On the road or in the air for homecoming, your legs can become a 'deadly weapon.' A physical therapist's practical guide to preventing 'Economy Class Syndrome' by taking off your shoes and lifting your heels #PR

As the summer homecoming season approaches, we are suddenly forced to spend long periods in the same position. Car seats stuck in traffic, fully booked Shinkansen trains, and economy seats on airplanes. On this site, we have accumulated advice on how to protect your feet during your travels.Foot care to walk 20,000 steps at your destination covered how to deal with walking fatigue, and Travel 5-minute rescue kit covered first aid for blisters and swelling.

However, these were all related to 'walking.' This time, we will address a more dangerous problem lurking in the time spent 'sitting without moving.' It is the so-called 'Economy Class Syndrome,' where you feel chest pain the moment you stand up after a long journey, and in the worst case, it can even lead to death.

To be honest, I had long viewed this lightly as just 'a story about legs swelling on an airplane.' However, when I asked a physical therapist friend who previously taught me how to read walking habits from the uneven wear of shoe soles (that episode is summarized in Heard from a physical therapist: Reading walking habits from uneven sole wear), his face was unusually serious. 'You shouldn't think of it as just an extension of swelling. It is a full-fledged disease that can be fatal.' The following is my own organization of my conversation with him. Note that this is not a medical diagnosis but general information. Those with underlying conditions or those currently experiencing symptoms must consult a doctor—this was a point he emphasized repeatedly.

What exactly is 'Economy Class Syndrome'?

First, he explained the true nature of the name. '“Economy Class Syndrome” is just a common name. Medically, it collectively refers to traveler's thrombosis, deep vein thrombosis (DVT—blood clots that form in the deep veins of the legs), and pulmonary thromboembolism (PE—a condition where those clots block blood vessels in the lungs).'

The mechanism is as follows. When you sit for a long time without moving your legs, blood flow around the calves stagnates [Reference 1]. 'Normally, calf muscles expand and contract every time you walk, acting as a pump to push blood from your legs back to your heart. They are even called the “second heart.” But if you stay seated, that pump stops. Blood stagnates, and it becomes easy for blood clots to form in the veins of your legs.'

The formation of blood clots itself is a problem, but he lowered his voice when he said, 'The really scary part starts here,' as he continued. 'The blood clot formed in the leg can, at some point, detach from the vessel wall, enter the bloodstream, and travel to the lungs. If the blood vessels in the lungs are blocked, you cannot breathe. This is pulmonary embolism, which can lead to sudden death' [Reference 2]. It is not an extension of swelling, but a life-threatening condition—the reason he warned me so sternly at the beginning finally made sense.

Why is the 'moment you stand up' dangerous?

What I found surprising was that the danger is greater when you 'stand up' than while you are sitting.

'Someone who has been sitting for a long time during a trip arrives at their destination and stands up to get off. They stand up to go to the bathroom. At that moment, the calf muscles move sharply,' he continued, tapping his own leg lightly. 'Because of that pumping action, the accumulated blood flows out all at once. At that time, the blood clot that had formed in the leg can be pushed out along with it and travel to the lungs' [Reference 1].

'Therefore, if you suddenly feel chest pain, shortness of breath, or if one leg becomes swollen and painful shortly after you start walking after a flight or a long-distance drive, it might not just be fatigue.' Of course, most of those symptoms are likely due to other causes. However, his point was that you should keep the context that 'it happened after traveling' in the back of your mind. I think this point alone is worth knowing.

It's not just airplanes—the pitfall of 'sleeping in the car'

Because of the name 'Economy Class,' people tend to think it is an airplane problem. However, he said, 'In Japan, cars might actually be scarier than airplanes.'

'Whether it's a long-distance bus or a car stuck in traffic, the conditions are the same. The seats are narrow, and you cannot move your legs for a long time. In fact, the most serious example known is sleeping in a car during a disaster.'

He cited the 2016 Kumamoto earthquake. It is estimated that about 70% of evacuees experienced 'sleeping in a car' to spend the night [Reference 3]. 'Aftershocks are scary, you want to protect your privacy, you have pets. There are various reasons, and sleeping in a car itself is not something to be blamed. However, you end up spending days with your knees bent in a cramped driver's seat. Moreover, in disaster areas, people tend to drink less water. The conditions for blood to stagnate and clot are perfectly met.' In fact, it has been reported that deep vein thrombosis was confirmed in many evacuees who slept in cars during the Kumamoto earthquake, and some even lost their lives [Reference 3].

'Homecoming traffic jams and sleeping in a car during a disaster. The degree of severity is completely different. But in the one point of “not moving your legs for a long time in a narrow space,” they are connected.' For me, with summer homecoming ahead, these words resonated heavily.

Who should be especially careful?

He also says that even with the same travel, there are individual differences in the level of risk. The factors generally cited as making blood clots more likely to form are as follows [Reference 2] [Reference 4].

'First, dehydration. If you don't have enough water, your blood becomes thicker and more likely to clot. In summer, you lose a lot through sweat, so this is something to watch out for. Then, there is the posture of having your knees deeply bent in a narrow seat for a long time. Also, in terms of constitution, obesity, smoking habits, being elderly, having varicose veins in the legs (a condition where the veins in the legs bulge like lumps), or having had thrombosis in the past are considered to increase the risk.'

Even here, he did not forget the disclaimer. 'However, there are cases where young and healthy people have developed it. So, assuming “I am fine” is the most dangerous thing. For those who have many applicable items, and even for those who don't, it is better to take precautions just in case.'

Practical advice for travel that a friend shared with me

So, what exactly should you do? The preventive measures he suggested were surprisingly simple, yet logical. They also overlap with the advice repeatedly issued by the Ministry of Health, Labour and Welfare and relevant academic societies as warnings during disasters [Reference 1].

The first is to move your legs frequently. 'Ideally, you should stand up and walk around every hour or two. If you're on a plane, walk the aisle; if you stop at a service area, walk a bit. If that's difficult, you can do it while seated. Heel raises—keeping your toes on the floor and lifting your heels, then keeping your heels on the floor and lifting your toes. Just repeating these 'heel raises and toe raises' will activate the calf pump.' He added that rotating your ankles is also good.

The second is to drink water frequently. 'Some people avoid water because they don't want to deal with the restroom, but that's counterproductive. In fact, getting up to drink that water is exercise in itself. However, alcohol has a diuretic effect that leads to dehydration, so it's better to avoid heavy drinking while traveling' [Reference 1].

The third is to wear non-restrictive clothing. 'Tightening your belt or wearing underwear that constricts your legs will hinder blood circulation. Loose clothing is the basic rule.' He then touched on compression stockings. 'For those who are prone to swelling or are concerned about the risks, using compression stockings designed to prevent traveler's thrombosis is one option. Light compression (generally around 15–20 mmHg) is often recommended because it's easier to wear. In fact, there are reports that even in experiments where people sat for long periods in positions similar to economy seats, low-compression stockings suppressed the decrease in blood flow' [Reference 5]. 'However, they may not be suitable for people with arterial diseases, so if you're worried, it's best to consult with a pharmacy before choosing them,' he added.

The small preventive measure of taking off your shoes

And then, he added something from an unexpected angle: the topic of 'shoes'.

During a long trip, if you keep wearing tight shoes, your feet will swell and your blood circulation will worsen just from that. So, on a plane or during a long drive, you should go ahead and take your shoes off so you can rotate your ankles or raise and lower your heels.' In short, the goal is to make it easier to activate your leg pump.

Here, I thought of the loafer-style shoes from PRO-Keds, a brand our site is partial to. The PRO-Keds Royal Loafer is a pair without laces that you can slip on and off easily. Taking them off to rest your feet on the plane, then quickly putting them back on to walk once you arrive—this convenience is surprisingly effective during a trip home where you have to handle long travel and sightseeing in a single day. A lightweight pair like the canvas PRO-Keds Royal America is also a good match because it doesn't constrict the feet and allows you to feel the ground with a sensation close to being barefoot. In terms of the same 'ease of taking on and off,' a classic laceless shoe like the VANS Classic Slip-On would also be a logical choice for long-distance travel. If you want to maintain the neat look of leather shoes, even a smooth leather pair like the PRO-Keds Royal Plus Smooth can comfortably serve both the travel and the destination if you change into them after you arrive.

This isn't a sales pitch for shoes. It's just that after hearing his story, it made sense to me that 'choosing shoes that are easy to take off lowers the hurdle for moving your legs during travel,' which is a subtle but essential preventive measure. The lightness of the fit is directly linked to whether you can 'move your legs without feeling like it's a chore.'

When in doubt, don't self-diagnose; see a professional

Finally, I will write down what he emphasized most strongly in this interview. 'If you experience swelling or pain in only one leg, shortness of breath, or chest pain after traveling, please do not wait to see how it goes; visit a medical institution as soon as possible. Economy Class Syndrome is a condition that can be life-threatening if treatment is delayed.'

'Also, what I talked about here is just general preventive advice. For those with underlying medical conditions, a history of thrombosis, or those who are pregnant, it is best to consult your primary doctor in advance to confirm the measures that are right for you. That is much more reliable than self-diagnosing based on general information on the internet.' Since he is a professional himself, the weight of this statement is significant.

Conclusion—From 'enduring' travel to 'preparing' for it

For me, long travel has always been a time to just 'endure.' A time of unavoidable patience until reaching the destination. But after hearing my friend's story, my perspective changed a little. If left alone, the time spent sitting can turn your legs into a 'deadly weapon.' That is precisely why you should stand up frequently, raise your heels, drink water, and loosen your feet with shoes that are easy to take off. I realized that the accumulation of those small steps protects your own body.

When a man in his 40s grips the steering wheel of a car on the way home, or fastens his seatbelt in an economy seat on a plane, his body won't let him push it like he did when he was young. That is why I am rethinking travel from something to 'just endure' to something to 'prepare.' Loosening your footwear, moving your legs, and drinking water—I believe that these simple habits are the wisest travel preparations for an adult who has experienced both the bitter and the sweet. As we parted, my friend said with a smile, 'The trip isn't over until you get home safely.' It's a common saying, but after hearing about blood clots in the legs, no other words have ever felt so profound.

References

- [Reference 1] Ministry of Health, Labour and Welfare 'For the Prevention of Economy Class Syndrome' https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000170807.html -
[Reference 2] The Japanese Respiratory Society 'Q&A on Economy Class Syndrome (Pulmonary Thromboembolism)' https://www.jrs.or.jp/citizen/disaster/pcli/ -
[Reference 3] Kyoto Koka Women's University, Faculty of Sociology '[Lessons from the Kumamoto Earthquake]
Sleeping in a car,
which about 70% of evacuees experienced: How to prepare for the life-threatening Economy Class Syndrome' https://www.koka.ac.jp/sociology/news/bousailab/car-evacuation-economy-class-syndrome - [Reference 4] Otsuka Pharmaceutical 'Causes and Countermeasures for Traveler's Thrombosis (Economy Class Syndrome)' https://www.otsuka.co.jp/health-and-illness/thrombosis/cause/ - [Reference 5] Health Guidance Resource Guide 'Long periods of sitting increase the risk of thrombosis; Elastic stockings with low compression that are easy to wear can prevent a decrease in blood flow' (Research by Tokyo Medical University) https://tokuteikenshin-hokensidou.jp/news/2022/010910.php