By: Michael Zapf, D.P.M., M.P.H., F.A.C.F.O.

Linda is a supermarket checker with two problems. She is developing varicose veins, some of which hurt and her feet and ankles swell so much that she sometimes cannot fit into her pumps for a night on the town. She is experiencing a single common phenomenon that is responsible for both complaints: venous incompetence.

Life-giving oxygen-full blood gets to the feet through the arteries. Your heart pumps this blood into the a main artery and it is pretty much a straight shot to the foot. At every level there are horizontal branches to serve the needs of the skin, muscle, bone and organs found at that level. Once the oxygen is used up it is returned to the heart for "refueling." The return trip is the job of your veins and the subject of today’s article.

There are two systems of veins: deep and superficial. The deep veins are the large veins that return the greatest amount of blood to the heart. The superficial system are composed of the billions of tiny veins that crisscross just below the skin. The two system of veins are connected by perforator veins. If an analogy were made to our highway system, the deep veins are the freeways, the superficial veins are surface streets and the perforators are the freeway on ramps.

While the force of the heart beat is enough to get blood to the toes, it is not strong enough to return it back to the heart. For this the veins rely on a clever system of one way valves. Located an inch or two apart they make a series of chambers. Contracting muscles squeeze the chambers squirting the blood to the next higher chamber. For this system to work properly the veins need to be able to hold the blood and keep it from draining back into a lower chamber. Medically this is known as a competent valve. Unfortunately, many bad things happen when these little valves become incompetent. They become incompetent from a variety of reasons but the big two are family history and living long enough. Standing, such as Linda in the supermarket, and pressure from above, such as with a pregnancy make the condition worse.

A common complaint from a weakness in the vein system is swelling in the feet and ankle as the day goes on. With the swelling is a feeling of tiredness, aching and occasionally painful legs after standing for prolonged periods. Early in the condition elevation of the legs will make these symptoms go away. Elevation simply drains the veins of the de-oxygenated blood. If this condition lasts for a long time fluid seeps out of the veins and can causes permanent enlargement of the legs and ankles. Sometimes it causes a brown discoloration on the inside of the ankle. The discolored area of the skin is weak and prone to ulceration. Linda noted that her grandmother has such problems.

A second complaint of a weak venous system is the development of varicose veins. Pressure increases in the veins cause them to swell and elongate. Those near the surface can be seen and if they are full of blood appear purple. Finger pressure can push the blood out of the vein but it reappears as soon as you release the pressure. This can be a family trait if weakness in the walls of the veins are inherited.

Since we cannot choose our parents, treatment for varicose veins is limited to those veins that are either painful or just painful to look at. Individual varicose veins can be eliminated through ligation, stripping or sclerosing. In ligation a tiny absorbable suture is placed around two ends of a vein and it is allowed to whither away. Stripping also involves two small incisions and the vein is peeled out. Sclerosing involves injection of a drop of an irritating solution into he vein and then compressing it until it closes. There is disagreement in the medical community toward the choice of a particular method for a particular vein. Some doctors sclerose even the largest veins while others believe that it is not effective.

There are some therapies that help both varicose veins and the swelling of an incompetent vein system. The primary treatment is activity. Walking or exercising causes muscles to contract which improves the function of the venous system. For Linda she can shift her weight from leg to leg while working. There are some floor mats available with a variegated undersurface that promote such motions. As mentioned above, leg elevation is always helpful, if not always convenient. (I cannot imagine how Linda could do this while working,)

This finally brings us to the two little words that every patient with ankle swelling hates to hear: compression hose. Made right, compression hose has graduated compression forces from the toes to the knee. Worn correctly it will promote the venous drainage from the foot and leg to the point where symptoms from swelling disappear and the rate of varicose vein formation slows. This is probably the single best step a supermarket checker can take to counter swollen ankles. While the best compression hose is made by prescription, very effective alternatives can be found at the larger pharmacies and medical supply stores. Support hose from a department store often does not provide enough compression. I suggested that Linda start with level of 10-15 mm Hg (millimeters of mercury). While compression hose can keep the venous swelling from developing it usually cannot eliminate existing swelling . A trick to wearing compression hose is to shower at night before retiring and putting on the hose before you get out of bed in the morning. The swelling that accumulates while showering and hair drying might not be eliminated.