European Journal of Cardiovascular Medicine

Lower extremity venous diseases are widespread and can present with a wide range of severity—from asymptomatic valve failure to persistent leg ulceration. These are defined as “elongated subcutaneous veins” (1) present in the Lower extremities, dilated to ≥3mm in its diameter in the upright posture and are usually palpable” (2). The other findings may include telangiectasias or fine reticular varicosities. It affects around 10-30% of people in the western world, and in India it is around 5%. (3) These diseases cause considerable morbidity with about 2% of national resources of healthcare being spent on the management. (4) It has been estimated that chronic leg ulceration may affect around 1 % of the population and some surveys show that 57–80% of the patients with leg ulcers have an identifiable venous disease.(5,6)

Varicose veins can have primary or secondary etiology. Primary varicosities may result from the intrinsic defects of the walls of veins and absence of valves, whereas, secondary varicose veins have association with superficial or deep venous insufficiency or sequela of DVT. (7,8) The risk of developing varicose veins is heightened by factors such as older age, being female, hereditary influences, trauma to the limbs, having multiple pregnancies, prolonged standing, lack of physical activity, and a known family history.

The research explores how ankle mobility and the Tendo Achilles contribute to the onset of varicose veins in the lower limbs, aiding in the development of effective prevention and cause-specific treatment approaches.

Study design and setting:

A Prospective study conducted during the period of 2023 January to 2024 June in Department of General Surgery, Government General Hospital, Vizianagaram. Informed consent was obtained from each.

Sample size:

100 cases were included in the present study.

Inclusion Criteria:

1. All consenting patients aged 18 years and older presenting with primary lower limb varicose veins attributed to superficial and perforator vein incompetence.
2. Patients exhibiting complications such as:
    ➢ Persistent limb swelling
    ➢ Cutaneous changes
    ➢ Venous ulceration
3. Pregnant individuals diagnosed with varicose veins.

Exclusion Criteria:

1. Patients who did not provide informed consent.
2. Individuals with varicose veins affecting regions other than the lower limbs.
3. Patients diagnosed with deep vein thrombosis (DVT).

Selection of cases:

Patients attending the General Surgery Outpatient Department during the study period were evaluated to identify those who met the case definition for lower limb varicose veins (LLVV). Diagnosis and classification of LLVV were performed using the Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) classification system for chronic venous insufficiency, a widely recognized standard in clinical and research settings. A structured interview questionnaire was administered to gather the following information.

Sociodemographic data included participants' age, sex, rural/urban residence, education attainment and occupation of the participants.

Clinical examination was conducted to collect the following data:

• Clinical examination of lower limbs: Participants were subjected to a clinical examination of the lower limbs for the presence of Cases were classified into six categories following the CEAP system including: C0, no visible or palpable signs of CVI; C1, telangiectasia or reticular veins; C2, varicose vein > 4 mm in diameter; C3, edema as a sequel of varicose vein; C4, skin changes (pigmentations, venous eczema, etc.); C5, skin changes with healed ulcerations; and C6, skin changes with active ulcerations
• Ankle mobility was calculated by taking the measurements of dorsiflexion and plantar flexion at the ankle level using a The participants were asked to sit at the edge of the table and maximal dorsiflexion was calculated using a goniometer in a non-weight bearing area. The average value of dorsiflexion was taken as 15 degrees (10-20 degrees) and the average value of plantar flexion was taken as 35 degrees (20-50 degrees). The total range of movement of the ankle was calculated as the sum of both dorsiflexion and plantar flexion.

All collected data were kept confidential to ensure participant privacy.

Data Analysis:

Data analysis was performed using SPSS version 20.0, with a p-value of less than 0.05 considered statistically significant.

• The commonest age range of all patients was between 41 to 50 years (37 %.).
• Lower limb varicose veins were more common in females in our Out of 100 patients, 57 were females and 43 were males.
• The left side is predominantly involved with 53 cases followed by right side with 26 cases and 21 bilateral lower limb varicose vein
• Most the patients belong to category of manual labourers which include Coolie (30%), Farmers (16%) who have been exposed to continuous standing long hours of the
• The present study included majority of the limbs with C2 (56.19%) followed by C4 (24.79%), C5 (9.09%), C6 (5.78%) and C3 (4.13%).
• Most of them had Primary etiology (91%) where the exact cause was Others had secondary etiology (9%)- 6 patients of which 5 were pregnant females and 1 female was diagnosed to have a pelvic mass.
• 57 limbs had both superficial and perforator incompetence, 32 limbs had only perforator incompetence and 11 limbs had only superficial system
• 93% of the patients had pathology due to reflux and 7% had due to obstructive
• The normal value of dorsiflexion was taken as 15 degrees on average for normal

There was significant reduction of the dorsiflexion seen in the patients with ulceration-

• C5: 10 degrees followed by
• C6: 71 degrees.
• C2, C3, C4 were almost near the normal reference

This in turn suggested a positive correlation between the decrease in the dorsiflexion which in turn appears to be related to the Tendoachilis action, which may be affected due to the chronic venous insufficiency.

The plantar flexion is indirectly related to the action of the calf foot venous muscle pump which is deranged in chronic venous insufficiency related to impaired plantar flexion. The reference range was taken around 35 degrees as average. The participants with the complications showed decreased range of plantar flexion, C5 showing the least degree of 33.18, followed by C6.

Ankle mobility: The reference range was taken as 47°-69°. The most effected group was the patients who had ulceration due to the venous disease as a complication who had a total range of motion of 43.18 as average in C5 group and 45 in C6 group.

Venous disorders affecting the lower limbs are common and vary widely in severity, from mild, symptomless valve insufficiency to severe chronic leg ulcers. Early detection of the underlying causes can aid in slowing disease progression and preventing further complications. The present study consists of 100 cases with 121 affected lower limbs varicose veins who were studied and treated in Government General Hospital, Vizianagaram during the period of January 2023 to June 2024. The results were compared and analyzed with other similar studies. The analysis is as follows: This study included more people affected from the 5th decade of life. The average age according to the study is 48.24 years in females and 49.93 years in males. Various aged people with multiple complications have been included. In the present study, predominantly female patients were seen around 57%. Most of the studies in India have a male predominance, as females wear attires which usually covers up most of their legs. But in the present study, females were seen attending the outpatient as well as the inpatient department due to high rate of complications associated with varicose veins. Elizabeth Yim et al in their study, found out that severe CVI limbs had significantly reduced total range of motion. The present study also had a significant p value of 0.0015 which shows a positive correlation with significant reduced total range of motion in cases with complications. Plantar flexion and dorsiflexion have been analyzed in all the patients affected with varicose veins. An overall decrease in the plantar as well as dorsiflexion has been observed. This reduced dorsiflexion may be due to Achilles tendon due to the venous stasis, and the plantar flexion due to the calf muscle pump dysfunction. In this study, some of the many causative factors have been studied. This needs further genetic and colocalization studies for further workup which was limited in this study.

The current study concludes that several emerging factors contribute to the development of varicose veins, including impaired ankle mobility and abnormal dorsiflexion and plantar flexion. These findings align partly with the hypothesis that genetic alterations, such as gene mutations, play a role, highlighting the need for further combined epidemiological, genetic, and colocalization research. Enhanced understanding of the anatomical and physiological aspects of the leg venous system could also lead to improved compression therapy techniques. For effective prevention and treatment, it is crucial to identify the multiple causative factors of varicose veins. Targeted strategies addressing these risk factors may facilitate early detection and help prevent disease complications. Additionally, promoting general health education and raising public awareness about varicose veins are essential for ensuring timely intervention, better clinical outcomes, and reduced morbidity.

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