Varicose veins, venous ulcer, DVT and thrombophlebitis

1Definition

• Varicose veins: dilated, twisted superficial veins of the legs, 3 mm or more in diameter when standing, caused by faulty valves.
• Chronic venous insufficiency: long-term high pressure in the leg veins (venous hypertension) causing swelling, skin changes and ulcers.
• Venous ulcer: a break in the skin of the lower leg, usually above the inner ankle, caused by venous hypertension, that has not healed within about 2 weeks.
• Deep vein thrombosis (DVT): a blood clot in a deep vein, usually of the calf or thigh. Part of it can break off and block the lung arteries: pulmonary embolism (PE). DVT and PE together are called venous thromboembolism.
• Thrombophlebitis (superficial): inflammation of a superficial vein with a clot in it; a red, tender cord under the skin. Phlebothrombosis is the older term for a clot in a deep vein with little inflammation.

2Classification and grading

CEAP clinical classes (2020)

CEAP also records the Etiology (primary, secondary such as after DVT, congenital), Anatomy (superficial, deep, perforator veins) and Pathophysiology (reflux, obstruction).

DVT by site

• Distal (calf veins only): lower risk of PE.
• Proximal (popliteal, femoral, iliac): higher risk of PE and of post-thrombotic syndrome.

3Causes and risk factors

Varicose veins and venous insufficiency

• Jobs with prolonged standing: cooks (S17), shop and factory workers, teachers (W18), traffic police.
• Female sex, pregnancy, family history, older age, obesity.
• Previous DVT damaging the deep valves (post-thrombotic syndrome).
• Reduced calf pump: inactivity, ankle stiffness, paralysis.

DVT: Virchow's triad

• Stasis: bed rest, surgery (especially hip, knee, abdominal and cancer surgery), long travel, paralysis, heart failure.
• Vessel wall injury: trauma, fractures, surgery, central lines, previous DVT.
• Hypercoagulability: cancer, pregnancy and the weeks after delivery, oral contraceptive pill and hormone therapy, dehydration, inherited clotting disorders, obesity.

4Pathophysiology to impairments

The calf muscle pump

When the calf contracts during walking, it squeezes the deep veins and pushes blood up towards the heart. One-way valves stop it falling back. When the calf relaxes, the deep veins refill from the superficial veins through perforating veins.

1. If valves fail (in the saphenous veins, perforators or deep veins), blood falls back down when standing: reflux.
2. Pressure in the leg veins stays high even during walking: venous hypertension.
3. Superficial veins stretch and twist: varicose veins, with aching and heaviness that worsen as the day goes on.
4. Fluid, red cells and proteins leak into the tissues: oedema, brown pigmentation (haemosiderin), eczema.
5. Chronic inflammation hardens the skin and fat (lipodermatosclerosis); the skin breaks down after minor injury: venous ulcer.
6. A stiff ankle or weak calf (pain, ulcer, inactivity) makes the pump fail further, so healing slows.

Why the skin breaks down (S26: pathophysiology of varicose ulcer): two classic theories explain the step from venous hypertension to ulcer. In the fibrin cuff theory, high capillary pressure leaks fibrinogen, which forms cuffs of fibrin around the capillaries and blocks oxygen and nutrients from reaching the skin. In the white-cell trapping theory, white cells stick in the slowed capillaries and release enzymes and free radicals that damage the tissue. Either way the skin of the gaiter area becomes poorly nourished and inflamed, and a minor knock becomes an ulcer that will not heal while the venous pressure stays high.

5Clinical features

Varicose veins and venous insufficiency

• Dull aching, heaviness, tired legs, worse after long standing and in the evening; relieved by elevation (S17 case).
• Ankle swelling by evening; night cramps; itching.
• Visible dilated veins on standing; pigmentation, eczema, hard skin above the ankle.

Don't confuse: three kinds of leg ulcer

DVT

• One-sided calf or thigh swelling, pain, tenderness along the deep veins, warmth, redness, dilated superficial veins.
• Often silent, especially after surgery.
• Pulmonary embolism: sudden breathlessness, chest pain worse on breathing in, fast heart rate, low SpO₂, coughing blood, collapse.

Superficial thrombophlebitis

A red, hot, tender, hard cord along a superficial vein, often in a varicose vein or at a drip site.

6Investigations and special tests

"Two special tests to assess venous insufficiency" (S16) is the classic short question.

DVT diagnosis

• Wells score to estimate likelihood; D-dimer blood test (a normal result helps rule DVT out when likelihood is low); compression ultrasound to confirm.
• Suspected PE: CT pulmonary angiogram.

7Medical and surgical management

Varicose veins

• Conservative: compression stockings, exercise, leg elevation, weight control.
• Endovenous thermal ablation (laser or radiofrequency) of the incompetent saphenous vein: first-line in current guidelines.
• Foam sclerotherapy; surgery (high ligation and stripping); removal of side branches (phlebectomy).

Venous ulcer

• Compression is the main treatment: about 40 mmHg at the ankle with multilayer bandages or adjustable wraps, once ABPI shows adequate arterial supply.
• Wound cleaning, simple dressings, antibiotics only for spreading infection (W18 "infected" ulcer).
• Treat the underlying vein (ablation) to speed healing and prevent recurrence.

DVT

• Anticoagulation: heparin then oral anticoagulants (for example apixaban, rivaroxaban or warfarin), usually for at least 3 months.
• Clot-dissolving treatment or a vena cava filter in selected cases.

Superficial thrombophlebitis

• Anti-inflammatory drugs, warm compresses, compression, keep walking; anticoagulation if the clot is long or near the groin junction.

8Complications and prevention

9PT assessment

Asked as 7 marks in W19 (assessment of venous insufficiency) and as "evaluation" in the W21 air-hostess case.

• History: standing hours at work, pain pattern through the day, swelling, itching, previous DVT, pregnancies, surgery, diabetes (S17), smoking, home stairs.
• Inspection standing: varicose veins, oedema, pigmentation, eczema, lipodermatosclerosis, ulcer (site, size, depth, base, edge, exudate, smell).
• Measurements: calf and ankle circumference (compare sides), ulcer size (tracing or photograph).
• Palpation: temperature, pitting oedema, tenderness, pulses.
• Special tests: Trendelenburg, Perthes; ABPI before compression.
• Ankle ROM (dorsiflexion), calf strength (number of single-leg heel raises), gait.
• Sensation (monofilament) if diabetic.
• Outcome measures: Venous Clinical Severity Score, ulcer area, pain scale, quality of life (for example CIVIQ).

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (S17, 5 + 7 + 3 marks)

"A 55 year old widow, works as a cook and stays on second floor with no lift facility. She is a known diabetic. She complains of dull aching pain in bilateral lower limb which increases with sustained standing and swelling which increases by the end of the day. She also presents with dilated veins in both her lower limbs. Discuss ICF, physiotherapy management and preventive foot care for her condition."

11Problem list and goals

12PT management

1. Varicose veins and venous insufficiency

• Calf muscle pump exercises: ankle pumps 10–20 times every hour while standing or sitting; heel raises 2–3 sets of 10–15; toe walking.
• Walking 30 minutes most days.
• Ankle mobility: dorsiflexion stretches if stiff.
• Elevation: lie with the legs above the level of the heart for about 30 minutes, 3–4 times a day; raise the foot of the bed slightly at night.
• Compression stockings (after checking ABPI): put on in the morning before getting up, take off at night.
• Breathing: deep diaphragmatic breaths during elevation help venous return.
• Weight loss and general fitness.
• After vein ablation or surgery: walk the same day, wear compression as advised, avoid long standing or sitting for the first weeks.

2. Venous ulcer (7 marks in W16 and W20)

• Compression (by nurse or doctor) about 40 mmHg at the ankle if ABPI allows.
• Calf-pump exercise and walking with the bandage on: they work together. Progressive resistance calf exercise helps healing.
• Ankle ROM to keep the pump working.
• Elevation at rest.
• Electrotherapy as an add-on for slow-healing ulcers (see the diabetes and wound-healing page): electrical stimulation, ultrasound, ultraviolet for infected wounds.
• Skin care around the ulcer: moisturise, avoid scratching and injury.

3. DVT: prevention and management (7 marks in S18, W18, S22)

Prevention (anyone immobile or after surgery)

• Early mobilisation and walking.
• Ankle pumps 10 every hour while awake; deep breathing.
• Leg exercises in bed: static quadriceps, gluteal sets, knee bending.
• Hydration; avoid crossing legs and pillows behind the knees.
• Mechanical prophylaxis as prescribed: graduated compression stockings, intermittent pneumatic compression.
• Drug prophylaxis (heparin) as prescribed.

After a DVT is diagnosed

• Check the anticoagulant type and when it started. Begin walking once anticoagulation has reached its therapeutic level (APTA guideline, strong recommendation). Bed rest does not lower the risk of PE.
• Progress walking and leg exercises; elevate the leg at rest.
• Compression for symptom relief if swelling and pain persist.
• Watch for signs of PE and bleeding.

By impairment

13Precautions, contraindications and stop criteria

14Education, do's and don'ts, and foot care

"Patient education in varicose veins" (S20, 7 marks), "do's and don'ts" (W18) and "preventive foot care" (S17, 3 marks).

Do

• Walk every day; do ankle pumps and heel raises whenever you stand or sit for long.
• Raise your legs above heart level several times a day; sleep with the foot of the bed slightly raised.
• Wear compression stockings from morning till night; check the skin under them daily.
• Take short sitting or walking breaks at work; shift weight from foot to foot while standing; use a footrest.
• Keep a healthy weight; wear comfortable, low-heeled shoes.
• Moisturise the skin of the lower legs daily.

Don't

• Stand or sit still for long periods; cross your legs.
• Wear tight garters, socks with tight bands or tight clothing at the waist.
• Use hot water bags or sit close to a fire with bare legs.
• Scratch itchy skin or injure the legs.

Preventive foot care (especially with diabetes)

• Inspect feet and legs every day, including soles and between toes.
• Wash in lukewarm water, dry well, moisturise but not between the toes.
• Cut nails straight; never walk barefoot; wear well-fitting footwear with socks.
• Keep blood sugar controlled; report any wound, colour change or swelling early.

15Prognosis and discharge criteria

Prognosis: varicose veins tend to progress slowly; compression and exercise control symptoms, and vein ablation treats the cause. Venous ulcers usually heal with good compression but often recur unless compression and exercise continue. After a DVT, early walking with anticoagulation is safe; many patients later develop some post-thrombotic symptoms.

Discharge: independent with the exercise and elevation routine; correct use of stockings; knows do's and don'ts and foot care; ulcer healed or improving with a plan.

16Exam corner

Past questions (MUHS, 2016–2026)

• S17 Q3(b), 5 + 7 + 3 marksThe worked example in section 10.
• W18 Q3(b), 5 + 5 + 5 marks50-year-old female schoolteacher with infected venous ulcers on the lower third of the leg, managed conservatively. Functional diagnosis; physiotherapy; do's and don'ts.
• W21 Q4(a), 15 marks40-year-old air hostess, 10 years in the job, with swelling of both feet and calf pain for 3 months; has noticed spider veins in the popliteal fossa. Evaluation; functional diagnosis; management.
• S26 Q3(b), 15 marks (three parts)40-year-old bus conductor with a non-healing, oozing ulcer above the right medial malleolus; pigmentation and swelling of the foot and ankle; dilated, tortuous veins; finds it hard to walk and work. (i) Pathophysiology of varicose ulcers; (ii) goals with ICF; (iii) physiotherapy.
• 7-mark questionsPhysiotherapy of venous ulcers (W16) and varicose ulcers (W20). Prevention and physiotherapy of DVT (S18). Physiotherapy of DVT (W18). Patient education in varicose veins (S20). Complications of abdominal surgery and physiotherapy of DVT (S22). Two special tests for venous insufficiency (S16). Assessment of venous insufficiency (W19). Management of venous ulcers (W21).

Technique cards for this topic: bed rest, exercise physiology, compression and exercise for circulation.

Keywords to underline

calf muscle pump valve incompetence venous hypertension CEAP Trendelenburg test Perthes test ABPI before compression 40 mmHg elevation Virchow's triad mobilise once anticoagulated

Answer skeleton: venous long answer

1. Restate: age, job with standing, sides, swelling and pain pattern, ulcer site and infection, diabetes.
2. [ICF or functional diagnosis, 5] ICF diagram; reasoning (valve failure, venous hypertension, calf pump).
3. [Management, 5–7] Assessment (special tests, ABPI); calf-pump exercise and walking with doses; elevation; compression; ulcer care; electrotherapy add-on; post-surgery care.
4. [Add-on, 3–5] Do's and don'ts, or preventive foot care.

Draw these

• Virchow's triad (section 3)
• The leg-ulcer comparison table (section 5)
• A leg showing the gaiter area above the inner ankle

Viva questions

1. How does the calf muscle pump work?
2. How do you do the Trendelenburg test, and what does a positive result mean?
3. Why must you check ABPI before compression?
4. Where does a venous ulcer usually occur, and why there?
5. When can a patient with a new DVT start walking?
6. Why is Homans' sign no longer used?