By Dr. Marcus Judge

OSCE

During any examination in an OSCE it is important to understand the pathology and reasoning behind each of the signs and symptoms elicited, even if the patient being examined is ‘normal’. This article explains how to perform a varicose vein examination and the key findings you should look for, showing you what each sign means and what conditions it may indicate.

Varicose veins are dilated (widened), tortuous (twisted) superficial veins. They develop when the one-way valves of the leg veins become incompetent (fail to close properly), allowing blood to reflux (flow backwards) and pool under gravity. This examination assesses the superficial venous system, the deep venous system and the perforating veins that connect them. It also looks for the chronic skin changes that arise from sustained venous hypertension (raised pressure within the veins).

Contents

  1. Introduction
  2. General Inspection
  3. Inspection of the Legs
  4. Palpation
  5. Cough Impulse Test
  6. Tap Test
  7. Trendelenburg and Tourniquet Tests
  8. Perthes’ Test
  9. Auscultation
  10. Handheld Doppler
  11. Peripheral Pulses
  12. Completing the Examination
  13. Quiz

Introduction

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and mention your grade, for example 3rd year medical student, junior doctor or consultant.

Confirm the patient’s details taking three points of identification, usually full name, date of birth and NHS or hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail. Explain that you will need them to stand up for much of the examination, as varicose veins fill and become most apparent when the patient is upright.

Expose the patient’s legs fully from the groin down, ideally with the patient in underwear so that the saphenofemoral junction in the groin can be assessed. Maintain the patient’s dignity throughout, and offer a chaperone (a second member of staff who is present for the examination).

Ask the patient if they have any pain anywhere before you begin, and ask whether their legs are currently painful, aching or itchy.

General Inspection

Begin with a general inspection of the patient and the bedside. Look at the patient’s overall comfort and whether they appear to be in any distress. Note their body habitus (overall build), as obesity can increase the risk of developing varicose veins, probably because raised pressure inside the abdomen impairs venous return from the legs.

Look around the bedside for objects that give clues to the underlying problem or its management, such as compression stockings, compression bandaging, wound dressings, or mobility aids. The presence of dressings may point towards an active venous leg ulcer.

Inspection of the Legs

Inspect the legs with the patient standing, as this allows the veins to fill under gravity and makes varicosities (varicose veins) far more obvious than when the patient is lying down. Walk around the patient so that you inspect the front, sides and back of both legs, including the popliteal fossa behind the knee.

Ask the patient to point out the veins that trouble them before you start. This directs your attention and shows the examiner a patient-centred approach.

Identify the distribution of any varicose veins, as this helps localise the underlying incompetence:

  • Varicosities along the medial aspect of the thigh and calf typically follow the great (long) saphenous vein, which drains into the femoral vein at the saphenofemoral junction in the groin.
  • Varicosities over the posterior and lateral calf typically follow the small (short) saphenous vein, which drains into the popliteal vein at the saphenopopliteal junction behind the knee.

Also note any smaller intradermal vessels (those within the skin itself), as these reflect milder venous disease and can accompany frank (obvious) varicosities:

  • Thread veins (telangiectasia, ‘spider veins’): fine red or purple intradermal vessels under 1 mm in diameter.
  • Reticular veins: slightly larger bluish-green subdermal veins that do not bulge above the skin.
  • Corona phlebectatica (ankle flare) – a fan of dilated small veins around the ankle and instep. It is an early marker of established venous hypertension and a poor-prognosis sign for progression to ulceration.

Varicose Veins SimpleMed

Image - Dilated, tortuous varicose veins of the lower leg. Note how the veins follow the course of the superficial venous system

Creative commons source by the National Heart Lung and Blood Institute [Public domain]

Look for the chronic skin changes of venous insufficiency. These reflect long-standing venous hypertension and are typically most marked around the medial gaiter area (the lower third of the leg above the medial malleolus, the bony bump on the inner side of the ankle):

  • Haemosiderin staining: orange-brown patches of pigmentation. High venous pressure forces red blood cells out of the capillaries; as they break down, the iron-containing pigment haemosiderin is deposited in the skin.
  • Venous (varicose) eczema: itchy, dry, scaly and inflamed skin. Venous hypertension drives fluid into the tissues, and venous stasis (blood pooling in the veins) triggers a local inflammatory response.
  • Lipodermatosclerosis: hardened, tight, indurated (firm and thickened) skin caused by inflammation and fibrosis of the subcutaneous fat. In advanced disease the leg can take on the classic ‘inverted champagne bottle’ appearance, with a narrowed, fibrosed ankle and lower leg below a swollen calf.
  • Atrophie blanche: white, atrophic (thinned), scar-like patches surrounded by pigmentation, representing areas of skin that have healed after micro-injury.
  • Venous ulceration: typically shallow ulcers with sloping edges over the medial malleolus (gaiter area, from the ankle to mid-calf). Ulcers are a late complication of chronic venous hypertension, and they often heal and then recur.

Venous Eczema SimpleMed

Image - Venous (varicose) eczema with associated pigmentation, a sign of chronic venous hypertension

Creative commons source by Cardiologist61 [Public domain]

Chronic Venous Insufficiency SimpleMed

Image - Chronic venous insufficiency with haemosiderin staining and lipodermatosclerosis of the lower leg

Creative commons source by James Heilman, MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Finally, look carefully for any scars from previous varicose vein surgery (for example in the groin, the popliteal fossa or along the line of the saphenous veins), as these point towards recurrent disease. Also inspect for any healed or active ulcers.

Palpation

Always ask the patient again about pain before you touch the legs.

Palpate along the varicosities to assess their temperature and tenderness. A hard, warm, tender, erythematous (red) vein suggests superficial thrombophlebitis (inflammation and clotting within a superficial vein). Hardness within a vein may also represent a thrombosed varicosity.

Assess the texture of the surrounding skin for the induration of lipodermatosclerosis, which feels firm and bound-down compared with normal soft subcutaneous tissue.

Check for pitting oedema by pressing firmly over the medial malleolus or shin for a few seconds and watching for an indentation. Oedema reflects fluid leaking into the tissues as a result of venous hypertension. Remember that oedema in both legs has many other causes, such as heart failure, hypoalbuminaemia (low blood albumin) and chronic kidney disease.

Pitting Oedema SimpleMed

Image - Pitting oedema, demonstrated by the indentation that remains after firm pressure is released

SimpleMed original

Palpate the saphenofemoral junction (SFJ), located approximately 2–4 cm below and lateral to the pubic tubercle (the small bony bump at the front of the pubic bone). A soft, compressible lump at the SFJ that disappears on lying down may be a saphena varix (a dilatation of the great saphenous vein at its termination).

Cough Impulse Test

Place your fingers over the saphenofemoral junction (2–4 cm below and lateral to the pubic tubercle) and ask the patient to cough.

A palpable thrill or impulse transmitted to your fingers suggests incompetence of the valve at the saphenofemoral junction. Coughing raises intra-abdominal pressure, and if the SFJ valve is incompetent this pressure is transmitted down the great saphenous vein and felt as an impulse. A saphena varix gives a particularly prominent, palpable cough impulse. It can be mistaken for a femoral hernia (bowel or fat pushing through the femoral canal below the inguinal ligament), because both present as a lump in the groin. Telling them apart is therefore important.

Tap Test

The tap test assesses whether the valves along a segment of vein are competent or incompetent.

Place one finger over the saphenofemoral junction and the fingers of your other hand over a distal varicosity lower down the leg. Gently tap the distal varicosity and feel for a transmitted impulse at the SFJ.

If an impulse is felt at the SFJ, this suggests that the valves in the intervening segment of vein are incompetent, allowing the pressure wave to travel up the column of blood. In a healthy vein, competent valves interrupt this column and no impulse is transmitted. The test can also be performed in the opposite direction, by tapping proximally and feeling distally for a downward-transmitted impulse (one that travels down the leg). The tap test is a crude assessment and is rarely used in modern practice, because it misses many cases of reflux that duplex scanning finds.

Trendelenburg and Tourniquet Tests

These tests aim to localise the level of venous incompetence (find which valves are leaking). They are now considered outdated, because venous duplex ultrasound shows the level of reflux more accurately and is what plans treatment. Know the principle behind each test and its limits, and use the handheld Doppler (see the Handheld Doppler section) as the bedside method.

With the patient lying down, raise the leg as high as the patient finds comfortable and milk the blood out of the superficial veins (stroke it firmly along them) towards the groin to empty them.

Next, occlude the superficial venous system at the saphenofemoral junction. If you do this with firm finger pressure the manoeuvre is called the Trendelenburg test; if you use a tourniquet (a tight band around the thigh) instead it is called the tourniquet test. The two are otherwise identical in principle.

Ask the patient to stand while you maintain the pressure or keep the tourniquet in place, and observe the veins:

  • If the varicosities remain collapsed while pressure is applied at the SFJ, the site of incompetence lies at or above the SFJ. When you then release the pressure and the veins rapidly fill from above, this confirms saphenofemoral junction incompetence.
  • If the varicosities fill rapidly despite pressure at the SFJ, there must be an additional incompetent valve below the level of occlusion (for example an incompetent perforating vein).

The tourniquet test can be repeated at progressively lower levels down the leg: mid-thigh, above the knee and below the knee. Continue until you find the level at which the veins stay controlled. The point below which the veins start to fill localises the incompetent valve or perforator.

Perthes’ Test

Perthes’ test assesses the patency and competence of the deep venous system (whether the deep veins are open and their valves work). This matters because, if the deep veins are blocked or incompetent, the patient may rely on the superficial veins to return blood, and treating the superficial veins could cause chronic leg swelling.

With the patient standing, apply a tourniquet to the upper thigh to occlude the superficial veins. Then ask the patient to walk or repeatedly rise onto tip-toes for about five minutes to activate the calf muscle pump (the squeezing action of the calf muscles that pushes blood up through the deep veins).

  • If the superficial varicosities empty and become less distended, the deep veins and perforators are competent, and the calf pump is successfully draining blood from the superficial system into a patent deep system.
  • If the varicosities remain full or become more distended and painful, this suggests deep venous obstruction or incompetence, meaning that treating the superficial veins (for example by ablation or surgery) could be harmful, as they may be providing important collateral drainage (an alternative route for blood to return to the heart).

Auscultation

Auscultate over any prominent or unusually large varicosities using the diaphragm of your stethoscope.

A bruit (a continuous whooshing sound) over a varicosity is abnormal. It raises the suspicion of an underlying arteriovenous malformation or fistula, in which high-pressure arterial blood flows directly into the venous system. Auscultation is rarely performed in modern practice, because venous duplex scanning has largely replaced it, but a bruit is an important finding to recognise.

Handheld Doppler

A handheld Doppler probe (a small ultrasound device that lets you hear blood flow) is often available at the bedside and gives a quick assessment of valve competence at the major junctions. Place the probe over the saphenofemoral junction (or the saphenopopliteal junction for a posterior calf varicosity) and squeeze the calf to drive blood upwards.

You should hear a single ‘whoosh’ as blood flows up the vein. A second whoosh on release, as blood refluxes back down through an incompetent valve, indicates venous reflux at that junction. This is a useful screening manoeuvre, but the definitive test for mapping reflux remains venous duplex ultrasound (a scan that shows both the veins and the direction of blood flow in them).

Peripheral Pulses

Assess the arterial supply of the legs before compression treatment, as significant peripheral arterial disease can make compression unsafe. Compression is a mainstay of venous leg-ulcer care after assessment of the arterial supply, but it is not routine first-line treatment for varicose veins. NICE advises offering compression hosiery (specially fitted elastic stockings) to treat varicose veins only when interventional treatment (a procedure that closes or removes the vein) is unsuitable.

Palpate the lower limb pulses in both legs:

  • Femoral pulse: at the mid-inguinal point (halfway between the bony point at the front of the hip and the pubic bone).
  • Popliteal pulse: deep in the popliteal fossa behind the knee.
  • Posterior tibial pulse: behind and below the medial malleolus (the bony bump on the inner side of the ankle).
  • Dorsalis pedis pulse: on the dorsum (top) of the foot, lateral to the extensor hallucis longus tendon (the tendon that straightens the big toe).

Dorsalis Pedis Pulse SimpleMed

Image - Palpating the dorsalis pedis pulse on the dorsum of the foot, lateral to the extensor hallucis longus tendon

SimpleMed original

Absent or weak pedal pulses suggest co-existing peripheral arterial disease. For suspected venous leg ulcers, measure the ankle-brachial pressure index (ABPI) with a handheld Doppler before compression (the ABPI compares the blood pressure at the ankle with the blood pressure in the arm). Palpable pulses alone do not replace this measurement. The ABPI can be unreliable in people with diabetes or calcified arteries, so interpret it alongside the clinical findings.

Venous Ulcer SimpleMed

Image - A venous leg ulcer. Arterial supply must be confirmed with an ABPI before compression therapy is used to treat venous ulceration

Creative commons source by Jonathan Moore [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)]

Completing the Examination

Thank the patient and allow them to redress, then wash your hands.

Summarise your findings, commenting on the distribution of the varicosities, the presence of any skin changes or ulceration, and the results of the special tests localising the level of incompetence.

To complete the examination, suggest performing a full abdominal examination (to exclude a pelvic or abdominal mass causing venous obstruction), a digital rectal examination if a pelvic cause is suspected, and measuring the ankle-brachial pressure index (ABPI) to assess the arterial supply before any compression therapy.

The key investigation is a venous duplex ultrasound (an ultrasound scan that shows the veins and the direction of blood flow in them). It is usually done in a vascular service rather than at the bedside. NICE recommends it to confirm the diagnosis, show the extent of reflux and plan treatment. It also shows how well the deep veins are working, and it guides decisions about treatment such as endothermal ablation (closing the vein with heat from a radiofrequency or laser catheter), foam sclerotherapy (injecting a foam that closes the vein) or surgery.

Quiz

Preview the Varicose Vein OSCE Examination quiz

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