Chapter: Consultation hour
Article: 2 of 12
Update: Feb 24, 2021
Author(s): Wohlgemuth, Walter A.
Increased tissue pressure in the presence of pathological venous and lymphatic vessels, particularly in the lower extremities, leads to a feeling of pressure and tension in the affected leg (especially in the calf and foot). This is typically exercise-related and worsens in the evening and with strenuous physical exertion.
Increased tissue pressure, usually due to chronic venous hypertension or chronic venous insufficiency, is caused in most people by chronic venous disease. Superficial dilated varicose veins (varices) are a frequent accompanying symptom, as the venous walls on the surface of the legs cannot withstand the increased venous pressure and the veins therefore dilate with bulging of the stressed vein walls. The same principle applies to patients with lymphedema, as the superfluous tissue fluid is not sufficiently removed by the lymph vessels and remains in the leg. This increases the tissue pressure, resulting in a feeling of heaviness, pressure or tension, which can become painful if the patient stands or sits for a long time without moving.
The pressure of the tissue fluid increases from top to bottom towards the feet because of the higher hydrostatic pressure when a person is in an upright position. This is comparable to a water column, i.e., an upright standing pipe filled with water. Here, the pressure of gravity increases accordingly from top to bottom. Therefore, the feeling of heaviness and pressure is felt most strongly in the feet and calves, less so in the thighs.
The same therapeutic principles apply to patients with classic secondary venous hypertension as well as lymphatic hypertension. In patients with increased tissue pressure caused by pathological vascular changes, especially in the lower extremities, the feeling of pressure and tension as well as the pain, which worsens in the evening and with strenuous exercise, can be significantly relieved by compression, elevation and intermittent exercise. This is especially true for patients with venous and lymphatic malformations.
Typical features are the slow increase in symptoms during physical exertion and long periods of standing or long, immobile sitting, especially towards the evening and during periods of high physical exertion and stress. High-pressure-induced tissue edema can result in increasing swelling in the evening, especially of the lower leg, ankle and foot. Finally, there are skin signs of chronic venous insufficiency.
Those affected need to avoid long periods of immobile sitting and standing (almost always for work reasons) without any movement. In practice, this means not sitting or standing motionless for more than 15 to 20 minutes, changing position regularly and, above all, walking for 1 to 2 minutes and only then sitting down again.
Intermittent elevation of the affected limb is also helpful, especially when a person is working at a computer or in the office, as it reduces the vascular pressure in the limb. This is particularly helpful in the case of venous malformations, as the bulging venous spaces can drain more easily when the limb is elevated (pressure relief). Practically, when sitting, the affected leg should always be placed on a chair or the affected arm should be placed over the head for a certain period of time.
Video: High venous pressure within a venous malformation. The high pressure is visible from the rapid blood outflow after direct needle puncture of a venous malformation prior to minimally invasive therapy. © Wohlgemuth
Avoiding periods of very intense physical activity (fast running) or very long periods of moderate activity (long jogging) during periods of high tissue pressure is helpful. Long walks, on the other hand, can be beneficial, as the muscle pump is particularly efficient at removing increased lymph fluid and edema from the lower extremities by pumping out the leg veins. In times with few symptoms, when the affected individuals are doing well, strenuous physical exertion is also possible in principle.
However, the most important element is appropriate compression therapy. Compression leads to the application of counterpressure from outside against the leg. This promotes the removal of blood and tissue fluid such as lymph to the central body parts and reduces the pressure. The legs swell less, are less painful, standing time is longer and the superficial vessels do not dilate as much. Some of the skin changes can also be reduced or reversed.
Good control of body weight is also essential here. The greater the body weight, the higher the tissue pressure in the legs. Weight loss alone can be very beneficial in a patient with heavy legs.
In severe cases, however, it is necessary to repair the underlying vascular defect by invasive means.