VENOUS EXAMINATION OF THE LOWER LIMB
Historical Features of Note:
 Main problem
 Occupation
 Pain (in legs) worsens towards the end of the day
 Duration of symptoms
 Previous veins/treatments.
Predisposing Factors:
 Family history
 Previous pregnancy/history of swelling of legs in pregnancy
 Abdominal surgery
 Abdominal swellings (are clothes tighter?)
 Gynae symptoms (as appropriate-think of pelvic malignancies).
 Previous DVT
 Malignancy.
Examination:
This examination is performed with the trousers and socks off, with the patient standing
in front of you, preferably on a step.
Inspection:
 For visible dilated/tortuous veins.
 Signs if venous insufficiency in the gaiter area, (Medial aspect of leg, above
ankle) including:
o Oedema (-typically pitting in the early stages).
o Haemosiderin deposits (brown staining-iron deposits, due to chronic
leakage of blood into the tissues due to increased hydrostatic venous
pressure).
o Lipodermatosclerosis: “beer bottle legs” due to the progressive sclerosis of
skin and fat secondary to fibrin deposition, tissue death and scarring.
o Venous eczema: dry, flaky sometimes erythematos skin which can lead to
ulceration.
o Ulcers
Palpation:
General:
 Feel the varicose veins.
 Test the gaiter area for pitting oedema
 Palpate for defects in the deep fascia (by applying pressure along the medial
border of the tibia – caution- can be painful.
Groins:
 Saphenofemoral junction, ?varix. (SFJ located 2cm below and lateral to the
midpoint of the inguinal ligament.
 Cough impulse/thrill over the SFJ.
The Tap Test:
 Place right hand over a distal portion of varicose vein.
 Tap the vein proximally (e.g. 10-15cm proximally) with your left hand.
 A fluid thrill felt distally with the right hand implies the presence of incompetent
valves within the vein i.e. retrograde flow.
The Tourniquet Test:
 Lie the patient down on the couch .
 Sit on the couch facing the patient, gently lift the lower limb resting the ankle on
your shoulder.
 Using both hands, massage up the leg, emptying the veins, then apply the
tourniquet to the upper thigh (just below the SFJ).
 Ask the patient to stand up.
 Do the veins fill up immediately?
 YES: perforator vein incompetence below the tourniquet.
 NO: varicose veins controlled at the SFJ.
 Note, when performing this test, if you are unable to empty the veins, suspect
AV-fistula, or mechanical obstruction proximal to the SFJ.
The Trendelenburg Test:-now outdated, Doppler assessment of the SFJ is preferred.
 As for tourniquet test.
 Instead of applying the tourniquet, press firmly into the SFJ with two fingers after
emptying the veins.
 Stand the patient up, maintaining the pressure on the SFJ.
 Do the veins fill up immediately despite control of the SFJ:
 YES: perforator incompetence below SFJ
 NO: SFJ incompetence responsible for varicosities.
 Release the pressure on the SFJ, and the veins will re-fill promptly, confirming
incompetence of the SFJ.
Perthe’s Test:
 As for tourniquet test.
 Apply tourniquet to the upper thigh (below SFJ) after draining veins.
 Ask pt. to stand.
 Ask patient to stand up/down on tiptoes repeatedly:
 VEINS IMPROVE: deep venous system working effectively
 VEINS WORSEN/DISCOMFORT: ?deep venous obstruction, rule
out DVT.
To complete the Examination:
Offer ABDO and RECTAL examination (for masses).