Questions & Answers
Members of our medical team answer questions we’ve received from referring physicians.
Q: I’m an orthopedist. What can you tell me about vein conditions and joint pain? We seem to have some crossover when it comes to my patients’ symptoms.
A: Joint problems are usually secondary to musculoskeletal causes, or secondary to various types of arthritis or trauma. The symptoms are often localized to the affected joint that may have pain, swelling, redness, and effusion but can also be somewhat diffuse. Venous diseases cause symptoms from increased ambulatory venous pressure in case of chronic venous insufficiency or from obstruction in case of deep venous thrombosis. The two problems may occur simultaneously but they are often guilt by association and not transformation. However, both of these conditions occur more frequently in overweight or obese patients who have limited exercise capability. Joint pains limit walking, which results in decreased calf pump, which in turn reduces venous emptying and hence contributes to venous insufficiency.
Untreated venous insufficiency in some cases can cause chronic soft tissue changes and may lead to stiffness of the ankle joint, fixed plantar flexion and periostitis (reported by Krishnan et al in Seminars in Intervention Radiology, 2005 Sep;22(3);162-168), in addition to the classic findings of pain, swelling, skin color changes with hyperpigmentation and ulceration. Similarly, tendonitis around the distal leg and ankle can cause leg or foot swelling in patients with severe signs of venous insufficiency such as skin hyperpigmentation.
Successful management of patients with these conditions requires proper evaluation with imaging techniques such as CT or MRI by the orthopedic surgeon and complete Duplex ultrasound examination by the vein specialist.
Q: I’m a new family practice physician and eager to learn about conditions like varicose veins, which seem to be more common than I’d realized. What should I know and watch for?
A: Varicose veins are an extremely prevalent entity. In the U.S., it is estimated that up to 30% of men and 50% of women will develop varicosities by age 50. They can be caused by increased pressure in the venous system and inefficient bloodflow from the legs back to the heart. In fact, the presence of varicosities indicates a CEAP (Clinical Etiology Anatomy Pathology) class 2 in terms of venous disease severity. Not all varicosities are caused by severe underlying venous disease, however, and it is in the patient’s best interest to have an evaluation by a vein specialist to ensure there is no significant underlying venous disease including venous insufficiency. The diagnostic Doppler ultrasound used to evaluate for venous disease and insufficiency is non-invasive, fast, and painless. Think of a varicose vein as a clinical sign that there may be further underlying disease. It is in the patient’s best medical interest for us to recognize these early-warning clinical clues and rule out more significant diseases for our patients. After an evaluation, venous insufficiency as well as varicosities can be easily treated in an outpatient setting—improving vascular health, daily comfort, and even aesthetics for the patient.
Q: I’ve recently encountered more older patients with leg ulcers. Some of them already have limited mobility – will ulcers make this worse?
A: Leg ulcers can be the result of many disease processes but chronic venous insufficiency is a significant contributor to chronic wounds. The venous system is a low-pressure system in contrast to the high-pressure arterial system. Venous return depends on a number of factors to overcome the gravitational and hydrostatic challenge of returning blood to the heart from the lower extremities when in the upright position:
Patent veins with healthy walls,
Numerous bicuspid valves with normal coaptation of valve leaflets,
Calf, thigh and foot muscle pumps.
Any failure of these components results in venous insufficiencies of which one long-term sequalae are venous stasis ulcers.
The lower extremity muscle pumps require muscle contraction within a fascial compartment to empty the deep veins and subsequently be refilled by the superficial veins via perforating veins. Ninety percent of lower extremity venous return occurs via the deep venous system. The calf muscle pump has an ejection fraction of 65% and the thigh muscle pump an ejection fraction of 15%. Abnormal calf muscle pump function is associated with a high incidence of lower extremity ulceration. Dysfunction of muscle pump function such as seen in elderly patients who are not ambulatory and wheelchair bound is thus associated with increased incidence and poor healing of lower extremity stasis ulcers.