Clinical exam · General exam and vital signs

Edema: pitting, grading and distribution !

Sign

Swelling from fluid in the tissues: how to look for pitting, how to grade it and what its site tells you.

Updated 2026-11-01

See it in 3D: Skin · Tibia

What it is

Edema is the build-up of fluid in the interstitial space. It occurs when capillary hydrostatic pressure rises, plasma oncotic pressure falls, capillary permeability increases or lymphatic drainage is blocked. It is described by distribution (localised or generalised, one or both sides), whether it pits, its severity and its temperature and colour.

Key facts

1+: slight pit, about 2 mm, that disappears quickly.
2+: pit of about 4 mm that disappears in a few seconds.
3+: deep pit, about 6 mm, lasting around a minute.
4+: very deep pit, about 8 mm, persisting several minutes.
These values are teaching approximations; many institutions use their own scale.

The anatomy it tests

Fluid collects in the subcutaneous tissue; pressing against bone (tibia, malleolus) pushes the fluid aside and leaves the pit.
Starling forces: capillary hydrostatic pressure against plasma oncotic pressure; the lymphatics drain the excess.

How to elicit it

Inspect both bare legs, comparing size, colour, skin shine and lesions.
Press firmly with the thumb over the top of the foot, behind the medial malleolus and on the front of the tibia for about five seconds.
Lift the thumb and look and feel for a dent, its depth and how long it takes to fade.
Move up the leg to find where the edema ends (ankle, knee, thigh).
In bedbound patients check the sacrum; also look at eyelids, hands and abdominal wall.
Feel temperature and tenderness and compare calf circumference if it is asymmetric.
Record the distribution, whether it pits, the grade and the level it reaches.

What a positive result means

Right heart failure: bilateral, evening, dependent edema with raised jugular venous pressure.
Nephrotic syndrome: soft edema, in the eyelids in the morning, that can progress to anasarca; due to low albumin.
Cirrhosis: leg edema with ascites from low albumin and portal hypertension.
Deep vein thrombosis: unilateral edema with pain and a larger calf circumference.
Chronic venous insufficiency: evening edema with ochre dermatitis and varicose veins.
Lymphedema and myxedema: firm, non-pitting edema.
No edema does not rule out early fluid overload; daily weight is more sensitive.

Usefulness and limits

Grading has limited agreement between examiners; describing the level reached and its change is more useful.
Doppler ultrasound confirms deep vein thrombosis when edema is unilateral.

Test yourself

Think of the answer, then tap the question to see it.

Where is edema looked for in a patient who stays in bed?

Over the sacrum and back, because fluid collects in dependent areas.

What does unilateral leg edema with pain and warmth suggest?

Deep vein thrombosis or cellulitis, rather than a systemic cause.

Which type of edema does not pit?

Lymphedema and myxedema, because of protein or mucopolysaccharides in the interstitium.

What mechanism explains edema in nephrotic syndrome?

Loss of albumin in the urine lowers plasma oncotic pressure and fluid moves into the interstitium.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

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Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: Cardiovascular Examination - Cardiology - MSD Manual Professional Edition (Merck & Co. (MSD Manual Professional Edition), 2025); Swelling: MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine (MedlinePlus), 2025).

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Representative model, for educational purposes only.