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Leg health in our patients is extremely important but often not dealt with aggressively.

Leg Health encompasses arterial, venous, and lymphatic problems as well as degenerative arthritis and muscle issues. Quality of life depends on leg health.

Arterial problems are almost exclusively atherosclerotic in nature. Smoking accounts for 90% of arterial problems with diabetes and hypertension following in the distance. The most common presentation of peripheral arterial disease (PAD) is claudication (predictable calf and/or buttock cramping with walking). The cramping improves after stopping smoking and a committed walking program. Marked improvement is usually noted. Bypasses generally should not be performed for claudication. With new technology many are advocating endovascular procedures for quality of life. I say phoee!

Studies have shown that at two years those who are on a walking program do better than the interventional group. These patients must be responsible for their health. PAD should be used as an indicator; patients need to stop smoking, take a statin and begin a walking program. Claudication is generally benign and very rarely leads to amputation (<10%). Pain in the legs while lying, sitting or standing is generally not vascular. Testing should consist of a Doppler arterial evaluation which should include exercise to see how long the person walks before stopping and if they're stopped by calf cramps or shortness of breath or degenerative arthritis (hips, knees, and back). A CT angio or MR angio should not be performed. I am conservatively following many patients with superficial femoral artery occlusion.

Diabetes, especially, Type I should have an arterial evaluation with toe pulse evaluation if pulses are diminished or absent.

If peripheral neuropathy is found then careful attention should be focused on the shoes, especially in the obese who are more vulnerable to charcot joints. Soft leather, orthotics or even specialty made shoes should be worn. Care should be taken cutting the toenails. The feet should be soaked and nails should be cut straight across. The feet should also be checked for callus. I have seen numerous cases of infections with tenderness under calluses. If darkness is seen under a callus with tenderness or if the dorsum of a foot is swollen with cellulitis, a podiatry or surgical consult should be obtained ASAP. The patient should not be placed on antibiotics alone.

Patients with venous problems can be present with many symptoms ranging from cramping, aching and heaviness to restless leg syndrome. As mentioned in a previous article the mainstay in therapy should be elastic compression. Prophylactic 18-20mm knee high compression should be worn by those with strong family histories of venous insufficiency and in jobs that entail prolonged standing. If a person has any evidence of venous insufficiency - spider veins, varicose veins, swelling or pigment changes- 20 to 30 mm graduated compression to the knee will be sufficient. Patients are sometimes concerned they may "cut off circulation" or cause swelling above. They do not cut off circulation and edema above is not a significant problem as it is at the ankle where inflammatory proteins cause tissue destruction. TED stocking have no place except in a hospital in recumbent patients.

I feel symptomatic patients should be treated. Endovenous therapy is effective, safe and durable and entails less pain and recovery than stripping. In the hands of a physician experienced in vascular diagnosis and treatment, significant morbidity (skin changes and ulcers) can be avoided. Varicose veins are not just a cosmetic issue. A careful Doppler study should be performed and should include a standing study of the deep and superficial systems as well as perforators. Sites of reflux need to be noted along with their diameter. Any evidence of venous thrombosis whether it be chronic or acute should be documented.

Patients with lymphedema need a vascular evaluation and should be aggressively treated. These patients present with edema not only of the leg and ankle but also the dorsum of the foot and even the toes (Stemmer's sign). If the edema is significant or if there is seeping of fluid from the skin then short stretch bandages instead of regular elastic stocking should be used first. This can be instituted by dedicated nurses at a lymphedema clinic along with lymphatic massage.

Leg health is extremely important for all patients. Leg health includes the arterial, venous and lymphatic systems. Leg health does not just happen. We must be attentive to our patient's situations and give them direction to maintain a quality life.


Dr. Samuel P. Martin one of the leaders in venous diagnosis and treatment. Since their inception, the Vascular Vein Centers have served the Central Florida community as a recognized, educated resource with more than 25 years experience treating venous disease.

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