- Get Rid of Cankles for Good With These 7 Methods
- 1. Weighted calf raises
- 2. Jumping rope
- 3. Cankle-lift treatment
- 4. Plié squat and calf raise
- 5. Avoid sodium-rich foods
- 6. Hemorrhoid cream
- 7. High-knee jog in place
- 3 Reasons Women Get Cankles
- Try Amanda’s meal plan
- Nicki’s workout
- From This Episode:
- Ankle Sculpting Is A Thing And It’s As Wild As It Sounds
- How to get bigger calves: 5 tips
- Treating Cankles
- Physical examination
- An alternative approach: botulinum toxin
- Lipedema Treatments
- The brutal truth about cankles
Get Rid of Cankles for Good With These 7 Methods
Most people would be lying if they said they found chunky ankles an attractive asset. And if you’ve ever wondered why some people have been cursed with cankles, you’re not alone. According to The Dr. Oz Show, aside from being genetically predisposed to them, cankles can occur when a person’s weight gain increases fat stores in the leg, which are then pulled down by gravity. Cankles can also occur when your body retains too much fluid, causing the tissues in the lower calf and ankle to swell. This is common during pregnancy, or it can be a symptom of kidney disease, heart failure, a blood clot, or a blockage in the lymphatic system.
If you’re someone who struggles with unsightly cankles, we’ve got some tips for you to try. So, don’t toss those strappy sandals and sexy high heels just yet. Here are seven ways to get rid of cankles that actually work.
1. Weighted calf raises
Try getting rid of your cankles with these ways that actually work. | iStock.com
This exercise from Healthline requires either dumbbells, kettlebells, or a barbell, and it works the superficial calf muscle (gastrocnemius), and deep calf muscle (soleus). Begin standing straight with your feet shoulder-width apart, arms hanging down by your sides with a weight in each hand. Be sure your arms are extended and your shoulders relaxed, and then shift your weight onto the balls of your feet. As you raise your heels off the ground, press your weight down and push your body upward. Hold this position for a brief moment at the top, then slowly lower your heels back to the ground in one smooth, fluid movement. Be careful not to lock your knees; keep them slightly bent and maintain an athletic position. Healthline recommends doing three sets of 15 reps with a weight in each hand.
2. Jumping rope
Jumping rope can help reduce ankle fat. | iStock.com
Jumping rope is more than a great cardio workout — it can also be a useful hack for slenderizing your ankles, or at least making them appear as such. This exercise, The Dr. Oz Show says, will tone your calves to make your ankles look smaller. If your gym offers it, try taking a class that will target this problem area specifically or commit to jumping rope for 10 minutes a day.
3. Cankle-lift treatment
You can even get surgery. | iStock.com/tixti
Yes, you read that right. But be warned, this is a very new procedure and is not a foolproof solution. The Daily Mail reports that the procedure is offered by Professor Syed Haq at the Invictus Humanus clinic and is virtually pain-free. According to the article, “Microscopic threads are inserted into the hypodermis, the inner layer of the skin that contains the fatty deposits. The threads are made from polydioxanone (PDO), a colourless, crystalline, biodegradable synthetic polymer. They have been used in suturing in surgery for more than 20 years and are broken down naturally by the body over time, so the effects of the cankle-lift will last between two and three years.” While the story reported a handful of women were pleased with their cankle results, there isn’t any more conclusive evidence. We’ll let you be the judge, but hey, maybe one day a cankle-lift will be the new face-lift.
4. Plié squat and calf raise
This exercise really helps. | iStock.com/javi_indy
This move, according to Shape, should have you from sneaker to stiletto in no time. Begin with your feet wider than hip-width apart, with toes slightly turned out and hands on your hips. Bend knees over your toes to sink your body into a squat position. Holding this position, raise your heels off the ground without raising your hips. Slowly press them back down 10 times in a row, returning to standing position to complete one rep.
5. Avoid sodium-rich foods
Cut back on junk food. | iStock.com
While fluid retention is a main cause of a sudden onset of chunky ankles, it’s usually due to sodium intake or pregnancy, Dr. Caroline Cederquist tells Women’s Health. While compression socks can temporarily relieve swelling, a person’s diet needs to be addressed to really see long-term results. Cederquist recommends avoiding sodium-rich foods, such as processed and fast foods. Staying hydrated can also help prevent fluid retention. If cankles are the result of pregnancy, be sure to discuss it with your doctor.
6. Hemorrhoid cream
Surprisingly, this really can work. | iStock.com/CrailsheimStudio
Although it’s not a good long-term solution, if you’re looking for a quick fix for a night out, hemorrhoid cream might be the way to go. According to The Dr. Oz Show, these products can temporarily firm and tighten the skin. Just be sure to consult your doctor before using any new remedy or supplement.
7. High-knee jog in place
High knees can help slim down your calf muscles. | iStock.com/LarsZahnerPhotography
As part of a full workout, Women’s Health breaks down a simple exercise that targets your lower leg muscles. Start in a standing position, and raise your left leg and your right arm in front. Then, hop and switch so that your right leg and left arm are in front of your body. Throughout this running movement, the focus should be on staying on the balls of your feet.
3 Reasons Women Get Cankles
The word “cankle” was made popular in 2001 when Jason Alexander’s character in the movie Shallow Hal used the term to criticize an overweight women’s lower leg saying, “It’s like the calf merged with the foot, cut out the middleman.” Although the term is cringe-worthy, for some women, developing thick ankles could be more than just a cosmetic problem. Here, three distinctively different types of cankles and what can (and cannot) be done to get rid of them.
1. Genetic Predisposition
Many women who have cankles are genetically predisposed to this type of lower leg, meaning that if one of your parents had oversized ankles, you might have inherited them too. This may be caused by obesity or the structural absence of a well-defined calf muscle-even if you are physically fit.
What can I do? I’m not a proponent of this type of procedure, but surgery may work. Many women have gone under the knife in what is known as ankle liposuction. This one-hour, outpatient surgery is becoming extremely popular with women hoping to reduce their ankle circumference. However, with every surgery there are risks and nothing is guaranteed.
Will exercise help? As I’ve said time and again, you cannot spot reduce! This idea is still around, even after exercise physiologists and the medical community have proven that it cannot be accomplished. If you are predisposed to this body type, embrace the body you have and focus on nutrition, wellness, and sticking to a exercise regimen that is fun and boosts your confidence.
2. Fluid Retention
Fluid buildup in the ankle generally comes from a heavy sodium intake; it’s a pure reflection of one’s dietary habits.
What can I do? If you notice that your ankles have begun to swell and/or feel as though you are retaining water, visit your physician or schedule an appointment with a registered dietitian. Remember that 80 percent of your overall wellness is based on what you eat, not what you do physically.
Will exercise help? A structural wellness plan can be established with a certified personal trainer. But again, you cannot spot reduce-exercise is just part of the equation. Walking, running, hiking, or simply taking the stairs instead of the elevator will contribute to a healthy overall lifestyle.
My wife recently gave birth to our son Max, and I had the personal pleasure of witnessing the physical changes of a woman during pregnancy. During those nine months, my wife’s ankles swelled a great deal, which is quite common due to poor circulation.
What can I do? To help minimize swelling, avoid high-sodium, processed, and fast foods.
Will exercise help? Stay active. Regular exercise throughout pregnancy promotes circulation, just be sure to consult your OB/GYN before starting any fitness program. Massage and elevation also help with circulation and fluid retention.
Try Amanda’s meal plan
A SLIM ankle has been a mark of beauty for centuries. So it was only a
matter of time before the cankle – the calf merging with the ankle – claimed
its place beside the muffin top, love handle and saddlebag as another
problem area we are expected to sort out.
Here Sun fitness expert NICKI WATERMAN – who has guided the workouts of
slim-legged stars such as Denise Van Outen, Rachel Hunter and Kelly Brook –
and Sun nutritionist AMANDA URSELL tell you how.
OFTEN, especially if you are slim yet still have cankles, salt is the culprit.
When we eat more salt than our bodies need, we store water to help dilute the
salt levels in our blood and keep them within normal limits.
This water can pool around our ankles, which leads to a loss of definition of
A low-salt diet may not get rid of cankles completely but it can help to stop
them “bloating” which is a good starting place.
Currently women in the UK eat an average of around 9g of salt a day in our
diets. The Government recommend that we should reduce this to 6g a day.
If we can take this even lower and get right down to 3g, experts believe we
can lose up to ONE AND-A-HALF LITRES of excess water.
Not only does this show on the scales as a 2lb TO 3lb weight loss, it
can help you to de-bloat in lots of areas including your tummy, wrists and
Eating plenty of fruits and vegetables, which are rich in potassium, can also
help naturally balance body water.
Around 70 per cent of our salt intake comes from processed foods such as
bread, breakfast cereals, ready meals, takeaways, soups, pies, biscuits and
An important factor to keep in mind when buying prepared food is the way salt
is labelled on the packaging.
Some nutrition charts tell you the grams of salt the product contains. Others
tell you the milligrams of sodium.
To convert milligrams of sodium into grams of salt you need to multiply the
sodium by 2.5. For example: 1g of sodium = 2.5g of salt.
On a nutrition label a product containing 0.25g of salt (0.1g of sodium) is
“low”. A food containing 1.25g of salt (0.5g sodium) is high.
The best advice is to get back to basics and to start eating simple home-made
meals and snacks.
Below is a low-salt diet plan to cut down to just 3g of salt daily.
As far as fluid intake is concerned, it is a myth that drinking too much water
leads to fluid retention.
If your kidneys are in good working order, this is not the case.
Try to drink water at and between meal times and stick to around three to four
cups of caffeine-containing beverages such as tea and coffee during the day.
Green tea is believed to help to speed the metabolism and burn fat. The
effects are probably quite minimal but drinking three or four cups a day
will certainly do no harm. And green tea is rich in potentially
health-boosting antioxidants. Steer away from smoothies, fizzy drinks,
squashes and alcohol. They all add unnecessary calories if you are trying to
A natural tendency towards having cankles can be made worse if you are
carrying excess weight because it increases a tendency to swelling and an
accumulation of fat in this area.
The meal plans below, which help to lower salt, are also around 1,250 calories
and will assist almost all women to shed a good 2lb of body fat per week.
The more weight you have to lose, the more weight you will shed initially.
A combination of fat and water loss can lead to a weight loss of 5lb to 6lb
within seven days and hopefully a sleeker silhouette to your ankle, just
like the shapely pins on Kylie Minogue.
Breakfast: Porridge with a banana and sprinkling of toasted sunflower
Mid-morning: Handful of dried apricots.
Lunch: Plain pasta mixed with drained tuna, tomatoes, cucumber and red,
yellow or green peppers.
Mid-afternoon: A handful of unsalted cashew nuts.
Dinner: Jacket potato with ricotta cheese, mixed with cooked frozen
sweetcorn and lots of your favourite salad with balsamic vinegar. Big fruit
salad with plain yogurt for pudding.
Total: 1,250 calories and 3g salt.
Breakfast: Sugar-free muesli with skimmed milk and a grated apple
topped with a blob of fromage frais.
Mid-morning: A pear and a banana.
Lunch: Rice salad made from boiled and cooled rice with cooked chicken,
peas and other favourite vegetables.
Mid-afternoon: Total 2 per cent fat Greek yogurt with runny honey.
Dinner: Grilled lean steak with boiled new potatoes and your favourite
vegetables. For pudding, baked apple with low-fat custard.
Total: 1,250 calories and 1g salt.
Breakfast: Two Oatibix with some berries such as chopped strawberries
and skimmed milk.
Mid-morning: Slices of melon and grapes.
Lunch: Couscous with chickpeas (canned in water and drained) plus
vegetables of your choice such as mange tout and aubergines.
Dinner: Plain noodles with grilled salmon steak, served with roasted
vegetables such as tomatoes, peppers and mushrooms.
For pudding, mango and pineapple salad with fromage frais.
Total: 1,250 calories and 1g salt.
NICKI SAYS: I found combining cardio, jumping and stretching with weight
training gives you a great cankle-blasting workout.
My programme includes daily brisk walks of 30 to 60 minutes and a series of
squats and lateral jumps, ankle circles, calf raises and downward dog yoga
Give it a try.
1. Move in bed before you get up: When you wake up in the morning lie
in bed and circle your feet. This will get the blood circulating and warm up
your ankles for the day ahead.
2. Stretch out before your shower: Once out of bed, stretch those
Stand on the stairs or any incline and let your heels hang off the edge. Raise
and lower yourself slowly.
You will begin to feel the stretch in the back of your calves.
Hold a wall for balance and keep your abdominal muscles tight.
3. At work: Elevating your legs at the office may not be a possibility.
Instead try resting your elbows on your knees. Now lift your heels as high
as they will go, while digging your toes into the floor. Lower them back to
the floor and repeat several times during the day.
4. In the evening when you get home, do the heel/toe walk:
Find a space wide enough to walk comfortably up and down and about five metres
Stand at one end of this space and walk to the other on your heels, then
slowly lower on to your whole foot.
Turn around and walk back to the start on your toes, then slowly lower back on
to your full foot.
Repeat this until until you can feel your calves and ankles aching and make a
note of how many times you walked up and down. Do the same amount of
exercise every other evening and increase the repetitions each week.
5. Do the “plié squat” on tip-toes in front of the telly: Stand with
feet wider than shoulders, toes out at a comfortable angle, hands on hips.
Rise on to the toes, bend knees and lower as far as possible into a plié
squat, keeping knees in line with the toes. Press back up.
Try to stay on your toes the entire time. Repeat 20 times. Aim to complete
6. Jump squats: Stand with your feet slightly wider than shoulder-width
apart, keeping knees slightly bent. Squat slowly then jump off the ground,
landing back in the start position. As you land, make sure your knees are
bent to absorb the impact. Aim for three sets of 15 reps, taking three
seconds to squat down and one to jump up. Breathe in as you slowly lower
your body and out as you jump.
Most women will admit to experiencing the mysterious phenomenon known as “cankles” at one time or another in their lives. If you happen to be one of the lucky ones, the “thick ankle” fairy will only visit you while you’re pregnant. But if you’re anything like me and haven’t seen your ankles for quite some time, then you’re probably cursed with the dreaded cankle syndrome.
What are cankles?
While not a formal medical term or diagnosis, the word “cankle” is a slang word combining calf and ankle. It defines the part of the leg where the ankle meets the calf and when there is no definition or indentation — in other words, the calf doesn’t taper down to the ankle.
More: Mom Shares Story of Accidentally Starving Her Newborn
What causes cankles?
Pregnancy is usually the first thing that comes to mind when women talk about their ankles disappearing. But what many people don’t realize is that there are several other explanations for why their ankles have gone on vacation without them.
Looks like this is one more condition we can blame on our parents, grandparents and great-grandparents. Some women just have naturally larger bones/ankle joints and thicker calf muscles, which can be blamed on our genes — something we obviously cannot change. So if you are genetically predisposed to have a straight lower leg with no shape or curve, then there may not be a whole lot you can do to change the appearance of your ankles. And if you’re already at a healthy weight, eat well, exercise regularly and keep an eye on your sodium intake, then it may be time to just embrace your cankles.
If your body retains too much water, it can cause swelling in areas such as the lower calf and ankles. This gives them the appearance of fluid “pooling” in the ankles, which can be caused by poor circulation, sodium intake and pregnancy among other conditions. If this happens to be the cause of your cankles, it’s best to steer clear of sodium-rich foods (especially processed snack foods and fast food) and focus on getting plenty of fluids (water, not sodas and soft drinks) throughout the day.
More: What to Do When a Baby Just Stops Breastfeeding
Pregnancy causes your body to retain fluid, which in turn, creates the appearance of wide ankles for most women. If cankles are not something you normally deal with, this extra fluid that pools around the ankles usually resolves after the baby is born.
The heavier you are, the more likely cankles will appear. As you gain weight, your body increases fat stores in several areas of your body, including your legs and ankles. Cleaning up your diet, exercising and losing a few pounds may all help.
Certain medicines may also cause your legs to swell: antidepressants (including MAO inhibitors and tricyclics), blood pressure medicines called calcium channel blockers, steroids and hormones such as estrogen (found in birth control pills or hormone replacement therapy) and testosterone. Consider talking to your doctor about whether you can switch to a similar medication without the unwanted side effects.
More: The Weird Breastfeeding Problems No One Tells You About in Birthing Class
Do I need to worry?
Most women who deal with cankles have no reason to worry about any significant medical problem; however, if your cankles appeared over a short period of time, are progressively worsening, are painful or swollen, feel much warmer or cooler than your other skin or if the overlying skin is red, you should see your doctor. Medical conditions such as kidney disease, liver failure, heart failure, blood clots and others can all increase fluid retention, especially around the ankles.
Haven’t seen your ankles for a while? You could be suffering from the dreaded cankles. Many women complain about this common problem, when graceful ankles thicken and the calf appears to merge with the ankle. Learn when this problem is more than just cosmetic and what you can do to find your ankles again with this simple fact sheet.
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What causes cankles?
There are a few common things that can cause cankles, but some are more worrisome than others. First, weight gain can lead to cankles by increasing fat stores in the leg, which are then pulled downward by gravity. Second, if your body is retaining too much fluid, the tissues in the lower calf and ankle may swell, making the ankles appear wider. This commonly occurs during pregnancy and usually resolves after the baby is born, but it can also be due to kidney disease, heart failure, a blood clot or a blockage in the lymphatic system, among other medical problems. Third, some people may simply be genetically predisposed to having thicker ankles.
When should I worry?
Most cankles are not a sign of serious disease, and are simply due to genetics or weight gain. However, if your cankles appeared over a short period of time, are progressively worsening, are painful or swollen, feel much warmer or cooler than your other skin, or if the overlying skin is red, you should see a doctor. In addition, this simple test can help you decide if your cankles might be a sign of something more serious: Take a finger and push into your cankle. Fat and normal fluids will usually bounce right back. But, if your finger leaves a dent or imprint in your skin, that suggests that you have abnormal fluid buildup (medically termed “pitting edema”) and should see a doctor.
What can I do about cankles?
Anyone with the alarming signs listed above should see a doctor about his or her cankles. For others, however, a few creative solutions could help minimize cankles and give ankles back their graceful taper.
- Hemorrhoid cream: Over-the-counter hemorrhoid creams can temporarily firm and tighten the skin. This isn’t a good long-term fix and should only be used occasionally, but it can be a quick help if you’re dressing up for a night out. This may not be a good solution for everyone, so always ask your doctor before trying a new remedy or supplement.
- Parsley tea: Parsley can act as a natural diuretic, helping your body pee out excess fluids. You can buy this in a health food store or make your own by boiling fresh parsley in hot water. Drink a cup a day.
- Pointed-toe flats: Shoes with pointy toes can make your feet look longer, which gives the illusion of lengthening the whole leg. Nude-toned shoes can also have the same elongating effect.
- Jump rope: Without expensive surgery, it’s impossible to remove fat just from the ankles, but you can tone your calves to make your ankles look smaller. Many gyms now have classes that specifically target this problem area. Many of these exercise programs center around a childhood favorite – jumping rope. Try jumping rope for 10 minutes a day to help thin out your cankles.
Ankle Sculpting Is A Thing And It’s As Wild As It Sounds
In 2018, there aren’t many body parts exempt from insecurities that can’t be changed with a nip and a tuck. More of us are going to extreme lengths to improve our looks, with ear lobe reductions, knee lifts and armpit liposuction all on the up and up.
Now, ankles – or ‘cankles’ – are the next body part we’re going under the knife to alter. Cankles, for the uninitiated, refers to the area where the calf meets the ankle and there is no real distinction between the two leg parts. And women with thicker calves and ankles are turning to liposculpture.
“Small amounts of fat removal can change the shape of the ankle dramatically. The aim is to make the leg appear finer and more symmetrical,” explains cosmetic surgeon Dr Meaghan Heckenberg of Sydney’s Be Sculptured clinic.
Less invasive than conventional liposuction, it involves a local anaesthetic solution injected into the fatty tissue small horizontal incisions being made in the skin (about 3-5mm in length), then fine cannulas used to remove the fat, with the goal to reduce the bulk of the calf and make the lower leg look slender.
Before and six weeks after surgery. Image: SuppliedSource:Whimn
“It is often an area of fat deposition that has been a problem most of the patient’s life, which is resistant to diet and exercise. Sometimes there are hereditary collections of fat in these areas and removal of these can reduce the circumference of the ankle by half.”
Having performed over 700 liposculpture procedures since 2008, Heckenberg says the results of removing even a small amount can be dramatic.
Although it doesn’t come cheap. Smaller ankles will set you back around $7200 (this includes the whole calf and ankle area) and recovery is tough.
“A patient may not get final results until a year down the track. This is because this area is the most dependent area of the body and the body has to fight gravity for the reduction of swelling,” says Dr Heckenberg.
“The ankle is the farthest body part away from the heart. Very firm compression stockings are worn day and night for a month after the procedure to reduce swelling, whereas other body parts only require compression garments for two weeks.”
Of course, make sure you find a surgeon who is certified by the The Australasian College of Cosmetic Surgery (this is easily done by checking their credentials via the ACCS website) Also, choose someone whose speciality is in your chosen surgery and then get clued up on exactly what you’re after before going in for the initial consultation.
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The question: My ankles are not strong. I always roll them when I run and play sports. They feel wobbly. Can you give me some strength exercises for them?
The answer: Absolutely! A close friend of mine struggles with a similar problem, so I understand how frustrating unstable ankles can be.
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Do exercises that appropriately challenge your balance. For example, try standing on one leg. Once that gets easy, close your eyes. Balancing improves proprioception. Proprioception is the body’s ability to know where it is in time and space – a neurological ability vital for athletes, since no one can or should be consciously aware of their bodies positioning at all times.
To strengthen the muscles in your lower leg and foot, you should also try these exercises:
- Standing calf raises: Lift yourself up on your toes for 15 reps. To increase the challenge, stand on one leg or hold weights.
- Heel walks: Lift the front of your foot off the floor. Balance on your heels and walk across the room.
- Hand-Foot War: Put your right hand against the outside of your right foot. Push your hand into your foot. Resist the push with your foot. Next, place your hand on the inside of your right foot and repeat the push-resist sequence. Switch and repeat with your left foot.
- Towel pulls: Place one bare foot on a towel. Grab the towel with your toes. Lift your heel, pull the towel taut, then repeat the toe grabs. Continue for the length of the towel.
When your ankle feels strong enough, incorporate lateral and other sport-specific exercises. Simulating the athletic movements needed for your sport in a controlled environment is a great way to safely prepare your body.
For example, try lateral leaps: Start standing on your left leg. Propel yourself to the right with your left bum muscles, land on your right leg in an athletic stance, then jump back to the left.
Hopping exercises can also be useful: Stand on your right leg. Hop forward, sideways and backward for 10 to 30 repetitions. Then switch and repeat on left foot.
Trainer’s tip:Your weak link may be your ankles, but the stronger your entire lower body and core is, the more support your ankles will have. Make sure you are doing lower-body and core exercises such as squats, dead lifts and planks.
How to get bigger calves: 5 tips
It seems like a genetic lottery. Some people are born with big, shapely calves while others are forced to live much of their lives with twig-like lower legs. Frustratingly for many, the calves are one of the body’s muscles that are most resistant to growth. Think about it, every time you even take a step your calf muscles are activated, as they are lumbered with job of supporting your bodyweight all day. As a result of this you need to hit the calves extremely hard to activate them enough to see an increase in size. Normal training won’t do you much good when it comes to getting bigger calves. Try deploying the five tips below to build calves that’ll look great in shorts.
Don’t use all of the tips at once of course – you don’t want to overtrain your calves now do you? Try picking 1 or 2 tips from the list and change them around every other week.
8 more ways to build bigger legs.
1. Bed-time raises
Each night before you go to bed try doing a set of 100 slow standing calf raises, e sure to squeeze hard on each rep. No need for any weights, just use your bodyweight. Your calves are well equipped to take the burn on a daily basis, they are more than used to carrying your bodyweight after all.
2. Go barefoot
Arnold Schwarzenegger liked to train his calves in his bare feet. This way you can increase the range of motion for any calf movement that you do, forcing a far more intense contraction.
3. Tiptoe around
Ever wondered why ballet dancers have such enviable calves? It’s because they’re always on their tiptoes. We’re not going to tell you to pick up ballet a couple of times a week, but do try to walk around on your tiptoes instead of on flat feet for extra calf activation.
4. Have two calf days
Add two calf workouts per week to your workout routine. Do one of them with heavy weights for sets of 4-6 reps and one workout with much lighter weights for sets of 25-50 reps. This will help to attack muscle fibres that you probably haven’t hit before and therefore force your calves into growth.
5. Daily training
For an initial period of 2-4 weeks try to train your calves everyday before you go back to your normal workout program. Use 4-6 sets in each workout and use a different calf targeting exercise each day.
Figure 1: Ankle fat pad located at the lateral aspect of the ankle
It is also important to distinguish and to rule out lipoedema during a physical examination, which is a rare and long-term chronic condition that typically involves the abnormal build-up of fat cells in the legs, thighs and buttocks, where legs usually become enlarged from the ankles up to the hips.7 Increased awareness of lipoedema and its presentation may enable practitioners to diagnose and treat patients more efficiently.8 Diagnosis and treatment should be made as early as possible to prevent complications associated with increased functional and cosmetic morbidity.8
Lipoedema is a condition that can be treated through the use of surgical options such as liposuction and/or excisional lipectomy in patients who are resistant to non-surgical treatment such as exercise, compression therapy and massage. Liposuction appears to be one of the most effective and long-lasting treatments to date, although many patients often require ongoing non-surgical treatment postoperatively to maintain results.8
The fatty hypertrophy seen in patients typically starts at the hips and extends throughout the legs, one of the major distinguishing features of lipoedema is the sparing of the feet, which can create a distinct ‘step-off’ at the ankle.11,12 A helpful diagnostic tool during a physical examination to distinguish lipoedema from lymphoedema is to pinch the skin over the dorsum of the base of the second toe. If the skin appears thickened and is difficult to lift off of the underlying tissue, then this could be an indication of Stemmer’s sign, which is considered a diagnostic tool for lymphoedema.13 To avoid patients raising complaints that treatment has caused neurovascular conditions, I would advise performing a neurovascular evaluation prior to treatment. Review of family history may also be useful as patients with lipoedema often have other female family members with similar symptoms.10
A typical patient presenting for treatment will have subcutaneous fat around the ankle region. Typically, fat distribution, in my experience, is anterolateral and posteromedial in mild cases, while circumferential in patients with a larger amount of fat. It may be the only area of concern or may be associated with excess fat around the knee, medial and lateral thighs or involve the whole lower extremities. The pinch test will reveal areas amenable to treatment.
For practical purposes it is important to note that the two danger areas are the popliteal fossa (the shallow depression located at the back of the knee joint)4 and the area around the malleoli (the bony projection on either side of the ankles)5 as important nerves and vessels reside in this area superficially. In the superior aspect we have skin, superficial fascia and subcutaneous fat, followed by a deep fascia envelope around the anterior, posterior and lateral muscular compartments.5
Figure 2: Patient A has excess fat distribution along calves, ankles, knees, inner and outer thighs. Topographic markings for areas to be suctioned.
Figure 3: Patient A 12 weeks after the liposuction procedure. (Photos taken without flash to highlight contour abnormalities).
The posterior compartment has three layers of calf muscles, mainly gastrocnemius soleus and tibialis posterior. The anterior compartment has the tibialis anterior and extensor muscles and the lateral compartment has the peroneal muscles. Tendons of these muscles are located in the lower part, along with nerves and blood vessels, which are located superficially in this area.
It is of course important to take note of the nerves and blood vessels as any oedema here can cause compartment syndrome, which is a painful condition that occurs when pressure within the fascial envelope builds. Compartment syndrome is likely to cause neurovascular complications if it is not recognised and treated effectively.5
A fat pad called the lateral inframalleolar fat pad (LIMFP), located at the lateral aspect of the ankle, has been described in a clinical article by D. Brémond-Gignac and H. Copin et al; they claim it is not often referred to in anatomical texts so it is imperative to be aware of.6 They outline how the LIMFP is oval and made up of an unilocular fatty tissue that is distinct from the subcutaneous plane. The sural nerve is a sensory nerve in the calf region that runs over the surface of the fat pad and supplies cutaneous sensation to part of the fifth toe. This is accompanied by the short saphenous vein, which gives off a medial perforator that traverses the LIMFP. It is necessary to recognise the location of this fat pad before any procedure on the lower limbs, in order to prevent over correction or under corrections during treatment.6
Figure 4: Pre-op image in a slender patient with small amount of localised cankle fat highlighting area of maximum fat.
Figure 5: Post-op image, a small area of hyperpigmentation from cannula entry point is noticeable, treatment of laser liposuction.
Liposuction is one of the most evidence-based and preferred ways to remove fat.14 The two key principals for successful liposuction procedures are good patient selection and realistic expectations. Many liposuction procedures can be performed under local anesthesia in an office surgical suite. A conservative approach is always appropriate as overcorrection can be difficult to treat.14
Current technology for liposuction includes suction-assisted, ultrasound-assisted, power-assisted, laser-assisted, and radiofrequency-assisted liposuction. The choice of technology and technique often depends on patient characteristics and surgeon preference.15 My preferred approach is laser lipolysis2 and micro-cannula liposuction, administered under local anaesthesia.16 Sometimes a circumferential liposuction of knees, calves, and ankles is the best option to create more slender looking legs.17 This procedure can also be combined with fat injections into the calf area to achieve further reshaping and contrast between the calves and ankles.
Other procedures to augment calves include silicone calf implants.15 Calf contouring with endoscopic fascial release, calf implant, and structural fat grafting have also been described.18 In patients with minimal fat many practitioners opt not to aspirate, further limiting direct tissue trauma.19 As a result, patients can quickly return to daily activities within three to five days.19
Patient selection and a thorough pre-procedure discussion are necessary to minimise any difference between the patients’ expectations and treatment results
A variety of laser wavelengths have been used to try and correct excess fat. My preferred approach is laser lipolysis2 and micro-cannula liposuction under pure local anaesthesia20 due to the following advantages; fast patient recovery, diminished post-operative pain, ecchymosis and oedema.21,19 The coagulation of blood vessels may explain these advantages.9 I use tumescent anaesthesia followed by a 1470 nm diode laser lipolysis. The laser energy is delivered by a 600 micron laser fibre. Following this I use a 14G micro-cannula to suction the liquefied fat. I then provide patients with a compression bandage that is changed to Class 2 compression stockings at the post-op check up. Compression stockings are used day and night for at least one week. I encourage patients to use these during the daytime for as long as possible.
An alternative approach: botulinum toxin
Although not directly related to the appearance of cankles, enlarged medial gastrocnemius muscles in the calves can also cause psychological distress in some women.22 In 2004, Lee et al described the use of botulinum toxin injections for the reduction of calf muscle size.22 Botulinum toxin A injections of 32, 48 or 72 units were injected into each medial head of the gastrocnemius muscle in six women. In all of the participants there was a reduction in the medial gastrocnemius muscle after the injection. According to the study authors, the reduction in the medial calf was noticed even after one week and the effect was well maintained for six months. Leg contouring was obtained by the botulinum toxin treatment. The middle leg circumference indicated a slight decrease in five subjects. No functional disabilities were observed.23
As with any aesthetic treatment, complications can occur. Patient selection and a thorough pre-procedure discussion are necessary to minimise any difference between the patients’ expectations and treatment results. It is critical to avoid aggressive superficial liposuction, which could cause lipotrops and liponots. These indicate uneven areas where either too much or not enough fat has been removed, respectively. I advise that practitioners administering this procedure remain above the deep fascia and wait 30 minutes after the injection of tumescent fluid to allow for detumescence to be able to grasp the fat, before cannula introduction. Liposuction complications can include injury to adjacent structures, transient numbness, and temporary hyperpigmentation at cannula entry sites, but specific to this area is prolonged oedema.24 Due to their dependent position, legs and ankles are prone to oedema, which can last between six and 12 months. For this reason, I encourage the use of a small cannula of 14G or smaller, gentle technique and compression stockings.
Laser-assisted liposuction in the remodeling of the calf and ankle area is a safe and reproducible technique that is particularly appreciated by the patient. The procedure allows for homogeneous reduction of fatty tissue together with skin tightening.2
A treatment called complete decongestive therapy can ease painful symptoms. Complete decongestive therapy involves:
Manual lymphatic drainage. A form of massage that uses gentle, rhythmic pumping movements to stimulate the flow of lymph around blocked areas to healthy vessels, where it can drain into the venous system. This helps relieve pain and prevent fibrosis.
Compression. The use of stretch bandages or custom-fitted panty hose, panties, or spandex shorts to increase tissue pressure in the swollen legs and lessen the odds of fluid building up again.
Exercise. Helps to reduce fluid buildup, boost mobility, and maintain or improve how well your legs work.
Thorough skin and nail care. Helps lower the risk of wounds and infection if you have lipedema associated with swelling.
Liposuction, specifically water-assisted liposuction and tumescent liposuction, can remove the lipedema fat. The procedure uses a hollow tube that is placed under the skin to suction the fat tissue. Several sessions may be needed depending on the amount of abnormal fat.
The brutal truth about cankles
The word “cankle” became widespread in pop culture when Jason Alexander’s character in the movie Shallow Hal used the term to describe an overweight women’s lower leg. For some women, developing thick ankles is no laughing matter it could actually reveal an undiagnosed health issue and have very little to do with diet and exercise.
If your ankles are swollen, overlarge, or seem to merge with your calves rather than being clearly defined, you may have ‘cankles’. This term describes the appearance the lower leg has when there is excess fatty tissue below the knee. To help the public understand the causes and treatment of this common condition, Dr Peter Paraskevas, a leading phlebologist and cosmetic surgeon has developed a guide to explain the medical conditions that may cause cankles and the best way to treat them.
What medical conditions can cause swelling of the ankles?
Venous disease/insufficiency: When your veins have trouble sending blood from your limbs back to the heart, it’s known as venous insufficiency. In this condition, blood doesn’t flow back properly to the heart, causing blood to pool in the veins in your legs. Several factors can cause venous insufficiency, though it’s most commonly caused by deep vein thrombosis, (blood clot) or varicose veins.
Symptoms of venous insufficiency can include:
- Swelling of the legs or ankles
- Painful, throbbing and heavy legs
- Thickening of the skin on the legs and ankles
- Skin that changes colour around the ankles
Pregnancy: Varicose veins that appear during pregnancy can cause discomfort, cramps and swelling, especially around the ankles. Pregnancy can aggravate pre-existing varicose veins, or many women who have pregnancy related veins may have never ever noticed veins before. Pelvic varicose veins can develop during pregnancy which put pressure on veins in the thighs and lower legs and can lead to severe swelling in the ankles, causing extreme pain and discomfort.
Lymphoedema: Excess build-up of fluid in the lower legs is referred to as lymphoedema. Primary lymphoedema can occur in childhood, (congenital onset lymphoedema), in adolescence (lymphoedema praecox) or later in life (lymphoedema tarda), with no identifiable cause; Secondary lymphoedema can occur secondary to heart/liver/kidney failure, malnourishment (albumin deficiency), blood clots or blockages in the lymphatic system, varicose vein disease, and other medical issues. This form of fluid retention requires careful assessment and appropriate management.
Lipoedema: Lipoedema is a chronic progressive medical disease that causes disproportionate swollen fat deposition in the arms and legs. It tends to be passed down genetically and around 10- 15% of women will be affected at some point in their lives. Individuals with lipoedema have a marked discrepancy between their slim upper body and symmetrically enlarged lower body. It is difficult to resolve lipoedema with exercise and dieting alone. There may be a slight reduction in the amount of fat, but the thighs and/or legs will always appear disproportionate to the rest of the body. Varicose vein disease is often present in conjunction with lipoedema and associated mild lymphoedema.
What treatments are available?
Whether your ‘cankles’ are caused by an undiagnosed health issue or another condition, you deserve to get an effective treatment. As a starting point, see your GP to account for any of the medical causes of ankle swelling.
Conservative treatment should be considered as a method of controlling symptoms and swelling. Manual Lymphatic Drainage (usually provided by a Lymphatic Nurse) can help alleviate swelling in the legs along with wearing graduated compression stockings.
These temporary measures may treat the swelling and discomfort, but do not actually treat the fatty accumulation in the legs. This is where liposculpture can be offered as a more sustained and permanent solution.
Says, Dr Paraskevas of Paras Clinic “With liposculpture, we basically inject the fat with anaesthetic solution to help disperse it, and then gently suction the fat through a small microcannula. Once the fat is removed, it will not come back. Liposculpture not only improves the physical appearance of cankles by returning some balance to the body’s proportion, but improves any symptoms the patient may have been experiencing.
Tumescent Based Liposculpture is the Gold Standard for removing cankles permanently. It is best performed under local anaesthesia with a very mild sedation and pain relief for better results, faster recovery and less pain.
Dr Paraskevas says the main benefits of laser-assisted liposculpture for treating cankles includes:
- Removing the damaged inflammatory fat to preserve lymphatic health and circulation of the legs.
- It alleviates discomfort and swelling.
- Avoids the long-term dependence on compression garments and manual lymphatic drainage which can be costly and time consuming.
- Long-term, there is less chance of scar-like tissue called fibrosis, forming.
- It will preserve mobility and reduce degenerative conditions such as arthritis on the hips, knees and ankles.
- The appearance of the limbs will be in proportion with the rest of the body, relieving any psychological burdens from the patient.
“It is highly recommended patients that undertake this procedure maintain their weight with a healthy diet and exercise. Procedures like liposuction have become increasingly popular in the past 10 years. With new technologies and in the care of a credible surgeon in a registered day procedure centre these surgeries are quite safe, but I urge potential patients to do their research,” says Dr Paraskevas.
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