Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Leg swelling |
DVT |
Risk factors: malignancy, pregnancy, recent surgery, hormonal treatments, long-haul travel, immobility.
Unilateral hot swollen red and tender calf. Affected calf measures >3 cm larger than unaffected side. May be associated with symptoms of pulmonary embolism. |
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Chronic venous insufficiency |
Older patient, associated obesity or immobility.
May have associated venous disease e.g., varicose veins. Bilateral swelling & associated skin changes in gaiter region. Skin: eczematous, red, haemosiderosis, lipodermatosclerosis, atrophie blanche. |
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Post-thrombotic syndrome |
Presentation as for chronic venous insufficiency caused by previous DVT. May present years after DVT. | ||
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Varicose veins |
Risk factors: age, pregnancy, obesity, prolonged standing.
May be asymptomatic. Heaviness, aching, dragging sensation uni/bilateral legs. Itching or burning sensation, cramping pain, restless legs. May be associated with chronic venous insufficiency. |
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Superficial thrombophlebitis |
Common in people with pre-existing varicose veins.
Acute pain, itching and swelling over superficial vein. Hardened, tender vein with associated redness to skin. |
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| Leg skin changes |
Venous eczema |
Sign of chronic venous insufficiency. Bilateral changes likely
Red, dry, flaky, inflamed skin in gaiter region of legs. |
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Haemosiderin deposition |
Sign of chronic venous insufficiency. Bilateral change likely.
Brown or red skin discolouration, staining of skin in gaiter region of legs. |
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Lipodermatosclerosis |
Sign of chronic venous insufficiency. Bilateral change likely.
Inverted champagne bottle appearance to lower legs. Skin is hardened, tight and gaiter region is narrowed. |
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Cellulitis |
Acute redness, swelling, heat and pain to skin of lower leg.
May be associated with systemic upset e.g., pyrexia. Can be a consequence of chronic venous insufficiency. Unilateral change. |
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| Leg ulcer |
Venous ulcer |
Associated with chronic venous skin changes e.g., Eczema.
Arise in gaiter region just above the ankle/below calf. Larger, less painful, irregular edges, superficial, bleeding. Pain improved with leg elevation: relief of venous pressure. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient standing | ||
| Appropriate exposure of lower limbs | ||
| General Inspection | Body habitus | |
| Evidence of increased risk of varicose veins | ||
| Clues in bed space | ||
| Leg Inspection | Inspect standing (anterior/posterior/lateral) | |
| Colour | ||
| Scars | ||
| Swelling | ||
| Varicose veins | ||
| Saphena varix | ||
| Further inspection with patient reclining at 45° | ||
| Evidence of chronic venous insufficiency | ||
| Leg Palpation | Temperature | |
| Palpation of varicosities | ||
| Saphenofemoral junction | ||
| Auscultation | Auscultate varicosities | |
| Special Tests | Tap test | |
| Trendelenburg test | ||
| Perthes’ test | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your peripheral venous system. This involves looking at the veins in your legs. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient standing initially.
Ask the patient to expose their lower limbs.
General Inspection
Look at the patient and around the bed space for useful signs:
- Body habitus (e.g., overweight or underweight)
- Evidence of increased risk of varicose veins (e.g., pregnancy)
- Clues around the bed space (e.g., walking aids, compression bandages, etc)
Leg Inspection
With the patient standing, inspect the legs for:
- Colour (e.g., redness, pallor, haemosiderosis)
- Scars
- Swelling – unilateral or bilateral
Inspect the legs for any signs of varicose veins; these present as visible, prominent, tortuous, and dilated superficial veins of the lower limb. The position of the varicosities reflects the underlying venous system which is affected:
- Short saphenous vein – postero-lateral aspect of the lower leg
- Long saphenous vein – medial ‘trouser seam’ of leg and thigh
- Saphena varix – varicosity at the saphenofemoral junction (SFJ,) located 2-3 cm infero-lateral to the pubic tubercle. A saphena varix will disappear when the patient is lying down.
Then reposition the patient on the couch reclining at 45° for further inspection of the legs.
Inspect the legs for signs of concurrent venous disease including chronic venous insufficiency (skin changes especially in the gaiter region of the legs).
Leg Palpation
Palpate the varicosities along their course. Varicose veins are palpable dilated superficial veins but should feel bouncy and minimally tender; hardened, ‘cord–like’, or very tender varicose veins may indicate superficial thrombophlebitis (thrombosis and inflammation of the superficial veins). Increased temperature over varicosities may also be a feature of thrombophlebitis.
Palpate over the saphenofemoral junction (SFJ) located 2-3 cm infero-lateral to the pubic tubercle. Ask the patient to cough whilst palpating the SFJ. A swelling in this area with a positive cough impulse indicates a saphena varix.
Auscultation
Place stethoscope over a varicosity and listen for bruits. If present, bruits may indicate an arteriovenous malformation.
Special Tests
The special tests associated with varicose veins demonstrate venous valvular incompetence and are as follows:
- Tap test
- Trendelenburg test
- Perthes’ test
Tap test – apply pressure to the saphenofemoral junction and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ.
Trendelenburg’s test – with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.
Perthes’ test – apply a tourniquet to the thigh compressing the superficial veins and ask the patient to pump their calf muscles by performing heel raises whilst standing, or walk around the room. If the superficial veins disappear, the deep veins are functioning normally as the superficial varicosities are being drained into the deep venous system. Increased dilation of the superficial veins indicates a problem in the deep veins as blood is not able to drain from the superficial venous system to the deep venous system. This increases the risk of DVT in future.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings and your differential diagnosis, you may wish to carry out further investigations, including Doppler ultrasound to assess for venous valvular incompetence, as well as ABPI to exclude arterial disease and confirm suitability for compression treatment.
Last updated Dec 2024
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