Varicose Veins

Procedure

Patient standing with the veins full. Apply a tourniquet around the leg (below the knee, or on the thigh) tight enough to block the superficial veins but not the deep veins. Ask the patient to do 10 heel raises or walk on the spot for a minute.

Positive Finding

Varicose veins below the tourniquet empty, stay full, or become larger and painful.

Sensitivity / Specificity

Reference: Kim J, Richards S, Kent PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl. 2000;82(3):171-5.

Interpretation

Veins that empty suggest the deep veins are open and the reflux is above the tourniquet. Veins that stay full suggest reflux lower down, through perforating veins. Veins that become larger with calf pain suggest a blocked deep vein: stop the test and arrange same-day medical assessment. From 70 legs in 44 consecutive patients with untreated varicose veins, compared with a duplex ultrasound scan done by a technologist who did not know the clinical findings (Kim 2000). Reflux at the saphenofemoral junction was found in 39 legs and not in 31. All the traditional tourniquet and tap tests performed poorly; a hand-held Doppler was more accurate. One junior doctor did all the clinical tests. For this test, 21 of the 70 legs gave an unclear result and are not counted.

Procedure

Patient standing. Place the fingers of one hand over the great saphenous vein just above the knee. With the other hand, tap the vein at the saphenofemoral junction in the groin.

Positive Finding

An impulse felt at the knee when the vein is tapped at the groin.

Sensitivity / Specificity

Reference: Kim J, Richards S, Kent PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl. 2000;82(3):171-5.

Interpretation

An impulse travelling down the vein suggests the valves between the groin and the knee are not closing (reflux in the great saphenous vein). An impulse travelling up the vein is normal and means nothing. A negative test does not rule reflux out; duplex ultrasound is needed before treatment. From 70 legs in 44 consecutive patients with untreated varicose veins, compared with a duplex ultrasound scan done by a technologist who did not know the clinical findings (Kim 2000). Reflux at the saphenofemoral junction was found in 39 legs and not in 31. All the traditional tourniquet and tap tests performed poorly; a hand-held Doppler was more accurate. One junior doctor did all the clinical tests. A negative tap test does not rule reflux out.

Procedure

Patient lying down. Raise the leg to about 45° to empty the veins. Press firmly over the saphenofemoral junction in the groin (just below and lateral to the pubic tubercle), or apply a tourniquet around the upper thigh. Ask the patient to stand while you keep the pressure on and watch the veins for 20–30 seconds, then release.

Positive Finding

Veins stay empty while pressure is held but fill quickly from above when it is released (reflux at the saphenofemoral junction). Veins that fill quickly despite the pressure suggest reflux lower down, for example through perforating veins.

Sensitivity / Specificity

Reference: Kim J, Richards S, Kent PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl. 2000;82(3):171-5.

Interpretation

Suggests where the valves are failing, but it often gives a positive result in legs without junction reflux on ultrasound. Duplex ultrasound is needed before any treatment. Refer urgently for a bleeding varicose vein, an ulcer, or skin changes. From 70 legs in 44 consecutive patients with untreated varicose veins, compared with a duplex ultrasound scan done by a technologist who did not know the clinical findings (Kim 2000). Reflux at the saphenofemoral junction was found in 39 legs and not in 31. All the traditional tourniquet and tap tests performed poorly; a hand-held Doppler was more accurate. One junior doctor did all the clinical tests. The test was sensitive but gave a positive result in most legs without junction reflux too, so a positive result means little.

Procedure

Patient standing. Place your fingers over the saphenofemoral junction in the groin (just below and lateral to the pubic tubercle) and ask the patient to cough.

Positive Finding

A thrill or impulse felt over the junction on coughing.

Sensitivity / Specificity

Reference: Kim J, Richards S, Kent PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl. 2000;82(3):171-5.

Interpretation

Suggests the valve at the saphenofemoral junction is not closing. A saphena varix (a soft lump at the junction that disappears when lying down) gives the same impulse and can be mistaken for a femoral hernia. A positive result does not confirm reflux; duplex ultrasound is needed. From 70 legs in 44 consecutive patients with untreated varicose veins, compared with a duplex ultrasound scan done by a technologist who did not know the clinical findings (Kim 2000). Reflux at the saphenofemoral junction was found in 39 legs and not in 31. All the traditional tourniquet and tap tests performed poorly; a hand-held Doppler was more accurate. One junior doctor did all the clinical tests.

Procedure

Patient standing. Inspect both legs from groin to foot, front and back: thread veins, varicose veins, ankle swelling, brown skin staining, eczema, hardened skin, white scarred patches, and healed or open ulcers (usually around the inner ankle). Gently feel along any hard or tender vein.

Positive Finding

Visible varicose veins, with or without swelling, skin changes or an ulcer.

Interpretation

Grades how advanced the venous disease is, using the clinical part of the CEAP classification: thread veins, varicose veins, swelling, skin changes, then healed and open ulcers. Skin changes and ulcers need referral. A red, hot, tender cord along a vein suggests superficial thrombophlebitis and needs same-day medical review to check for DVT. Venography is an X-ray dye test and is not part of this examination.