Venous Leg Ulcers
The topic of venous leg ulcers is a wonderfully challenging one because there are so many possible components to it, but fortunately it is fairly straight forward for most patients.
It is my opinion, based on 25 years of treating leg ulcers, that the underlying problem is “venous pump failure†and the diagnostic work up and treatment is ultimately focused on this. Venous pump failure (VPF) is what goes wrong with the “peripheral heart†usually resulting in some degree of calf hypertrophy, and accompanied by varying degrees of peripheral edema (similar to the edema of cardiac pump failure). In patients with “minimal†edema, and failing to heal, I will look at the ulcer edges with a magnifying glass where I often find hidden edema. This must be eliminated also.
I usually begin by noting the largest calf circumferential measurements and the narrowest ankle measurements. Other contributing factors are painful ambulation (from painful ulcer, painful knee and ankle joints) which prevent an adequate calf contraction (which causes a reduced venous output). So getting rid of the leg pain is the primary goal, and boosting the venous pump output with isometric compression is next. I like to get the patient walking without pain (and wearing isometric compression) on the first treatment session.
I see varicose veins in ulcer patients as representing the “leaks†in the peripheral pump, and its management by medical methods making more sense than surgical management (too crude and too much unnecessary tissue damage from surgery) especially since the introduction of venous “mapping†and foam sclerotherapy.
Failure to heal is often due to inadequate evaluation or getting the wrong treatment (e.g., skin grafts) while missing the underlying venous reflux.
And to answer the important question posed by my learned colleague about the role of isometric compression: it works by not only increasing the venous output during calf contraction, but more importantly the higher venous output is followed by a much greater negative phase in the deep venous system. This is the important function of the venous pump because it removes the venous blood and edema from the peripheral tissues. (This is what we measured when we performed PPG and LRR tests.)
I see the edema as drowning the tissue in and around an ulcer as well as competing with the micro-circulation, and when the edema is removed, the healing is usually rapid.
Brian McDonagh, MD
The information found on this website is not designed to replace the patient/physician relationship.
June 14th, 2007 at 4:19 am
My Doctor has prescribed a pair of “Jobst” gradient compression stockings for me to wear but they cause pain and tightness around the back of my knee and it seems as if they are cutting circulation in this area. I asked him if knee stockings instead of thigh high would be ok and he said no. I don’t know what to do.
August 2nd, 2007 at 5:57 pm
First, I would like to thank each and every doctor who is working on a solution to these leg ulcers. We patients need help badly! I have never been sure whether leg ulcers should be pierced and drained with a sterilized needle or left as they are, puffed up. My particular problem now is two large ulcers which developed following a fall. They are located on the backs of both legs. I drained them, and they have been probably the most painful things I’ve ever experienced. They seem to be healing, but the right leg is having a great deal of sharp pain beneath that ulcer. Because they are open, I cannot use stockings. I’m at a loss about how to proceed. My physician seems to have no answers, and I have scoured the web for information, with no results. If anyone here can possibly offer good advice, I would be eternally grateful. Thank you for this website and to all who participate in it.