What is the most common cause of swelling in the legs and hands?

Common Causes of Swelling in Legs and Hands

The most common cause of bilateral leg and hand swelling is chronic venous insufficiency, particularly in patients over 50 years of age, followed by heart failure as the second most common systemic cause. 1

Primary Causes by Frequency

Most Common: Chronic Venous Insufficiency

• Venous insufficiency is the leading cause of symmetrical leg swelling in patients over 50 years old 1
• Presents with pitting edema that worsens throughout the day and improves with leg elevation 2
• Often accompanied by skin changes including pigmentation, thickening, and varicosities over time 3

Second Most Common: Heart Failure

• Right-sided heart failure causes bilateral leg edema through increased hydrostatic pressure 4
• Presents with pitting edema, typically accompanied by dyspnea, elevated jugular venous pressure, and orthopnea 5, 4
• Increased right atrial pressure and venous congestion are the dominant mechanisms, not low cardiac output in most cases 5

Upper Extremity Involvement

When both legs AND hands are swollen together, consider these specific causes:

• Deep vein thrombosis (DVT): Upper extremity DVT accounts for 10% of all DVTs and presents with ipsilateral arm edema, pain, and paresthesia 5
• Superior vena cava syndrome: Causes bilateral upper extremity swelling with facial edema 5
• Systemic causes affecting all extremities: hypoalbuminemia (liver cirrhosis, nephrotic syndrome, protein-losing enteropathy), heart failure, or medication effects 2, 4

Pathophysiologic Mechanisms

The underlying mechanisms causing extremity swelling include 2, 4:

• Increased hydrostatic pressure: venous insufficiency, heart failure, DVT
• Decreased oncotic pressure: hypoalbuminemia from liver disease, nephrotic syndrome, malnutrition
• Increased capillary permeability: infection, inflammation, allergic reactions
• Lymphatic obstruction: primary or secondary lymphedema, malignancy
• Volume overload: renal failure, heart failure

Critical Differential Diagnoses

Drug-Induced Edema

• Antihypertensive medications (particularly calcium channel blockers) and anti-inflammatory drugs frequently cause leg edema 6
• Chronic diuretic abuse can paradoxically cause diuretic-induced edema, particularly in women with idiopathic cyclic edema 4

Systemic Diseases

• Renal disease and liver disease are much rarer causes compared to venous insufficiency and heart failure 6
• Thyroid disorders can present with bilateral extremity edema 3
• Hypoproteinemia from any cause (liver, kidney, or gut protein loss) reduces oncotic pressure 4

Rare but Important Causes

• Erythromelalgia: episodic burning pain with red, hot, swollen feet and occasionally hands, triggered by heat and exercise 5
• Psoriatic arthritis: painful, swollen joints in hands and feet with dactylitis ("sausage digits") 5
• Connective tissue diseases (scleroderma): can present with hand swelling, Raynaud's phenomenon, and associated pulmonary hypertension 5

Diagnostic Approach

Key Clinical Features to Assess

• Duration: acute (DVT, infection, trauma) versus chronic (venous insufficiency, heart failure) 3
• Distribution: unilateral (DVT, local obstruction) versus bilateral (systemic causes) 3
• Pitting quality: present in venous insufficiency and heart failure; absent in lymphedema 2
• Associated symptoms: dyspnea (heart failure), pain (DVT, infection), skin changes (venous insufficiency) 3

Physical Examination Priorities

• Assess for jugular venous distension and cardiac findings suggesting heart failure 5
• Examine for skin pigmentation, varicosities, and ulcerations indicating chronic venous disease 3
• Check for unilateral versus bilateral distribution to distinguish local from systemic causes 5
• Evaluate for signs of liver disease (ascites, jaundice) or renal disease 6

Initial Testing When Diagnosis Unclear

• Basic laboratory tests: serum albumin, creatinine, liver function tests, urinalysis 6
• Chest radiography if heart failure suspected 6
• Echocardiogram for suspected cardiac dysfunction 6
• Duplex ultrasound for suspected DVT (sensitivity and specificity >80% for upper extremity DVT) 5

Common Pitfalls

• Avoid empiric diuretic therapy without determining the underlying cause, as this can lead to severe electrolyte imbalances, volume depletion, and falls in older patients 6
• Do not assume bilateral edema is always cardiac; chronic venous insufficiency is actually more common in patients over 50 1
• Recognize that upper extremity DVT may be asymptomatic and manifest only as catheter dysfunction or incidental imaging finding 5
• In patients with hand and foot swelling, consider psoriatic arthritis even with minimal skin disease, as severe arthritis can occur with little cutaneous involvement 5