or kidneys, it is always worth mentioning it to your doctor if you have any doubts or concerns.
Causes
Between 50% and 60% of your total body weight is made up of water. If you weigh 60 kg (about 132 lbs), roughly thirty of those kilograms, or even more if you are male, should be water. Part of this water is contained inside your cells, while another part is found in what is called the extracellular space, which also includes the blood itself.
Everything that is not inside a cell and is not blood is referred to as interstitial fluid. This fluid is far more than just filler; it actually represents an extremely important resource for the body, which uses it to regulate the exchange of substances between the blood and the cells. There is therefore a delicate, dynamic balance between the fluid in the blood and the fluid surrounding the cells, a balance that is carefully regulated by the brain according to the body’s needs at any given moment.
Excess interstitial fluid is then drained away by the lymphatic system. Without getting into further technical detail, it’s important to understand that this represents a very delicate, constantly shifting equilibrium. You can picture it as an alpine lake, where:
- the blood delivers fluids and other substances, much like a stream flowing down from the mountaintop,
- the cells take what they need and release their waste products, like small fishermen working along the shore,
- and finally, the veins and, when needed, the lymphatic system carry part of the fluid back downstream.
Any disturbance capable of disrupting this delicate balance, particularly one that hinders the return of fluid through the lymphatic vessels, leads to an abnormal accumulation of fluid in the interstitial space, the space between the cells. This accumulation is called edema, and you can see it visually in the form of swelling.
The legs, ankles, and feet are among the first areas of the body to show this phenomenon, simply due to their position. Because of the effect of gravity, this is the area where fluid most commonly tends to accumulate. Upon waking up in the morning, it’s also common to notice similar swelling in other areas of the body, such as the hands and eyelids.
The most common cause of peripheral edema in patients over the age of 50 is venous insufficiency, a condition characterized by the progressive deterioration of the internal mechanisms within the veins that are responsible for helping return venous blood back to the heart.
However, especially in patients who present with specific risk factors, it is essential to rule out more serious systemic conditions, including:
- heart failure,
- kidney failure,
- liver failure.
In cases of heart failure, the heart is no longer able to effectively perform its pumping function, causing blood to accumulate in the peripheral parts of the body, where the force of circulation is naturally weaker.
In cases of kidney failure, the kidneys may lose their ability to properly manage the amounts of sodium, protein, and water that need to be either retained or eliminated, leading to disruptions in the body’s overall fluid balance.
In cases of liver failure, the liver, which is responsible for producing and managing the distribution of numerous important proteins (most notably albumin), can no longer perform this task with its usual efficiency, once again disturbing the body’s delicate fluid balance.
Other conditions that, through different mechanisms, can also explain the appearance of ankle swelling include:
- premenstrual syndrome, due to hormonal fluctuations,
- malnutrition or malabsorption, again related to available proteins and certain vitamins,
- myxedema in cases of hypothyroidism,
- lymphedema,
- pulmonary hypertension.
Medications
Certain medications are also known to cause ankle swelling as a side effect, including:
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some blood pressure medications (specifically calcium channel blockers),
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hormonal therapies, such as:
the birth control pill, hormone replacement therapy, testosterone therapy,
-
certain antidepressants (specifically MAO inhibitors and tricyclic antidepressants),
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corticosteroids (cortisone-based medications).
When Only One Ankle Swells
When swelling is limited to just one ankle (unilateral edema), it is generally linked to a localized problem affecting that specific leg, typically including:
- deep vein thrombosis (DVT),
- compartment syndrome,
- chronic venous insufficiency,
- burns,
- insect bites and stings,
- cellulitis (a bacterial skin infection),
- local allergic reactions,
- trauma or injury.
Swollen Ankles at Night, Normal in the Morning?
Throughout the day, excess fluid tends to accumulate in the lowest parts of the body, especially during warmer months and after long periods of standing. For this reason, it’s quite common for symptoms to worsen in the evening hours, regardless of the underlying cause. The most common culprit remains venous insufficiency, which is often made worse by a diet that is too high in salt.
Swelling in Older Adults
Noticeable ankle swelling is very common among older adults. Although the possible underlying causes remain largely the same as those already discussed, in many cases elderly patients experience an overlap of several different conditions at once, such as venous insufficiency, cardiac problems, kidney issues, and the use of multiple medications, all of which can combine in various ways to produce the symptom.
Other Symptoms
Edema by itself does not typically cause many other symptoms, aside from an occasional sensation of tightness or mild tenderness, sometimes described by patients as a feeling of tired, heavy legs and ankles.
When to Worry
Swelling in the ankles, feet, or legs often resolves on its own, but it is recommended to mention it to your doctor if it does not fully resolve within a few days.
The following situations warrant immediate medical evaluation:
- unilateral swelling (affecting only one ankle, foot, or leg) with no obvious cause, such as a recent injury,
- swelling that is particularly severe, painful, or that appears suddenly,
- the presence of redness or warmth to the touch,
- fever or chills,
- a personal history of diabetes or current pregnancy.
Pregnancy
Mild swelling during pregnancy, particularly affecting the legs, ankles, feet, and fingers, is quite common and expected, especially in the evening hours and during the later weeks of pregnancy.
In most cases, this is simply a minor discomfort for the expectant mother and not a cause for concern. However, a sudden increase in swelling, or particularly severe swelling, could be a sign of pre-eclampsia, a condition that requires immediate attention from an obstetrician.
You should seek emergency medical care if you experience:
- a sudden increase in swelling affecting the face, hands, or feet,
- a very severe headache,
- vision disturbances,
- pain just below the ribs,
- high blood pressure,
- foamy or frothy urine.
To reduce the discomfort associated with normal fluid retention during pregnancy, it’s recommended to:
- avoid standing for long periods of time,
- wear comfortable shoes and socks that are not overly tight,
- rest with your feet elevated whenever possible,
- drink plenty of water,
- engage in regular physical activity, as appropriate for your condition.
Tests and Diagnostic Workup
The first step whenever you’re concerned about swollen ankles is always to consult your doctor, since any necessary tests will only be prescribed following a careful medical history and physical examination.
Taking a thorough medical history involves gathering information not only about the specific circumstances surrounding the onset of the symptom, but also about the patient’s overall health status and any family history of heart, kidney, or liver disease.
For example:
- sudden swelling that develops over just 2 to 3 days often points toward deep vein thrombosis (DVT), localized infections or trauma, or the recent start of a new medication;
- chronic, more gradual fluid accumulation is usually caused by an underlying systemic condition, such as heart failure, liver disease, or kidney disease;
- edema caused by venous insufficiency generally responds very well to simple remedies such as elevating the legs at night, unlike edema caused by malabsorption, liver failure, or nephrotic syndrome.
The presence of specific risk factors can also help guide the doctor toward a particular diagnosis, such as a family history of heart disease or type 2 diabetes, an occupation that requires standing for long periods, a poor diet, or excessive alcohol consumption.
A thorough physical examination, often considered the true core of the medical visit, can reveal symptoms suggestive of specific underlying conditions, such as shortness of breath pointing to heart problems, high blood pressure pointing to kidney issues, or jaundice (yellowing of the skin) pointing to liver disease.
Based on these initial findings, your doctor may order a variety of laboratory or imaging tests, such as:
When there is no specific clinical suspicion:
complete blood count with differential, serum electrolytes, blood urea nitrogen (BUN), creatinine, liver function tests, serum protein levels, and urinalysis.
If heart failure is suspected:
chest X-ray, electrocardiogram (ECG), and brain natriuretic peptide (BNP) levels.
If kidney-related causes are suspected:
blood creatinine and urine protein levels.
If liver disorders are suspected:
liver enzymes (transaminases) and albumin levels.
If hypothyroidism is suspected:
TSH, along with FT3 and FT4 levels.
If deep vein thrombosis is suspected:
venous Doppler ultrasound.
Remedies: What Can Be Done?
Treatment always depends heavily on the underlying cause of the swelling. For example:
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Chronic venous insufficiency: this condition responds very well to mechanical therapies, including leg elevation and the use of compression stockings, which are often quite effective at managing symptoms, although unfortunately a complete reversal of the underlying condition is unlikely.
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Heart failure, liver disease, or kidney disease: diuretic medications are typically the first-line treatment, though it is often advisable to also incorporate the same self-care strategies recommended for chronic venous insufficiency, at the physician’s discretion.
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Deep vein thrombosis: treatment involves anticoagulant therapy, either with heparin or with the newer class of oral anticoagulants (also known as direct oral anticoagulants, or DOACs), such as rivaroxaban or apixaban.
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Lymphedema: treatment typically involves decongestive physiotherapy, which combines manual lymphatic drainage massage with multilayer bandaging, along with the use of compression stockings.
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Medication-induced edema: in these cases, the medication responsible for the swelling should be reassessed by a physician and modified if possible.
Home Remedies and Self-Care Tips
Regardless of the underlying cause, patients are typically advised to follow a series of general recommendations aimed at reducing swelling and preventing it from worsening again. Some of the most effective strategies include:
- following a varied, healthy diet, particularly one that is low in sodium, which is one of the most effective strategies available,
- staying well hydrated by drinking plenty of water, even though this may seem counterintuitive,
- engaging in regular physical activity appropriate to your overall health condition, which helps improve circulation and maintain healthy leg muscle tone,
- elevating your legs at night, for example by placing pillows or a folded blanket under the mattress at the foot of the bed,
- losing weight if necessary,
- avoiding staying in the same position, whether standing or sitting, for extended periods of time,
- wearing shoes that are not overly tight or restrictive.
As always, if you are dealing with an underlying medical condition, be sure to consult your doctor before trying any new self-care approach or remedy.
