ORIGINAL PAPER Arch Physiother Glob Res 2016; 20 (3): 29-32

Diagnosis of varicose veins of the lower limbs – functional tests

Agnieszka Pedrycz ABCDEFG, Beata Budzyńska ABCDEFG

Departament of Histology and Embryology, Medical University in Lublin, Poland

Abstract Varicose veins of the lower limbs are dilated, gnarled, swirled and twisted superficial veins with balloon -like bulges. They are divided into two types – primary varicose veins with normal deep veins and secondary ones which develop after trauma or superficial phlebitis. They form in various locations, e.g. on the great saphenous vein, accessory posterior and anterior saphenous vein and small saphenous vein. Present study presents functional tests used in diagnosis of variose veins.

Key words: varicose veins, functional tests

Symptoms and causes sence of valves in the superficial veins. When a Primary varicose veins are caused by a decrease of valve is not present or cannot close completely, the the elastic tissue amount in venous walls, which be- blood carried to the heart flows partly backward. come less stretching-resistant. The dilation of venous It accumulates in the veins and increased pressure walls leads to valve failure resulting in backward flow stretches the veins leading to the development of and accumulation of larger amounts of blood and varices [7]. contributes to further dilation of vessels. [1]. Malfunctioning of vein valves is often a genetic Secondary varicose veins are caused by incre- defect. The risk of varicose veins in children of the ased volumes of blood flowing through superficial affected parents is 90%. If varices are present only in veins of lower limbs due to obstructed deep veins. one of the parents, the risk is 60% in females and 25% In many cases, an increased blood flow may result in males. Varicose veins are extremely rare in children from valve malfunction in the perforator and deep whereas their incidence in 60-year-olds individuals is veins [2, 3, 4]. sixfold higher, compared to 30-year-olds. At the initial stage, varicose veins do not always In the standing position, the distance the blood cause pain. The main reason why patients seek me- has to travel to reach the heart is prolonged. When dical attention at this point is a cosmetic defect. the legs do not move, the muscle pump stops and The first symptom is a discomfort – tiredness and the immobilized calf muscles do not push blood heaviness of legs, night cramps. The subsequent towards the heart [8]. In the sitting position, the symptoms include swelling of the lateral and me- legs do not move and are bent in the hip and knee dial ankle as well as the dorsum of the foot, dull joints; therefore, the blood flow towards the heart or burning pain, paraesthesia. The changes visible is more difficult resulting in muscle pump mal- on the lower limbs include spider veins or wiggly function. -shaped small swellings under the skin surface. The Individuals with the recommended body we- swellings are soft and painless and their sizes de- ight increased by 20% are susceptible to venous pend on the limb position. On palpation, the gre- insufficiency. Excessive weight overburdens the at saphenous vein is an elastic strained robe, often legs, which hinders movements and provokes the enlarging on coughing. Moreover, the skin in the sedentary lifestyle. Consequently, the venous blo- ankle area may undergo the following changes: di- od flow is impaired. Obesity increases the risk of scolourations, hardenings, eczema and swellings in varices, especially in female patients [9]. the shin area which may persist even after a night Hormonal changes during pregnancy and the rest [5]. accompanying circulatory strain cause venous in- Varicose veins in pregnant women cause more sufficiency of the lower limbs. symptoms than those in non-pregnant individuals The other factors that may contribute to the [4, 6]. development of varicose veins include oral con- One of the main causes of the development of traceptives, hormone replacement therapy, tobac- varicose veins is malfunctioning or complete ab- co, low-fibre diet, hot baths, sauna, solarium (high

Copyright © 2016 Vincent Pol University in Lublin, Poland 30 Pedrycz Agnieszka, Budzyńska Beata temperature dilates the vein, which slows the blood – obstetric medical history, flow to the heart), weight lifting (increased pressu- – injuries – surgeries, immobilization, re in the abdominal cavity exerts pressure on veins – overweight, obesity, which impairs the blood flow to the legs). – tobacco smoking, Moreover, the way we dress affects the develop- – history of vein diseases (deep vein thrombosis, ment of varicose veins as well. Tight underwear or previous varicose veins, pulmonary embolism, uncomfortable high heel shoes, which disturb the lower leg ulcerations, superficial thrombophle- proper heel-to-toe movement, considerably reduce bitis, previous antithrombotic treatment, tem- the activity of calf muscles. porary oedema of legs after an injury, immobi- The performance of the lower limb muscle lization after surgery or labour) [13, 14]. pump is also impaired by hindered movement of Functional tests the joints caused by changes in their structure [10]. When the functional tests of the vascular sys- tem have become routinely applied, the venous Diagnosis of varicose veins functional tests are less commonly used. Howe- During the first stage of diagnosis, the patient`s ver, some of them, such as Linton, Schwartz or medical history is carefully taken. Subsequently, Tredelenburg tests are still popular since they are the patient undergoes the physical examination time- and cost-effective, providing simple and qu- aided with detailed diagnostic methods. Duplex ick classification of patients. The other tests may be and Doppler ultrasound procedures allow more replaced by Doppler US or plethysmography. All accurate anatomical and functional evaluation of these diagnostic methods enable quick assessment the deep vein system [11]. of the condition of deep and perforating veins.

Case history SCHWARTZ TEST (wave test, percussion The characteristics and localization of the ail- symptom) ments reported by patients with venous insuffi- ciency are often non-specific. Diagnosis requires The test reveals incompetence of valves of the su- extreme scrutiny. Questions should focus on pre- perficial veins. disposing factors, causes and symptoms of venous Procedure: the patient is in a standing position insufficiency. and the physician palpates the varicose vein with the It is crucial to analyze present health problems, fingertips of one hand and taps the varicosity or the the way they manifest themselves, their duration, closest vein with the fingertips of the other hand. speed of development, type of discomfort and the Interpretation: the occurrence of the shock wave applied treatment. confirms the venous reflex. The test can also be mo- Moreover, the time that lapsed from the first si- dified so that the doctor taps the further segment of gns and the size of the affected area (both or one the vein and presses the vein or the closest varicosity leg) are of importance. with the fingertips. The shock wave proves the rela- The patient’s lifestyle should also be analyzed, tion between the two vein segments [14]. including physical activity, living environment – such as temperature and climate, use of compres- LINTON TEST sion therapy and its effectiveness [12]. The test confirms occlusions in the deep vein The symptom indicating venous insufficiency is system. difficulty with putting on shoes at the end of the Procedure: the patient is in a standing position day, including pain (location), swelling (time of and a tourniquet is placed below the knee blocking the day, size), restless legs syndrome, night cramps, superficial return of venous blood. Subsequently, “heavy” legs. the patient is quickly placed supine and elevates the leg. Assessment of risk factors Interpretation: if the blood flow in the deep vein – lifestyle – sports, physical activity, type of system is not disturbed, the varices empty quickly. work (physical, standing, sedentary), If, on the other hand, the system is occluded, the – genetic predispositions – varicose veins, em- varices empty slowly or remain dilated [14]. bolism, chronic venous insufficiency, thrombosis, ulcerations, – drugs – hormones and oral contraception,

Arch Physiother Glob Res 2016; 20 (3): 30-32 Diagnosis of varicose veins of the lower limbs – functional tests 31

TREDELENBURG TEST pathological reflexes. Moreover, it allows to gather The test evaluates varicosity of thighs. It con- preliminary information concerning anatomical trols the function of the small saphenous vein and conditions. The examination is most often perfor- perforating veins. med: Procedure: the patient is placed supine with the • to determine the direction of the blood flow in leg elevated, the therapist looks for dilated veins, superficial veins, applies a tourniquet on the upper part of the thigh • to test the efficiency of the valves in femoral and allows the patient to stand up. and popliteal veins, great and small saphenous Interpretation: If the varices do not fill or fill veins, femoral and popliteal veins and crural slowly within half a minute after standing up but veins. when the tourniquet is removed they fill fast within Ultrasound examinations using the Doppler effect a few seconds, it means the great saphenous vein is offer inexpensive and noninvasive phlebologic dia- occluded but the perforating veins are not affected. gnosis and therefore they are widely used superse- Their relatively fast filling from the proximal side ding X-ray examinations. may indicate small saphenous vein occlusion and In recent years, apart from the Doppler test from the distal side – insufficiency of perforating commonly used, some other methods are applied veins [14]. that provide hemodynamic information. One of them is plethysmography. PRATT TEST Venous plethysmography enables to determine The test is used to locate the places of perforating changes in the blood volume in the lower limbs. vein insufficiency. The examination is performed under various phy- Procedure: the patient elevates the leg and the siological conditions (with tourniquets, at rest as doctor places a tourniquet between the foot and well as during physical activity) and in different the upper 1/3 of the thigh. Elastic bandage is placed body areas (thigh, shin, foot). proximally and the patient stands up. The doctor ap- Results – the differences in blood volume may plies another elastic bandage in place of the tourniqu- be recorded using the following techniques: strain et. The lower bandage is slowly unveiled whereas the gauge plethysmography, photoplethysmography upper one is wrapped around the limb. The therapist (reography in reflected light), air plethysmography, tries to leave only a small fragment of the skin be- impedance plethysmography, gravimetric etc. Ho- tween the bandages not pressed. wever, the above techniques are used very seldom Interpretation: the fragment where the skin is not [15, 16, 17, 18]. pressed reveals incompetent perforating veins [14]. References: Invasive tests 1. Wang L, Chu K, Zeng L, Wang L. Primary varicose ve- In order to supplement the physical examina- ins treated with HE’s fire needle therapy: a rando- tion, some function-assessing tests are performed, mized controlled trial Zhongguo Zhen Jiu. 2016; including the following: 36:231-236. • Duplex – Doppler test, 2. Andziak P. Chirurgia naczyniowa. In: Medycyna po • Duplex ultrasounu imaging, Dyplomie. 2012; 63-64. 3. Creager MA, Loscalzo J. Choroby naczyń. Lublin: • X-ray examination, Czelej; 2008. • magnetic resonance imaging (with a contrast 4. Szmidt J. Podstawy chirurgii. Medycyna Praktyczna. agent), Kraków: 2003. • phlebodynanometry, 5. Korzhyk NP. Varicose disease of the lower extremities: • plethysmography (during exercise and at rest), causes, complications, choice of methods for tre- • transcutaneous oximetry, atment and prophylaxis. Klin Khir. 2016; 2:52-55. • thermography, 6. Smyth RM, Aflaifel N, Bamigboye AA. Interventions • angioscopy, for varicose veins and leg oedema in pregnancy. • capillaroscopy. Cochrane Database Syst Rev. 2015; 19: CD001066. One on the most frequently performed tests is doi: 10.1002/14651858.CD001066.pub3. 7. Tisi PV. Varicose veins. BMJ Clin Evid. 2011; 5: pii: the one using the Doppler effect. 0212. The Doppler test is essential for evaluating 8. Randall S. Looking after your health. 3. Avoiding vari- the dynamics of the blood flow and detecting cose veins. Pract Midwife. 2015;18:32-34.

Arch Physiother Glob Res 2016; 20 (3): 30-32 32 Pedrycz Agnieszka, Budzyńska Beata

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