Venous insufficiency of the lower limbs is a condition in which blood returns from the legs to the heart less efficiently. It may result from reflux, valve dysfunction, impaired outflow or the consequences of a thrombosis, and may cause heavy legs, swelling, varicose veins or skin changes. Symptoms alone do not establish a diagnosis: a clinical assessment and, when indicated,venous colour duplex ultrasound help identify the location and mechanism of the problem.
At a glance
Possible symptoms
Heaviness, swelling, pain, itching, cramps, varicose veins and skin changes.
Main investigation
Venous colour duplex ultrasound combined with clinical assessment and dynamic manoeuvres.
Treatment
Depends on the cause and may include movement, compression, sclerotherapy or saphenous vein procedures.
Warning signs
Sudden swelling of one leg or difficulty breathing requires urgent assessment.
Assessment in Naples
Lower-limb venous colour duplex ultrasound with a phlebological consultation included
Appointment duration: 60 minutes · Price shown in the booking calendar.
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What is venous insufficiency?
The veins in the legs return blood to the heart against gravity. Venous valves, the calf muscle pump and ankle movements all contribute to this process. When the system cannot maintain effective flow, pressure in the veins may rise and lead to chronic venous disease.
“Chronic venous disease”, “venous insufficiency” and “varicose veins” are not exact synonyms. Varicose veins are enlarged, tortuous superficial veins; venous insufficiency describes an impairment of venous return, often associated with reflux or obstruction. Venous symptoms may occur without large visible varicose veins, while isolated thread veins may be present without significant venous insufficiency.
Symptoms and signs of venous insufficiency
Symptoms may be more noticeable at the end of the day, in hot weather or after many hours standing or sitting. Common symptoms and signs include:
- heaviness, tiredness or a feeling of tension in the legs;
- swelling of the ankles or lower limbs;
- pain, burning, itching or night cramps;
- reticular veins, thread veins or varicose veins;
- brownish pigmentation, venous eczema or skin hardening;
- slow-healing wounds or venous ulcers in more advanced cases.
The severity of symptoms does not always match the size of the visible veins. A proper assessment relates the patient’s symptoms to the clinical signs and haemodynamics observed on colour duplex ultrasound.
Causes, contributing factors and differential diagnosis
Venous insufficiency may be primary, with valve dysfunction and reflux predominating, or secondary, for example following venous thrombosis. Family history, age, pregnancy, excess weight, a sedentary lifestyle and prolonged standing or sitting may contribute to or worsen the condition, but do not establish the diagnosis on their own.
Not all swollen legs are caused by veins. Oedema and pain may have lymphatic, cardiac, renal, hepatic, medication-related, joint or muscular causes; lymphoedema and lipoedema also require specific assessment. The page on swollen and heavy legs explores this differential diagnosis in more detail.
How venous insufficiency is diagnosed
Diagnosis begins with the medical history and clinical examination: the pattern of symptoms, family history, pregnancies, medication, work, physical activity, previous thrombosis or vein treatments. The clinical examination assesses oedema, the distribution of varicose veins, thread veins, skin, arterial pulses and any findings suggesting non-venous causes.
When indicated, venous colour duplex ultrasound assesses the patency of the deep venous system, any post-thrombotic changes, the behaviour of the saphenous veins and major junctions, the direction and distribution of reflux, and its relationship with varicose tributaries. The result is more than an anatomical description: it provides a haemodynamic map to guide treatment decisions.
Why venous colour duplex ultrasound is a dynamic examination
In my protocol, the examination is performed with the patient both lying down, in the supine position, and standing, in the upright position. Standing changes the pressure exerted by the column of blood and may reveal reflux that is less apparent at rest. An examination performed only while lying down may therefore not fully describe the haemodynamic behaviour of the veins.
Valsalva manoeuvre
During the Valsalva manoeuvre I ask the patient to strain for a few seconds as if having a bowel movement. The temporary increase in chest and abdominal pressure changes venous return and allows assessment of flow, particularly in proximal segments and at the saphenofemoral junction. Valsalva does not replace the other manoeuvres: each test explores a different aspect of venous function.
Calf compression and release
Manual compression followed by release of the calf, often called squeezing, rapidly changes blood flow and helps identify any pathological reversal. The manoeuvre must be adapted to the area being examined and the patient’s tolerance.
Paraná manoeuvre
During the Paraná manoeuvre the patient stands and receives a gentle, controlled push from behind. To maintain balance, the lower-limb muscles and calf pump activate automatically. This allows me to observe flow during contraction and subsequent relaxation under conditions closer to the physiology of movement.
In my clinical experience, the Paraná manoeuvre may reveal reflux that is less apparent with simple manual calf squeezing. It is particularly useful when the calf is tender to palpation: it avoids potentially painful direct compression and, in some patients, may be the best-tolerated provocative manoeuvre or the only one that can realistically be performed.
What I assess during the consultation and colour duplex ultrasound
- deep-vein patency and compressibility, including any post-thrombotic changes;
- the saphenofemoral and saphenopopliteal junctions and valve function;
- the great and small saphenous veins, their diameter and course, and any segmental or axial reflux;
- reticular veins, varicose tributaries and clinically relevant perforating veins;
- the duration, direction, origin and distribution of reflux provoked by the different manoeuvres;
- the relationship between ultrasound findings, symptoms and clinical signs;
- whether further assessment of lymphatic, arterial or systemic causes of swelling is needed.
The manoeuvres are not automatically applied in the same way to everyone. The choice depends on the venous segment being examined, the findings, the patient’s mobility and any pain. This provides clinically useful information while keeping interpretation central to the examination.
How venous insufficiency is treated
There is no single treatment suitable for everyone. The choice depends on symptoms, the site of reflux or obstruction, the condition of the deep venous system, the characteristics of the visible veins, general health and the patient’s goals.
Movement, daily habits and compression
Walking, regularly moving the ankle, breaking up prolonged immobility and addressing aggravating factors may reduce heaviness and venous pooling. Compression stockings may be useful in selected cases, but their type, size and compression class must be appropriate; arterial circulation may also need assessment before they are prescribed.
Sclerotherapy and treatment of varicose veins
Liquid or foam sclerotherapy may be used for thread veins, reticular veins and selected varicose veins; in appropriate cases it can be performed under ultrasound guidance. Treatment of visible veins is planned after establishing whether there is a feeding vein or more proximal reflux.
Saphenous vein treatment
When clinically significant saphenous reflux is present, endovenous procedures such as radiofrequency ablation, or other conservative or interventional strategies, may be considered. Not every enlarged saphenous vein needs treatment: the indication depends on the haemodynamic map, symptoms and the balance of benefits and limitations. More information is available on the page about saphenous vein treatment.
Skin changes, ulcers and post-thrombotic conditions
Skin changes, ulcers and post-thrombotic syndrome require a specific care pathway that may combine dressings, compression, treatment of the responsible veins and management of other medical conditions. Complex cases may require the involvement of other specialists.
Phlebological assessment at Centro Medico Gargano
At Centro Medico Gargano in Naples, the assessment is performed by Dr Ciro Gargano, a specialist in diagnostic radiology with a second-level university Master’s qualification in Haemodynamics and Advanced Venous Surgery. Combining clinical examination, colour duplex ultrasound and haemodynamic interpretation enables a care pathway based on the problem identified, rather than simply on the presence of a visible vein.
For guidance on when to see a specialist, also visit the Phlebologist in Naples page. The clinic is at Via Marchese Giuseppe Palmieri 71, 80141 Naples, Italy.
Frequently asked questions about venous insufficiency
Can venous insufficiency be cured permanently?
This depends on its cause and extent. Treatment may reduce reflux, symptoms and complications, but the underlying venous predisposition may persist and new veins may appear over time. It is therefore more accurate to discuss personalised management and treatment than to guarantee a permanent cure.
What is the difference between venous insufficiency and varicose veins?
Varicose veins are enlarged, tortuous superficial veins. Venous insufficiency is an impairment of blood return, often due to reflux or obstruction. The two conditions may coexist, but they are not equivalent.
Why is colour duplex ultrasound also performed while standing?
Standing changes the pressure of the column of blood, making some reflux more apparent. The examination may therefore include assessments while lying down and standing, together with Valsalva, compression-release and the Paraná manoeuvre.
Are compression stockings always necessary?
No. They may be useful in selected cases, but the type, size and compression class should be chosen according to the diagnosis, tolerance and any arterial problems or other contraindications.
Why can varicose veins return after treatment?
A treated vein may remain closed or be removed, but venous disease can progress and affect other segments. New varicose or reticular veins may also develop; recurrence does not automatically mean that the previous treatment was performed incorrectly.
When does a swollen leg require urgent attention?
Sudden swelling, particularly of one leg, requires prompt assessment even when not all the other signs are present. If sudden difficulty breathing or chest pain occurs, call 112 or 118 in Italy.
Can I book sclerotherapy directly?
For varicose and thread veins, a preliminary assessment with colour duplex ultrasound performed by Dr Gargano at the Centre is required. Treatment is scheduled only after the anatomy and haemodynamics of the venous system have been established.
Related information
For more information about diagnosis, symptoms and possible treatments, explore these clinical pages:
Scientific sources and guidelines
- NICE: Varicose veins — diagnosis and management.
- ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs.
- Ricci et al.: Valsalva maneuver in phlebologic practice.
- Franceschi: stress test, manual compression and the Paraná manoeuvre.
Book an assessment for venous insufficiency
Lower-limb venous colour duplex ultrasound with a phlebological consultation assesses the deep and superficial venous systems, the saphenous veins, reflux and possible causes of symptoms. The consultation is included.