Varicose vein

Physiotherapeutic assessment & Physiotherapeutic Management of Varicose vein with complete idea of its causes and forms.

1. Varicose Veins
Simran Shaw

2. What is Varicose
Vein???
Dilated, lengthened and tortuous
superficial veins of the limb with
incompetent valves are called
varicose veins.

3. Anatomy of venous system

4. Predisposing
Factors
Compression of pelvic veins during
pregnancy
Constant standing e.g. shop assistant.
Tight corsets or garters
Age
Genetic Factor also plays role
Basic weakness of vein wall.
Obesity
Therefore depending on the factors, varicose veins are :-
Primary
Secondary
1.
2.

5. Primary
Varicose Veins
1.CONGENITAL
WEAKNESS IN THE VEIN
Due to defective connective tissue &
smooth muscle.
2.CONGENITAL
ABSENCE OF VALVES
Klippel-Trenaunay syndrome -
congenital venous abnormality wherein
superficial and deep veins do not have
any valves..
3.MUSCULAR
WEAKNESS
Calf muscles weaken, lose their
pumping action and support for the
veins.

6. Secondary
varicose veins
1.PREGNANCY
cause proximal obstruction to the blood
flow.
4.CONGENITAL
ARTERIOVENOUS
FISTULA
increases blood flow & increases
venous pressure.
2.PELVIC TUMORS
cause proximal obstruction to the blood
flow.
3.ORAL
CONTRACEPTIVE PILLS
Alter the viscosity of blood.
5.SECONDARY TO DVT
can lead to destruction of valves

7. Pathology

8. DEMOGRAPHIC DATA1.
Name
Age - more commonly in 40-50 years.
Sex - not clear
Height - tall individuals suffer more
Weight - obesity may weaken the wall
Side - left is affected more than right
Address
Phone No.
Subjective Assessment

9. 2. CHIEF COMPLAIN
Dilated or tortuous veins
Dragging pain or dull ache
Night Cramps (calf muscles)
Fatigue in legs
Difficulty in walking
3. HISTORY OF PRESENT ILLNESS
Onset of pain
Fever
Oedema
Ulceration
Subjective Assessment
Note :- Pain is relieved on
exercice, while pain due to
arterial disease gets worse on
exercise.

10. 4.PAST HISTORY
Pelvic tumors
DVT
Chronic systemic disease
5.PERSONAL HISTORY
Prolonged standing activities
6. FAMILY HISTORY
Genetic abnormality inherited in the FOXC2
gene.
Subjective Assessment

11. 7. OCCUPATIONAL HISTORY
Hotel workers
Policeman
Shopkeepers
Tailors
8. DRUG HISTORY
Oral contraceptive pills
9. SOCIOECONOMIC HISTORY
Subjective Assessment

12. INSPECTION
Gait
Body Build
Posture
Dilated Veins or Tortuous Veins
Pigmented Skin
Ankle Flare
Dermatitis, Eczema
Healed Scar
Look for complications
1.
2.
3.
4.
5.
6.
7.
8.
9.
COMPLICATIONS
Bleeding
Venous ulcer
SVT
Oedema
Objective Assessment

13. Ankle Flare
Varicose Vein
Oedema
Eczema Healed ulceration
Active
ulceration

14. Objective Assessment
PALPATION
Hard nodule - thrombosed vein
Tenderness - thrombophlebitis
Whole length of vein is palpated
1.
2.
PERCUSSION (TAP TEST)
1. Place one finger, with a small amount of pressure, onto the
saphenofemoral junction (SFJ) which is located 4cm inferior-lateral
to the pubic tubercle.
2. Tap the varicose vein you are assessing, which should be located
lower down the leg.

15. Objective Assessment
EXAMINATION
Cough impulse Test (Morrissey's test)
Trendelenburg Test
Multiple Tourniquet Test
Modified Perthes' Test
Examine for DVT & Abdomen
PERCUSSION (TAP TEST)
3. If your finger over the SFJ detects a thrill, this suggests that there is
continuity of the vein due to incompetent venous valves (normally the
venous valves should prevent the thrill transmitting along the entirety
of the vessel)

16. Cough Impulse Test
(Morrissey's test
Place your hand over the saphenofemoral
junction (2-3cm below and lateral to the pubic
tubercle) and ask the patient to cough.
2. If you feel an impulse over the SFJ this
indicates a saphena varix (dilatation of the
saphenous vein at the SFJ).

17. Trendelenburg test
Done in 2 parts.
METHOD. Supine lying. Leg elevated above the level of heart
and the vein emptied. SF junction is occluded with the help of
the thumb ( or a tourniquet) & the patient is asked to stand.
TRENDELENBURG I. Release the thumb or tourniquet
immediately. Rapid gush of blood from above downwards
indicated SF incompetence.
TRENDELENBURG II. The pressure at SF junction is maintained
without releasing the thumb or tourniquet. Patient is then
asked to stand. Slow filling of the long saphenous is seen.
It is due to perforator incompetence.

18. Trendelenburg Test
Part 1
Rapid filling on
releasing pressure

19. Multiple Tourniquet Test
Done to find out exact site of perforators.
METHOD. Supine lying
The vein is emptied by elevation. 3-5 Tourniquets can be
applied.
Ankle, Knee & thigh perforators - 4 tourniquets are
applied..
1st Tourniquet - At the level of SF junction.
2nd Tourniquet - Middle of the thigh
3rd Tourniquet - just below the knee
4th Tourniquet - lower 3rd of the leg

20. Multiple Tourniquet
test

21. Modified Perthes'
test
To rule out DVT
Patient is asked to stand, tourniquet is
applied at SF junction and he is asked to
have a brisk walk.
INFERENCE:- If patient complains of
severe pain in calf region or if superficial
veins become more prominent, it is
indication of DVT.

22. Investigations
DOPPLER ULTRASOUND
Presentations are tools.
DUPLEX ULTRASOUND
IMAGING
Presentations are tools.
VENOGRAPHY
Presentations are tools.
PLETHYSMOGRAPHY

23. Management
Conservative Treatment
Injection of sclerosant solution into the vein + Firm Bandaging of the leg for 6 weeks.
Physiotherapy Treatment
Elastic stockings or elastic bandages.
Pneumatic Compression Devices
Long term graduated compression stockings
Encourage walking but avoid prolonged standing.
Elevation of lower legs for 10 minutes 3 times a day.
Sleep with end of bed raised.
Foot and ankle exercises in elevation
Walk 1-2 miles per a day with stockings, if necessary
Kinesiology Taping

24. Management
Surgical Treatment
Remove as many dilated veins as possible and ligate others.
Post-Operative Physiotherapy Treatment
Bandaging and Elevation of the leg.
Leg exercises hourly as soon as possible.
Foot ankle pumping exercises.
Hip & knee flexion & extension.
Quadriceps contractions.
Gluteal contractions.

25. Management
Post-Operative Physiotherapy Treatment
Post-Op First Day:-
Post-Op 2nd day:-
Home Regime
Patient is helped out of bed & walking is commenced with the legs well bandaged.
Gait training - correct pushoff, timing , stride length
Distance progressed
Stair Climbing
Discharged within 48 hours
Stockings for weeks
Leg Exercises contd..

26. Manipal Manual of
Surgery by K Rajgopal
Shinoy
Tidy's Physiotherapy
(12th edition)
SRB's Manual of
Surgery
Physiopedia
References

27. Thank You