Peripheral venous examination (varicose vein examination) frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs of venous disease using your examination skills. This venous examination OSCE guide provides a clear step-by-step approach to examining the venous system.
Confirm patient details: Name and date of birth (DOB)
Explain the procedure:
“I would like to examine the veins in your legs today.”
“This will involve me looking at your legs whilst standing, feeling the veins and performing some other tests. You’ll need to take your trousers off to allow me to see and examine the legs, however, you’ll be keeping your underwear on.”
“Are you in any pain at the moment? Do you have any trouble standing?”
Check the patient’s understanding:“Do you understand everything I’ve mentioned? Do you have any questions?”
Gain consent and offer a chaperone:“Are you happy for me to continue with the examination? One of the nursing staff will be present whilst I examine you, acting as a chaperone, is that ok?”
Expose the patient from the waist downwards (keeping their underwear on)
Check if the patient has any pain before you begin
Do the patient look comfortable?
Do they appear clinically unstable? (e.g. shortness of breath)
Look around the bed for clues (e.g. compression stockings, wound dressings/bandages)
1. With the patient standing (if able) look for signs of venous disease from the front, side and back of the legs.
Things to look for
Surgical scars are important to recognise, as this may be relevant to the patient’s presentation. It is worth clarifying what operation the patient had by checking the medical records and asking the patient.
It is important to note that modern venous treatments are now minimally invasive and therefore they’ll be no scars (NICE now recommends minimally invasive surgery for varicose veins as first line treatment). Traditional treatment in the past did result in a low groin scar on the affected side.
Venous eczema occurs as a result of venous hypertension causing fluid to collect in the tissues. The stasis of this fluid in the soft tissues results in activation of the innate immune response and subsequent inflammation.
Venous eczema has the following clinical characteristics:
Itchy red, blistered and crusted plaques; or dry fissured and scalyplaques on one or both lower legs (commonly mistaken for cellulitis)
Atrophie blanche (white irregular scars surrounded by red spots)
Orange-brown patches pigmentation due to haemosiderin deposition
Lipodermatosclerosis (as below)
If you’re not sure if the patient has venous eczema, ask “Is it itchy?”. Varicose eczema is often intensely pruritic and a this is a common indication for intervention.
Lipodermatosclerosis is a form of panniculitis (inflammation of the subcutaneous fat), caused by ongoing activation of the innate immune response in soft tissues (secondary to venous hypertension).
It is an advanced manifestation of chronic venous insufficiency (CVI) – one cause of CVI is of course varicose veins (other causes include deep venous incompetence and calf muscle pump failure).
Lipodermatosclerosis has the following clinical characteristics:
Skin hardening (often called induration)
“Inverted champagne bottle” appearance
Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves. They are the major cause of chronic wounds. Venous ulcers typically develop along the medial distal leg.
A venous ulcer can be defined as a full-thickness defect of the skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease.
Venous ulcers present with the following clinical characteristics:
Large, irregular border with sloping edges
Shallow in depth
Often located over the medial aspect of the ankle (referred to as the gaiter region)
Associated with mild pain
Arterial ulcers, on the other hand, are often smaller, deeper, punched out, with more well-defined borders and classically acutely painful
A Saphena Varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin. It appears as a swelling around 2-4cm inferior-lateral to the pubic tubercle. It often has a bluish tinge, is soft to palpate and will vanish when the patient lies down, which can help differentiate it from an inguinal hernia.
Arterial disease is important to be aware of when assessing and treating problems of the venous system. One of the common treatment options for varicose veins is compression therapy (with compression stockings or bandages). If a patient has a significant degree of arterial disease (which can be assessed by calculating the ankle-brachial pressure index or ABPI*) then they may not be suitable for compression therapy due to the risk of secondary ischaemia. Likewise, if the patient has venous ulcers, the first treatment is to ensure adequate arterial supply before treating any superficial venous disease.
*Can be falsely elevated in diabetic patients with calcified arteries
Clinical signs of arterial disease include:
Arterial ulcers: deep, punched out, well-defined and very painful ulcers
Varicose veins appear as tortuous dilated superficial veins.
The area of the varicose vein can help inform you as to which part of the venous system is affected:
The great saphenous vein originates at the merging of the dorsal vein of the big toe with the dorsal venous arch of the foot. After passing in front of the medial malleolus (where it often can be visualized and palpated), it runs up the medial side of the leg (classically known as the trouser seam). At the knee, it runs over the posterior border of the medial epicondyle of the femur bone. In the proximal anterior thigh 3-4 centimetres inferolateral to the pubic tubercle, the great saphenous vein dives down deep through the cribriform fascia of the saphenous opening to join the femoral vein. ¹
The small saphenous vein originates at the merging of the dorsal vein of the fifth digit with the dorsal venous arch of the foot. From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg, where it passes between the heads of the gastrocnemius muscle. The small saphenous vein drains into the popliteal vein, at or above the level of the knee joint. ² The saphenopopliteal junction (SPJ) is anatomically more variable in position compared to the saphenofemoral junction (SFJ).
In summary, the great saphenous vein runs all the way up the medialside of the leg and the smallsaphenousvein drains the lateralside of the lowerleg.
Varicose veins on the buttocks and around the genitals suggest problems of the venous system within the pelvis.
1.Assess the temperature of any varicosities:
Place the back of your hand along varicosities to assess the temperature
Increased temperature can indicate inflammation (e.g. phlebitis)
The primary treatment of thrombophlebitis is anti-inflammatories (not antibiotics) and consideration of varicose vein treatment
2.Palpate any visible varicosities:
Ask the patient to let you know if they experience any pain
Palpate the entire length of the varicosity
If there is overlying erythema in the distribution of the vessel and it is tender on palpation, this is suggestive of phlebitis
If the vessel feels hard (often referred to as “cord-like”) and pain is reported, this is strongly suggestive of thrombophlebitis (thrombosis with associated inflammation)
3. Assess for pitting oedema in the limb:
Apply some pressure with a fingertip above the medial malleolus for a few seconds and then remove to see if an indentation has been left behind (e.g. pitting oedema).
Continue to move upwards along the leg, repeating this process until you establish at what level oedema extends to.
Pitting oedema is commonly caused by heart failure and can impact the integrity of the skin if severe (as the skin becomes stretched and easily damaged).
Oedema is one of the first signs of complicated varicose veins.
4.Palpate the pulses in the legs to briefly assess the arterial blood supply of each leg:
Femoral pulse: mid-inguinal point (halfway between the anterior superior iliac spine and the pubic symphysis)
Popliteal pulse: inferior region of the popliteal fossa
Posterior tibial pulse: posterior to the medial malleolus of the tibia
Dorsalis pedis: dorsum of the foot
Phlebitis is the inflammation of a vein. It most commonly occurs in superficial veins. Phlebitis often occurs in conjunction with thrombosis and is then called thrombophlebitis. It is typically caused by trauma and infection (e.g. secondary to insertion of an intravenous cannula). In a small number of cases it can be caused by systemic inflammatory disorders such as lupus.
Percussion (“Tap test”)
The “Tap test” allows a crude assessment of the competency of venous valves.
The Tap Test is rarely performed in modern clinical practice, but it is described below so that you can be aware of its existence.
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.
3. If a thrill is felt by your finger over the SFJ, this suggests that there is continuity of the vein secondary to incompetent valves (as normally the venous valves should prevent the thrill transmitting along the entirety of the vessel).
Again, auscultation is rarely performed in modern clinical practice and has largely been replaced by modern venous duplex scanning. It is described below, so that you are aware of its existence.
1. With the bell of your stethoscope auscultate any varicosity you have identified.
2. The presence of a bruit indicates turbulent blood flow which may suggest an underlying arteriovenous malformation.
Please note that in modern practice all patients under consideration of varicose vein treatment will undergo a venous duplex scan of the entire superficial venous system to:
Confirm the origin of the incompetence (e.g. SFJ, SPJ).
Assess whether the veins are suitable for endovenous treatment (radiofrequency or laser ablation) as veins need to relatively straight to permit the passage of the catheters.
Establish the function of the deep venous system – if the deep veins are incompetent the patient may be relying on the superficial venous system for return of venous blood thus treating the superficial veins may cause chronic limb swelling.
You should be aware of traditional tests that were performed routinely before the advent of venous duplex scanning, but note they are rarelyperformed in modern practice.
The most common special test would be the use of a handheldDoppler. As a vascular surgeon, I would be far more interested in whether a candidate could assess the competence of the SFJ with a hand held doppler than perform any of the other outdated old fashioned special tests.
Trendelenburg test (a.k.a Tourniquet test)
This test is used to locate the site of the incompetentvenousvalves. It is now rarely performed in modern clinical practice.
If using fingers, it is called the Trendelenburgtest, if using a tourniquet instead it’s called the Tourniquettest.
You should assess onelegatatime.
1. Position the patient lying flat on the examination couch
2. Lift the patient’s leg up (as far as the patient is comfortable with) and empty the superficial veins by “milking” the leg towards the groin (SFJ).
3. Place a tourniquet over the saphenofemoral junction (SFJ) – this is found approximately 2-3cm below and lateral to the pubic tubercle.
4. Ask the patient to stand and observe for filling of the veins:
At this point, if the veins have not filled and remain collapsed, it indicates the incompetent venous valve(s) was at the level of the SFJ
If the veins have filled up again, it indicates the incompetent valve(s) are inferior to the SFJ (i.e. perforator veins – veins that drain venous blood from superficial to deep veins within the muscle)
5. Repeat the test with the patient lying, place tourniquet 3cm lower than the previous position, ask the patient to stand and observe venous filling.
6. Repeat until filling stops and the location of the incompetent venous valves is localised.
Cough impulse test
1. 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).
Perthe’s test is used to distinguish between venous valvular insufficiency in the deep, perforator and superficial venous systems.
1. Apply a tourniquet at the proximal mid-thigh level whilst the patient is standing.
2. Ask the patient to walk around the room (or continually alternate between standing on tip-toes and flat feet) for 5 minutes.
Varicose veins become less distended
If the varicose veins become lessdistended, it suggests that there is nodeepvenousvalvularinsufficiency, because the calf muscle is able to empty the varicoseveins by pumping blood from the superficial venous system to the deep venous system. This result would suggest there is a primary problem with the superficial veins.
Varicose veins stay the same or become more distended
If the varicose veins remaindistended (or become more distended) it suggests there isalsoaproblem with the deepvenoussystem, preventing the drainage of blood from the superficial varicose veins. In this circumstance, the patient may also experience pain in the leg due to venoushypertension. A potential cause of deep venous obstruction is a deepveinthrombosis.
To complete the examination…
Thank the patient and ask if they need any help getting dressed
Document your findings in the notes
Suggest further assessment and investigations
Abdominal examination: Occasionally increased pressure in the abdomen or pelvis (e.g. a large tumour) can occlude venous return from the legs leading to varicose veins
Doppler ultrasoundof any varicosities noted: Allows further investigation of incompetent venous valves and can identify thrombosis