Leg Swelling

Experience From - Rich Schick , Bob Pearson , Jay Hodde , Suzi T , Bonnie Busch , Hartmut Franck, MD.

Rich Schick

I wouldn't lose any sleep over it, probably just dependent edema. Simply the effect of gravity. Running actually minimizes the problem. The East block countries used to make folks stand stationary for long periods (24-48)hours as a form of torture, these folks would get so swollen they couldn't bend their knees. Elevating your legs and avoiding stationary standing will help this resolve quicker.

Bob Pearson

I ran a 24 hr track run 5 days ago and also now have swelling of my lower legs and ankles. Other than some expected muscle soreness, I have no other problems associated with the run.

The swelling is edema (accumulation of fluid between the cells) and it definitely indents when pushed on. My edema is in both legs, but worse on the left and is primarily on the inner shin. I had no edema until 2 days after the run.

The most common causes of edema are

  1. increased capillary pressure
  2. increased capillary permeability
  3. reduction of plasma proteins (hypoproteinemia)
  4. lymphatic obstruction.

I am not a physician (I'm a veterinarian), but I will give my best guess as to what is happening. The edema in my legs is in the subcutaneous tissues and I doubt it is associated with muscle injury. I would be guessing that when we run distances of 100 miles or more we somehow damage the capillaries in our lower legs and this increases the capillary permeability. With increased permeability, fluid (but no cells) leak from the capillaries into the intercellular spaces.

I am wondering if when we are vertical (running) for 24 hours that blood may tend to pool more in our lower legs than normal. With chronic pooling of blood in our lower legs it may tend to increase capillary pressure which damages the capillaries. This eventually results in edema.

Well, that's my un-researched assessment of this syndrome. We need to give it a name. If three people have already reported having it on this list, I'm sure many more have experienced it. How about SEA-24 Syndrome (sounds official, I think) --- Stands for Shin Edema After 24 hr runs.

Jay Hodde

Subject: Swelling leg after VT100

Dave and many others wrote:

"I'm curious too as my calves and feet are really swollen to the point of moderately severe discomfort. I haven't been able to get into shoes since Sunday. I don't seem to fit in (again). I was able to wear shoes on Monday morning, which is rare for me. Usually, it takes a couple of days for the swelling to go down.

Even though I have no scientific proof of what is happening, I'll contribute my hypothesis (this is how I have explained it to myself in the past).

When I run, blood flow is increased to the working muscles. Along with this increase in blood flow comes an increase in capillary permeability. Tissue damage also leads to changes in vessel permeability (just like when you swell after an injury). When I am running, blood flow is great enough (in most cases) to allow removal of the leaking fluid, but when I stop, it is not. Since I don't rest with my feet above my head, gravity contributes to the swelling, too.

I would then say that the swelling is due to:

  1. Increased capillary permeability associated with exercise and injury.
  2. A failure of the body to adequately remove that fluid upon cessation of exercise.
  3. Gravity dependent edema.
I think the problem may be exaggerated at Vermont and other events that are primarily road courses. The surface is harder, and more damage occurs to the legs (at a microscopic level).

Suzi T

Well Bob, I can tell you SEA-24hr also occurs after a 46:45 at Hardrock! Is it almost twice as bad? Not really. I've never run a 100 without experiencing some SEA-24hr. Out of the thirty plus runs that includes, some left just a wee bit of swelling, while I remember one Barkley 34 hour that made my ankles, calves, and knees all the same size as my quads!

I have learned to treat myself like I would treat a good racehorse post race. You know the old RICE rest, ice, compression and elevation of course. Some runners don't take this seriously until AFTER the crisis has occurred. I go prepared to a hundred because I KNOW it will happen. Especially if I'm looking at another 100 coming up in a month or so. I have to start recovery right away. I think I fine tuned the method during the Grand Slam in '89.

First step is cooling those legs down. A racehorse comes back to the paddock and the grooms and hot walkers go to work. They hose those legs with cold water and then use alcohol or a rub like absorbine, along with a good massage.

I like to take a moment in the post run shower, (usually sitting on the floor because I don't want to stand on THOSE feet) to massage the legs. Especially the area along the shin where you can feel the tendon sheath and gauge it's tenderness. Baby oil makes this process easier as well as soothing. Willow scratches from Hardrock added an extra dimension here ;)

Then you apply the compression before you lay down for that much needed first nap. I use ace bandages, one roll of 4; and one of 6 for each leg. The 4 goes from toes to just above the ankle, while the 6 overlaps that and goes up to just below the knee. If I have to work on my feet for 8-10 hours the day after a 100, these wraps are a life saver. The second and third day can really be painful due to swelling if you can't keep your feet elevated.

The airlines just hate it when I put my feet on the food tray during my coast to coast flight home.

Just as important as the wrap, is the ice therapy. You can do a form of ice therapy any where, if you just get resourceful. The best I've found in the hotel situation is two hotel room trash cans placed in the bath tub, filled with water and ice I could sit on the side of the tub, and cool both legs at once.

I usually include a few freezer strength large plastic baggies in my packing, for the mobile ice pack. Whether you are driving or flying, you can take a cold pack with you and refill with ice as needed.

I believe in drugs, so I add non steroidal anti inflammatory drugs to this regimen, but I honesty believe the key is tincture of time.

The distinct swelling of the anterior tibial tarsal tendon, along the shin bone, is a phenomenon Dr. Bob Lind at Western States said was entirely indigenous to 100's. He even wrote an article about it in a medical journal, but said most physicians would be hard pressed to recognize it for a transient occurrence. Gene and I have both had some nasty cases of it, including bright red color and crepatis (sic) crackle feeling in the tissue.

Anyway, boys and girls, the bottom line is, this to shall pass. With alternating rounds of ice, re-bandaging, massage, elevation, and plenty of rest, it just goes away.

Bonnie Busch

Thanks, Suzy "T" Cope! I found her comments on target as how to avoid leg swelling after an ultra. The recovery from a run can start in the very late stage of the race or immediately thereafter.

A couple of additional thoughts on the subject- Getting some exercise while recovering can also help. Yes, I too know people that avoid it, but I find that some slooow running (neighbors would describe it as brisk walking) or some other activities (cycling, stairs, etc.) can help push the fluids out of the muscles. The duration, the activity, and effort should all be determined based on how you feel, not a watch or measured distance.

Warm temperatures, humid conditions, and eating habits (and damage or injury go without saying) can make a difference on how much swelling I experience.

Shoes worn after an ultra can also contribute to a bad situation. I seldom make the mistake of putting on a normal pair of shoes on Monday when I go to work any more, only to feel like the seams are leaving permanent marks on my feet by noon. Wear or take along a bigger pair of shoes so as not to restrict a portion of your foot. Tight socks also can be a cause of discomfort.

Frozen bags of peas are my choice if icing is necessary.

Support hose and 1 1/2 inch heels in Moline, IL with temperatures of 90 and matching humidity.

Hartmut Franck, MD.

I was very moved by what happened to Joel Zucker. The cause of his death the day after finishing his 3rd Hardrock 100M is still not public. Tissue damage during a 100M run increases dangerously the risk of single or multiple organ failures like cardiovascular, pulmonary failure or renal shutdown etc., depending on our state of health when we enter such an event. I would like to contribute to the understanding of the mechanisms and possible dangers of ultra races.

Damage to tissue in our body is called trauma. There is a bunch of factors that causes tissue trauma in aerobic endurance workouts like a 100M races: Oxygen radicals (O-), ozon (O3), hypoxemia (lack of oxygen, only in higher altitude races like Hardrock, Leadville), peroxynitrite (metabolic product of NO radical and oxygen radicals), toxic metabolites (accumulated in case of insufficient kidney clearance), activation of coagulation and inflammation cascades and dehydration. Hypoxemia for example can be the initial trauma cause, making tissue all the more sensitive to free radicals. All factors potentially lead to shock, which further increases trauma in a vicious circle. Antioxidants like Vit. E and C do help during endurance aerobic workouts, but trauma will occur in any case at least to a certain extent. Tissue trauma happens in all organ systems of our body. It results in membrane breakdown of cells. In a 100M event, when we run in good shape from the start to the finish, trauma at least occurs in muscles and capillaries. Radicals bind to the cell membrane, start the breakdown processes, than phospholipases start in, produce arachidonic acid, inflammatory metabolites like prostaglandins and leukotriens build up and increase the permeability of capillary membranes. The result is that in a vicious circle leaking holes open up in the membrane, which let water, electrolytes, and if big enough even the osmotic carriers like albumin and other plasmaproteins pass into the space outside the vascular system, between the cells. This is called edema.

Back to the point. When edema occurs during and immediately after an ultra, but disappears within 3 days, it is mostly based on leak of water and electrolytes. The capillary membranes heal within 1-4 days. The plasmaproteins, which are lost into the tissue, can not be recovered. So, leg swelling that occurs later than that time frame, indicates either one or both of the 2 following points:

  1. Significant dehydration was persistent or even increased after the race. After a 100M, because of the fluid shift between intracellular and extracellular space (one of the mechanisms how the body responds to dehydration) we need to drink 2-3times as much as normally for 2-3 days and need adequate sodium intake. The point is, if you're dehydrated for 2-3 days after the race no edema will show up until your fluid volume is back to normal. So, when you notice late edema, you might need to improve hydration during and up to 24 h after the race. If edema increases to a dangerous point you need to balance your fluid and salt intake carefully, of course. But early prevention of dehydration is the goal. This will prevent further trauma.

  2. I would like to confirm this by actual blood albumin level measurements, every runner appears to loose moderate to significant amounts of plasmaproteins by capillary trauma over 100M. A decrease of plasmaprotein concentration in the cardivascular system lowers the onkotic pressure of the blood, in consequence the balance of fluid leak out of the capillaries and reabsorption back from the tissue into the distal capillaries is offset. This balance is regulated by hydrostatic vascular pressure, tissue pressure and onkotic (osmotic) pressure. Offsetting the balance causes that not all the fluid leak can be reabsorbed into the vascular system. Fluid, or edema is left behind. The hydrostatic pressure is responsible for edema showing up in the lower parts of our body, only. Hydrostatic pressure is a function of gravity. So edema of every cause will show up in the lower legs if we are sitting or standing.

    Since the symptom leg swelling is a function of the balance, a decreased total amount of plasmaprotein in our vascular system won't show up as long as we are still dehydrated (!).

    The liver needs to syntesize new plasmaproteins, which, depending on synthetic liver function and the amount of proteins lost, takes 2-14 days. So, avoiding liver damage by e.g. alcohol, and boosting protein food intake makes sense early during recovery.