Chronic venous insufficiency

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) is a long-term condition in which the vein walls and the valves in your legs have been weakened or harmed and cannot function properly¹. The valves no longer stop blood flowing backwards, so blood collects in the veins of your legs¹. It is sometimes called chronic venous disease¹.

CVI is common². Over time it can bring heavy, uncomfortable legs, swelling, changes in skin colour and, in some people, leg ulcers (open sores)²¹.

What causes it, and who gets it?

When the valves in your leg veins fail, blood flows back down and pools instead of travelling up towards your heart¹³⁴. This raises the pressure in the veins, and that raised pressure is a major factor in skin breakdown and ulcers³⁵. Valves can also become less effective as you get older⁴.

A weak calf muscle pump also contributes to CVI³⁶. Being inactive, standing for long periods and being overweight are linked with it⁶.

These are linked with chronic venous disease, not proven causes: older age, being female, a family history, previous pregnancies, obesity and standing for long periods⁷. Past leg clots (DVT), leg injury, arthritis and a sedentary lifestyle can also damage the valves⁸.

What does it feel like, and how is it diagnosed?

Symptoms of venous insufficiency include dull leg pain that worsens on standing, cramping, aching or heavy legs, itchy skin and swelling in the lower legs¹. Discomfort generally gets worse with prolonged standing and eases when you raise your leg⁵. Over time your skin may turn brown and thicker, sometimes called venous (varicose) eczema¹.

A podiatrist or doctor will ask about your symptoms and examine both legs, looking at swelling, varicose veins, skin changes and any sores. They will also check the pulses in your feet and ankles⁹. If you have a leg ulcer due to venous insufficiency, or if the pulses in your foot or ankle are weak or can't be felt before compression starts, they should measure your ankle-brachial pressure index (ABPI)⁸⁹. An ABPI above 0.8 is generally used to rule out significant arterial disease⁸, as severe arterial disease means compression stockings should not be used⁹.

What helps first?

Walking, moving your calf muscles and taking breaks from long spells of standing or sitting are encouraged, though it isn't clear yet whether this stops CVI developing.

Compression stockings are often the first treatment, and they help most people without much discomfort⁶. They should only be used once your leg's arteries have been checked, because they may worsen poor arterial supply⁶, and once the fit has been checked⁹. Extra care is needed with diabetes, reduced feeling in your feet, fragile skin or severe heart failure⁹¹⁰.

Take your stockings off at the end of the day. Wash and dry them, check your skin, and make sure they fit with no bunching¹¹⁴. Stop wearing them and report significant increased pain, numbness or colour change in your toes¹²⁴.

What helps if that isn't enough?

If a venous leg ulcer (an open sore caused by poor vein function) isn't healing despite proper compression, a podiatrist or doctor can re-check the diagnosis and your leg's arteries. They may add a device that helps your calf muscle pump work better¹³. This can also be an option if compression can't be used or isn't comfortable enough to keep wearing¹³.

If an ulcer still hasn't healed after about 12 weeks of appropriate treatment, they may refer you on for further assessment¹⁴. It isn't clear yet how well procedures for CVI work or how they compare with each other.

How long does it take, and how can I stop it coming back?

CVI is a long-term condition, so the aim is to manage it over time¹. A weak calf muscle pump goes with slower ulcer healing and larger ulcers in people with advanced CVI⁶. Compression stockings help most people without much discomfort⁶. Regular walking and calf movement are worth keeping up.

It isn't clear yet what best stops ulcers coming back.

What can make it serious?

• A wound or sore on your foot or leg hasn't started to heal after two weeks, or keeps coming back.
• A spot, mole or sore on the skin of your foot or leg is new, changing, bleeding or not healing.
• Your calf or leg on one side becomes swollen and painful, especially if it is also warm or red.
• Redness from a wound, sore or infection is spreading into your foot or leg, or red streaks run up from it.
• You have a foot wound, ulcer or infection, or a red, hot, swollen foot, and also have a fever, chills, a fast heartbeat or feel unwell.
• Your foot, or a patch of skin on your foot or leg, becomes red, hot, swollen and painful.
• You have diabetes, poor circulation or reduced feeling in your feet and notice a new wound, sore, blister or colour change on your foot, or a sore that isn't healing.
• You have constant pain in your foot or toes that is worse at night or when your legs are raised, and eases when you hang your leg down (this can be a sign of poor circulation).
• The skin on your toes or foot turns dark or black, or a wound turns black and smells bad.
• Numbness or tingling in your foot or leg spreads quickly, or comes with new weakness.
• A varicose vein on your leg has bled.
• You have a foot wound, ulcer or infection and also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine (possible sepsis).
• The skin over your infection turns dusky, purple or blistered, or the redness spreads very fast and the pain is much worse than the skin looks.
• You suddenly become short of breath, have chest pain or cough up blood.
• Your leg or foot suddenly turns cold and pale, with pain or numbness, or you suddenly can't move it.
• You have bleeding that won't stop when you press firmly on it.