Swelling in Athletes: Causes and the Link With Pharmacology
Puffy ankles after a flight, swollen fingers after a marathon, a "watery" look during a bulk: swelling is common in sport. Our editorial team explains the usual causes, how medicines and performance-enhancing drugs contribute, and which signs need urgent attention.
What oedema is and why athletes notice it
Oedema is swelling caused by excess fluid in the tissues. It most often appears in the ankles, feet and hands, but it can also affect the face, the abdomen or a single limb. Pressing on swollen skin may leave a dent, known as pitting.
Athletes tend to notice swelling quickly because they pay attention to their bodies, measure themselves and track weight. A ring that will not come off after a long run, puffy ankles after a flight to a competition or a "soft" look during a bulking phase are all common observations.
Much swelling is harmless and temporary. However, oedema can also be the first sign of a blood clot, heart or kidney problem, or a side effect of medicines and performance-enhancing drugs. That is why the cause matters more than the swelling itself.
This article reviews the most frequent causes in active people and explains how pharmacology fits into the picture.
Everyday causes linked to training and lifestyle
Heat makes blood vessels in the skin dilate, so hands and feet swell during warm-weather sessions. Prolonged standing, sitting during long journeys and the reduced muscle pump on rest days have a similar effect on the lower legs.
Local swelling is part of the normal response to injury, such as a sprained ankle or a muscle strain. Very intense or unaccustomed exercise can also cause temporary swelling of the working muscles.
Diet plays a role. A sudden increase in salt or carbohydrate intake, for example during carb-loading or a bulk, leads to extra water being stored. This is usually modest and resolves as intake stabilises.
Endurance athletes should know about exercise-associated hyponatraemia, a low blood sodium caused mainly by drinking more fluid than the body loses. Swollen hands and fingers, nausea, headache and confusion during or after a long event can be warning signs and require urgent medical help.
The pharmacological link
Several medicines and substances used in or around sport can cause fluid retention. The table summarises the main groups.
| Substance group | How it may cause swelling | Comment |
|---|---|---|
| NSAIDs (e.g. ibuprofen, naproxen) | Reduce kidney sodium excretion | More likely with regular use or dehydration |
| Corticosteroids | Sodium and water retention | Dose- and duration-dependent |
| Calcium channel blockers (e.g. amlodipine) | Dilation of small arteries in the legs | A known effect listed in product information |
| Anabolic-androgenic steroids | Sodium retention; oestrogenic effects of aromatising compounds | Also associated with raised blood pressure |
| Growth hormone | Fluid retention | Oedema and joint pain are well-documented adverse effects |
| Insulin | Sodium retention, especially at the start of treatment | Misuse in sport carries a risk of fatal hypoglycaemia |
A systematic review of growth hormone in healthy older people by Liu and colleagues found soft-tissue oedema to be one of the most frequent adverse effects. The Endocrine Society statement on performance-enhancing drugs also lists fluid retention and hypertension among the consequences of anabolic steroid misuse.
Creatine is often blamed for "bloating". It increases water inside muscle cells and can raise body weight by a kilogram or so, but this is not the same as tissue oedema and is not considered harmful in healthy people.
Warning signs that need a doctor
Some patterns of swelling require prompt assessment rather than waiting for them to settle.
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- One calf swollen, warm, red or painful, especially after a long journey or injury: possible deep vein thrombosis. Seek same-day care.
- Swelling with breathlessness, chest pain or coughing up blood: call 999, as this could indicate a clot in the lungs or heart failure.
- Swelling of the face, lips or tongue with difficulty breathing: possible anaphylaxis; call 999.
- Puffy eyes and frothy urine: may point to kidney problems.
- Swelling that is new, persistent or getting worse without an obvious reason.
When you see a doctor, mention all medicines, supplements and any performance-enhancing substances. This information can change the diagnosis and is treated confidentially.
Basic investigations may include blood pressure, urine testing, kidney and liver blood tests and, if a clot is suspected, a D-dimer test or ultrasound scan.
Managing harmless swelling
For simple, symmetric swelling related to heat, travel or standing, practical measures usually help. Move regularly on long journeys, raise the legs when resting and consider compression socks for flights.
Keep salt intake moderate, especially during bulking phases. Spread fluids through the day and avoid both dehydration and excessive drinking.
Review regular use of painkillers. If you rely on NSAIDs to train through pain, discuss alternatives and the underlying problem with a GP or physiotherapist.
Never use diuretics to remove swelling or to make weight without medical supervision. They can cause dangerous electrolyte disturbances and are prohibited in sport as masking agents.
Editorial conclusions
Swelling in athletes is usually linked to heat, travel, salt intake or minor injury and resolves on its own. Pharmacology is an important but often overlooked cause: NSAIDs, corticosteroids, blood pressure medicines and performance-enhancing drugs such as anabolic steroids and growth hormone can all cause fluid retention.
One-sided leg swelling, breathlessness or facial swelling with breathing difficulty are emergencies.
An honest conversation with a doctor about everything you take makes diagnosis faster and safer.
Further reading on our site: exercise-associated hyponatraemia, high blood pressure in athletes, and the side effects of growth hormone.
References
- Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013;88(2):102–110.
- Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.
- Liu H, Bravata DM, Olkin I, et al. Systematic review: the safety and efficacy of growth hormone in the healthy elderly. Ann Intern Med. 2007;146(2):104–115.
- Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015;25(4):303–320.
- Sica DA. Calcium channel blocker-related peripheral edema: can it be resolved? J Clin Hypertens (Greenwich). 2003;5(4):291–294.
