Hand Swelling

Experience from - Melanie Jonker , Sue Norwood , Gerry Wales , Jay Hodde#1 , Pete Petri , LeRoy , Mike Schupp , Karl King , Rich Schick , Randi Young , Ray Zirblis , Karl King#2 , unknown , Jay Hodde#2 , Ed Friedlander, M.D. "the Pathology Guy"

I have a real problem with swollen hands when I walk long distances. I do try and keep my arms bent to alleviate the problem but it still occurs. At the end of a walk my hands resemble a rubber glove that's been blown up. They feel very tight and it's hard to bend my hands to make a fist.

Does anyone else suffer from this?

How can I alleviate it?

Is it dangerous? (I hope not!!)

I've got the same problem in ultras and training runs after about four hours, and haven't determined a pattern except that it seems to occur more when it's cold. I've been told it is dehydration or too few electrolytes/salt, so I've experimented over the years with fluids (water vs. various types of beverages, drinking more, etc.) and the food/energy bars and gels, etc. I eat during the race or run. But I continue to have the problem of "fat hands" after some long runs. The swelling goes down fairly quickly after I'm done and there's no real discomfort, but I always wonder what's going on.

I'd also appreciate some enlightenment on the topic from others who experience this and/or have a brief and understandable scientific explanation (no dissertations required!).

Yes, yes, yes I do or should I say I did. My cause was lack of salt and lack of enough water while exercising. My cure was electrolyte capsules one for every hour of my run and plenty of water to go with them. Not only were my fingers swelling but my ankles as well. The swelling occurred within an hour of running and continued until about 30 minutes after I stopped.

There could be a couple of explanations for this (maybe more?) but this is what I've seen in my experience as an ultrarunner.

1. If you are walking / running properly, the centrifugal force generated by swinging your arms will gradually lead to edema in the hands. I see this to a minor extent in most every 100-miler I attempt -- the problem is later in the run, and usually during the cooler part of the day when I'm not sweating as much.

2. Electrolyte *imbalance*, mainly either too much or too little sodium. For most people, I would suspect the problem lies with too little salt, but for those using buffered electrolyte caps or other salt tablets, I've seen sodium overload occur (end up peeing a lot and you still can't get out all the water).

I have had problems with this in the past (the swelling of the hands), during warm or cool weather. I drink a lot, and, up till now, have used rock salt.

I tried the famous Succeed! Electrolyte Caps this weekend at AR...it was a cool day, probably never over 60. I took 1 cap after 1 hour, then every 1.5-1.75 hours after; I drank, on average, 1 20 oz bottle of water per hour. I didn't take in any other forms of salt, other than whatever sodium is present in a half cup of Coke every other aid station. I also ate app 1/4 banana at maybe 2 out of 3 aid stations, and had a cup of Chicken broth at Granite Bay. I thought this was a good balance, but after about 4 hours, I noticed the swelling again. I also peed freely the first 2 hours, but I don't think I peed at all after that. By the last hour, I noticed that the swelling was spreading down my hands to my wrists, which is a first.

So, I can't tell if this was from water retention from too much water, too much sodium, not enough...????

It seems simple at first glance, but this one gets more and more complicated.

I've had the same problem to some degree when I run. However, it is especially true when I backpack. I believe it is related to elevation and circulation. The blood seems to pool in those extremities at elevation. Since a lot of those ultras are done in the mountains at elevation of something just short of elevation I assumed (I know) that it was due to salt/water retention/elevation.

I'm a low-lander here around Kansas City. I experience the hand swelling during easy long runs if I am only drinking water. If I take a salt tablet each hour, even at moderate to cool temps or am consuming sports drinks and GU I don't have the problem. I almost always have the problem when walking for longer periods of time. I think with the walking it has to do with holding my hands down at my sides and not getting the "pumping" action with the muscles that is there with the running.

Thanks to Jay Hodde for a concise explanation of the consequences of too little and too much sodium. We had plenty of conversation about these topics on the Lists before. the Sodium discussion is at: Sodium

and the commercial info on electrolyte caps is at: Electrolyte Caps

Last year provided a lot of practical experience with electrolyte caps. What we saw was that early in the year most runners had lost their heat acclimation during Winter running and they needed lots of electrolytes to replenish their losses ( very salty on the sides of the face after a run ). Later in the Summer, after we got used to the hot conditions, our bodies were better at conserving salt and a lower rate of electrolyte replacement was adequate.

I've made a little project out of this and managed to recruit some outside brain power from the land of academia. Below is my letter of inquiry and the two responses so far. The short version, Thumbs down for the electrolyte imbalance camp, Thumbs up for increase pressure from centrifugal force and possible from the force exerted by heavy breathing.

Content of notes sent to Dr. Friedlander from Rich:

"Dr. Friedlander,
In keeping in the spirit of "Starling Equation" I would hypothesize that the increased centrifugal force created by the swinging arms would increase the Pc (capillary hydrostatic pressure). This maybe somewhat offset by the increase of capillary oncotic, but Pc should be the dominant force."

I hope you can help resolve a question which is now a topic of discussion amongst a group with a somewhat unusual pastime. Running long distances, mostly 50 - 100 miles but some events as long as 1300 miles. The problem is edema of the hands. It is painless, resolves in a day or two, and seems to have no long term ill effects. It only effects 5 - 10 percent of runners.

It seems to happen more in cold than warm weather. Theories have included electrolyte imbalances.

That doesn't make much sense physiologically.

Though I doubt this because people have won races and were still running strong at the finish and feeling fine, yet had the problem. Dependent edema - seems to equally effect those with high or low carrying positions of the hand. It seems to me to be an increased capillary permeability, but I can't come up with a good theory for cause no less prevention. Any ideas?

Thanks for your attention,
Rich Schick

I've noticed this myself, and attributed it to the centrifugal forces generated during running as the hands are moved rapidly, coupled with the intermittent unusually-high pressure in the subclavian veins from the heavy breathing.

I'm going to pass this along to our physiology and pathology interests groups. Perhaps one of our young people will know the answer.

Here's the only article that seemed applicable. Perhaps you could contact the authors as well.

Unique Identifier: 96093132
Authors: Cloughley WB. Mawdsley RH.
Institution Health Tour, Andover, MA, USA.
Title: Effect of running on volume of the foot and ankle.
Source: Journal of Orthopaedic and Sports Physical Therapy. 22(4):151-4, 1995 Oct.
Abstract:
Increases in volume of the lower extremities have been demonstrated in some exercises of short duration and varied intensities. The purpose of this study was to determine if running on a treadmill for 15 minutes increased volume of the foot and ankle when compared with walking. Twenty-one volunteers walked during one treatment session and ran during another session. Volumetric measurements were taken before and after each exercise. A change score was calculated for each subject for both sessions. A test for related measures demonstrated a statistically significant difference (p < or = 0.05), with a larger volume occurring after running. Increases in volume most likely would not create problems in healthy individuals. Increases, however, may be harmful in individuals with circulatory disorders or with edema as a sequela of a foot or ankle injury.

Regards,
Ed Friedlander, M.D.

Dana Roueche wrote:

"Based on my experience, hand swelling will happen in the absence of centrifugal force and heavy breathing. That leads me to believe something else must be causing it."

I'd have to agree with Dana, based on my personal experience. On high altitude mountaineering trips, I get edema (I guess) at night, and typically wake up in the morning with swollen hands for a few hours. Quite painful, but generally after a week it goes away. The temperature is typically extremely cold, for what it's worth. I have no medical or tech experience other than what I've picked up, but this seems like a different phenomenon than the "dead hands" or "foot falling asleep" I occasionally get hiking or running.

My uneducated, anecdotal sense is that swelling is related to fluid storage more than to centrifugal force. Maybe we are looking a two or three different phenomenon here.

If you dig into the physiology and biochemistry of the human body, you quickly find that it is wonderful and complex system that often has multiple modes for adaptation.

The swelling of hands and feet is likely to have multiple causes depending on the circumstances. Let's consider just a few. Others may find additional ones.

Electrolytes
The concentration of sodium in the blood must stay within certain limits.

If more sodium is lost through sweating than is being ingested, plasma sodium levels can fall to fatal levels. Before that happens, the regulatory mechanisms in the body will try to maintain viable levels. If sodium is too low, water must be "lost" through urination and/or transfer to extra cellular spaces. Water shifting into those spaces makes hands and feet swell. Swollen feet are much more prone to "black toenails". I used to get a few damaged toenails in each ultra. Since taking electrolytes, that has ceased and I now have 10 pink nails. We can see the swollen hands, but we are less aware of the swollen feet because they hidden in our shoes.

Jay Hodde ( an "academic" with *real* ultra experience ) posted recently on how excess sodium will be transferred, with water, to extra cellular spaces, also swelling those tissues.

Too little sodium, or too much sodium should both be avoided. Too much degrades performance, but too little is more dangerous in that it can be fatal.

Pressure drop
As Randi and Dana pointed out, climbing in altitude can cause swelling by means of physical pressure drop. It wouldn't seem that the drop would be enough to trigger that, but I got first hand experience in that last Summer while on training runs at Vail, Aspen and Leadville. A climb of 400 to 2000' would regularly trigger urination and slight swelling. Descending reversed the swelling and increased my thirst to make up the lost water.

Mechanical abuse
Last Summer there were questions about foot and ankle swelling after running the Vermont 100. My experience after finishing Vermont was that when I took my shoes off, I couldn't believe I was looking at my own feet and ankles. They didn't hurt, they were just swollen by an alarming amount. It took days for the swelling to go down. This, by the way, was before I started regular use of electrolytes during a run. My sodium intake at Vermont was insufficient, but not dangerously so. Jay Hodde posted what I think is the most plausible explanation, that the physical abuse from the roads led to increased capillary permeability. IE, the walls of the blood vessels allowed more water to "leak" into the extra cellular spaces. Jay's post can be read on Kevin Sayers' website. Also saved there is a post from Suzi T about wrapping after an ultra to counteract the swelling.

Endocrine status
The level of many hormones circulating in the blood changes dramatically during an ultra as a protective reaction to sustained stress on the body. This is a good thing, because it aids the body in surviving the abnormal workload being forced upon it by the mind. One effect of this action is to increase the blood flow to the skin and exercising muscles, while restricting blood flow to internal organs that are less important during exercise. Some wit might say that running an ultra clearly reduces blood flow to the brain, causing a lack of common sense. In any case, this shunting of blood for working muscle, or for cooling, puts more fluid in the extremities where it has a chance to permeate and collect.

Arm muscle contraction
The concept that centrifugal force is a factor seems rather weak to me. When you examine what your arms are doing when you run, you'll probably find that there are no strong forces involved. After so many hours of training, runners get very efficient in their body movements. Track speedsters have a high heel kick that nearly reaches the butt; ultra runners barely lift their feet. Novices run with considerable vertical bounce; ultra runners have virtually none. 100 yard dash runners like Carl Lewis have significant arm swing; ultra runners swing their arms very little, especially if the hand is holding a water bottle. The next time you're running, notice the amplitude of your own arm swing.

However, consider that an arm at rest hangs at one's side. While running, the elbow is bent at about a 90 degree angle. To hold that position, there must be muscle contraction in the upper arm. It could be that contraction allows blood flow into the forearm and hand, but impedes the return of blood from those areas. That "back pressure" could gradually force fluid into the extra cellular spaces, collecting in the lowest point, the hand and wrist.

The cold weather has nothing to do with it. I've seen it in several people where the outside temperature is in the 80-90 degree range.

There was a problem with this in many of the competitors at Ice Age last year -- increased electrolytes helped them a lot.

The problem, as I see it, is less a state of electrolyte depletion OR over hydration than it is a state of fluid-electrolyte BALANCE. There's a big difference.

Jay Hodde #2

Rich Shick wrote:

"I am seeing a common factor of the problem being worse in cold weather. To me that argues against the electrolyte involvement unless one were arguing that it was over hydration as the culprit. In that case additional salt would tend to hold the fluid in the blood vessels, but at the cost of running up the Blood pressure. The obvious solution would be decreased fluid intake."

I think that there is a *big* electrolyte component to this phenomenon, but I am not willing to say that it is due to excess or depletion of electrolytes OR a state of over hydration. Instead, I think it more an issue of fluid-electrolyte BALANCE than anything.

I've heard the centrifugal force argument from the exercise scientists for years. I still don't buy into it as being the major cause of hand and foot edema during ultras. Why? I used to swell, but I don't anymore. The key *for me* has been an increase in electrolyte intake.

Rich says that extra salt (due to over hydration?-- I admit, I'm a bit confused by what you mean) and fluid volume would increase blood pressure. I agree, but consider this: 1) During exercise, systolic blood pressure is already extremely high. I doubt that the increase due to any excess fluid would be noticed in clinical studies; 2) Diastolic pressure would also increase, and since the normal trend in exercise is a very slight elevation of the diastolic measure, you might see the effect here. Don't know for sure; 3) Blood Pressure is one of the most tightly regulated physiological parameters in the human body and is not the best indicator of perfusion imbalance (when a patient suffers from shock, blood pressure is one of the last signs to drop -- if the BP is off, you know there is a severe problem).

Over hydration alone is not likely the problem, as if everything else is in "balance", excess fluid will not be absorbed, reabsorbed by the kidney and you'll just pee it out. Often.

I feel that electrolyte levels are important to this phenomenon, and equally important, the body's production of stress hormones and ADH.

A question that I feel needs to be addressed:

• What is the nature of the swelling? Is it occurring within the cells, or is it in the pericellular space?

The popular explanation within the sport is the electrolyte imbalance theory. If that were true, then hand edema would be typical of people in the hospital who have electrolyte problems. It's not.

Ed's Pathology Notes:

http://worldmall.com/erf/lectures.htm

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