Calf Pain and Varicose Veins

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Varicose veins plague an estimated 20% of our population and those who are fit and active are unfortunately not immune. These tortuous veins are early manifestations of chronic venous disease.

Member Question

My left calf hurts. I developed a varicose vein a few years ago in my left leg. It's a big ugly ropey looking thing. Sometimes it hurts, sometimes it doesn't. Do you have any advice to share? 

And the pointer of staying off my feet for a few days doesn't apply. I work in hospitality and walk an average of four to nine miles everyday of work, five to seven days a week.

Answer from Chris Koutures, MD
Member AMSSM

You are not alone in the pain you’re suffering! Varicose veins plague an estimated 20% of our population(i) and those who are fit and active like yourself are unfortunately not immune. These tortuous veins are early manifestations of chronic venous disease and often present with the pain you described in your calf. Symptoms of chronic venous disease can be highly variable but many report a spectrum of discomfort that can range from fullness or heaviness, dragging or achiness, to frank pain. Such discomfort is often localized to the calf or thigh and tends to progress throughout the day, and is particularly aggravated by prolonged standing.

An overview of the proper function of our circulatory system helps in understanding the pathology of chronic venous disease. Blood is pumped away from our heart through arteries and returns to the heart through veins. Our veins depend on a series of valves and muscle pumps in order to deliver blood back to the heart. Blood that enters the lower extremity venous system in our legs has the additional work of fighting against gravity and the pressure of our abdominal and thoracic cavities in order to return to central circulation when in an erect position. Contraction of muscle pumps primarily in the calf, but also in the foot and thigh, helps propel blood back to the heart and the one way valves help prevent backward flow.

The development of muscle pump dysfunction or valvular incompetence leads to blood pooling in the lower extremity. Failure of the valves at the junction of the deep and superficial veins causes retrograde flow of blood from deep veins back to the superficial veins creating the dilatation seen in varicose veins(ii). Progression of disease can lead to further complications including persistent pain and discomfort, swelling of the legs, bleeding, clot formation, and progressive skin changes that may ultimately lead to ulceration.

Common risk factors for chronic venous disease include the inevitable contributions of age and genetics. Age causes wear and tear on the valves and over time the vessel wall becomes thickened with disorganized collagen bundles(iii). Heredity plays a prominent role with one study revealing a 90% risk for developing varicose veins if both parents had the disease, 25% for males and 62% for females when one parent had disease, and 20% if neither parent affected(iv). Other notable risk factors include female gender, hormonal changes with increased progesterone, number of children given birth, body weight, constipation, and history of venous thrombosis all of which can lead to increased intravenous pressure. Increased pressure from prolonged standing or sitting, especially with legs crossed, can also contribute to chronic venous disease

What can be done to prevent the development and progression of chronic venous disease? I would of course recommend against standing or sitting for long periods of time, however, understand that it can often be unavoidable. If prolonged standing is necessary you should attempt to shift weight from one leg to another every few minutes. Likewise, attempt to stand and walk around every 30 minutes if forced to sit for a prolonged period of time. Compression stockings, either over the counter or prescribed, can place helpful pressure on your veins contributing to proper blood flow back to central circulation. Wearing loose and non-restrictive clothing around abdomen, waist, and thighs can also help prevent any obstruction of blood flow. Weight control should also be emphasized to prevent placing too much pressure on legs. Eating a low salt and high fiber diet can minimize swelling and reduce the chance of constipation, respectively. Additionally, avoid wearing high heels and crossing your legs. Finally, regular exercise will help improve leg strength and circulation and promote overall health.

In addition to the above preventive methods a primary care physician should also evaluate any individual with varicose veins, especially when painful. Some tests that can be run for further evaluation of appropriate blood flow include Doppler ultrasonography and less commonly venography, light reflex rheography, photoplethysmography, and foot volumetry(v). If conservative management with compression stocking and lifestyle modifications are ineffective in controlling symptoms and progression of disease then surgery as well as new non-surgical interventional procedures including are available that should be discussed with your physician.

(i) Fiebig et al. Heritability of chronic venous disease. Human Genetics, 2010. 127: 669-674.

(ii) Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005. 111: 2398-2409

(iii) Sansilvestri-Morel-P et al. Comparison of extracellular matrix in skin and saphenous veins from patients with varicose veins: does the skin reflect venous matrix changes? Clinical Science. 2007. 122: 229-239.

(iv) Chen C, Guo H. Varicose veins in hairdressers and associated risk factors: a cross sectional study. BMC Public Health. 2014, 14: 885

(v) Jones RH, Carek PJ. Management of varicose veins. Am Family Physician. 2008 Dec; 78(11): 1289-1294

Kathleen Linzmeier MD, Pediatric Resident (and sports fellow to be) at UC Irvine/Children's Hospital of Orange Count. 

CHRIS KOUTURES, MD
Sports Medicine Physician

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date: November 12, 2014

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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