What causes a sensation of heavy feet at night?

Causes of Heavy Feet Sensation at Night

The sensation of heavy feet at night is most commonly caused by Restless Legs Syndrome (RLS), peripheral neuropathy, venous insufficiency, or nocturnal leg cramps, with RLS being the most likely culprit when symptoms specifically worsen at night. 1, 2

Restless Legs Syndrome (RLS)

RLS is characterized by:

• An urge to move the legs usually accompanied by uncomfortable and unpleasant sensations
• Symptoms that begin or worsen during periods of rest or inactivity
• Partial or total relief with movement such as walking or stretching
• Symptoms that are more pronounced in the evening or night 1

RLS affects approximately 2-3% of the general population and can significantly impact sleep quality and overall quality of life 3.

Peripheral Neuropathy

Diabetic peripheral neuropathy commonly presents with:

• Burning pain, "electrical shock" sensations, or lancinating pain
• Uncomfortable tingling (paresthesia)
• Subjective sensations of altered temperature in the feet
• Non-specific aching feelings in the feet
• Symptoms typically worse at night 1

Patients often describe the sensation as "walking barefoot on marbles" or "walking barefoot on hot sand" 1.

Venous Insufficiency

Venous insufficiency can cause:

• Heaviness in the legs that worsens throughout the day
• Swelling (edema) that may be more pronounced in the evening
• Discomfort that improves with elevation 1

Nocturnal Leg Cramps

Nocturnal leg cramps affect up to 60% of adults and are characterized by:

• Recurrent, painful tightening usually in the calf muscles
• Can cause severe insomnia
• Associated with various medical conditions including vascular disease, lumbar canal stenosis, cirrhosis, and pregnancy 2, 4

Other Potential Causes

• Overtraining syndrome in athletes (associated with hemorheologic disturbances) 5
• Burning feet syndrome, especially common in the elderly 6
• Medication side effects (intravenous iron sucrose, conjugated estrogens, raloxifene, naproxen, and teriparatide) 4

Differential Diagnosis

It's important to differentiate between:

• RLS (urge to move with uncomfortable sensations, relieved by movement)
• Nocturnal leg cramps (painful muscle contractions)
• Periodic limb movements of sleep (repetitive limb movements that aren't painful)
• Claudication (pain with activity, relieved with rest)
• Myositis (muscle inflammation)
• Peripheral neuropathy (sensory disturbances) 1, 2, 7

Diagnostic Approach

1. Evaluate timing of symptoms (worse at night suggests RLS or nocturnal cramps)
2. Determine if movement helps (suggests RLS)
3. Check for associated symptoms (pain, tingling, burning)
4. Consider medical history (diabetes, vascular disease, pregnancy)
5. Review medication list for potential contributors
6. Physical examination to check for signs of vascular insufficiency or neuropathy

Management

Treatment depends on the underlying cause:

• For RLS: Dopaminergic agents (pramipexole, ropinirole) are first-line for moderate to severe cases 3
• For nocturnal leg cramps: Exercise, stretching, magnesium supplements, or calcium channel blockers 4
• For peripheral neuropathy: Address underlying cause and consider medications for neuropathic pain 1
• For venous insufficiency: Elevation, compression stockings, and avoiding prolonged sitting or standing 1

General sleep hygiene measures that may help include:

• Regular exercise (morning/afternoon)
• Avoiding heavy meals within 3 hours of bedtime
• Avoiding alcohol, caffeine, and nicotine close to bedtime
• Creating a comfortable sleep environment 1

Remember that the sensation of heavy feet at night can significantly impact sleep quality and overall quality of life, so proper diagnosis and management are essential for improving patient outcomes.