Heavy, tired legs

Heavy, tired legs: The most common early sign of varicose veins

"Heavy legs at the end of the day" is one of the most common symptoms in general practice and the earliest subjective sign of chronic venous insufficiency - often appearing years before visible varicose veins develop [1]. In large European population studies, 30-50% of adults report heavy legs at least once a week [2].

---

What do you feel?

Classic symptoms of venous origin include:

• Heaviness and tiredness in the legs - especially at the end of the day
• Soreness or a "dull ache" in the calves or thighs
• A burning sensation along a visible vein
• Itching around the ankle
• Swelling that gradually increases during the day
• Relief from walking, elevating the legs, or using compression stockings
• Worsening with prolonged standing/sitting, heat, and menstruation

The symptoms are worst in the evening and best in the morning - the opposite of arthritic pain or ischaemic pain [3].

---

Why do they occur?

When the vein valves fail, blood flows backwards down into the legs (reflux). This causes:

• Increased venous pressure in the lower leg (venous hypertension)
• Stretching of the vein wall and micro-inflammation
• Activation of sensory nerve fibres (C-fibres) - hence the feeling of heaviness
• Fluid leakage into the tissue - swelling

Even before veins become visible, the reflux can be measured with a Doppler ultrasound [4].

---

What is it not?

Important differential diagnoses:

Condition	Characteristics
Peripheral arterial disease (claudication)	Pain on walking, eased by rest, coldness
Lumbar spinal stenosis	Pain on standing/walking, eased by bending forward
Osteoarthritis	Load-induced pain in joints, morning stiffness
Polyneuropathy	Burning/tingling, often symmetrical, diabetes
Lymphoedema	Hard, non-pitting swelling, Stemmer's sign
DVT (acute)	Sudden, one-sided, pain, warmth - requires urgent assessment

Venous heaviness is relieved by elevation and movement - a useful clinical indicator.

---

When should you see a doctor?

• Daily symptoms for more than 4-6 weeks
• Visible varicose veins or spider veins
• Swelling, itching, or brownish discolouration around the ankle
• Impact on your ability to work or quality of life
• Previous DVT in the same leg
• One-sided or sudden-onset symptoms (requires urgent assessment)

---

Investigation

Doppler ultrasound is the gold standard and should be offered for venous symptoms combined with clinical findings. The examination assesses:

• Reflux in the great and small saphenous veins (v. saphena magna and parva) (>0.5 sec = pathological)
• Reflux in perforator veins (>0.35 sec = pathological)
• Deep venous patency
• Diameter of the trunk veins [5]

---

Treatment

Conservative - effective for many:

• Graduated compression stockings class I-II (15-32 mmHg) reduce the feeling of heaviness in up to 70% of cases within 2-4 weeks [6]
• Elevation of the legs for 15-20 minutes several times a day
• Daily exercise - walking, cycling, or swimming activates the calf muscle pump [7]
• Weight reduction if BMI >25
• Avoid prolonged sitting or standing
• Frequent breaks with heel raises or short walks

Medical:

• Micronised purified flavonoid fraction (diosmin) has a documented moderate effect on symptoms and oedema [8]
• Cochrane review: significant effect on heaviness, swelling, and cramps, but limited effect on the veins themselves [9]

Endovenous treatment: For documented reflux in the trunk veins, endovenous laser therapy (EVLT) is the first-choice treatment:

• 95% closure rate after 5 years [10]
• Significant reduction in heaviness, swelling, and impact on quality of life
• Local anaesthetic, outpatient procedure, home the same day
• Faster return to work than traditional stripping [11]

---

Treatment at Kirurgen.dk

We offer investigation with Doppler ultrasound and endovenous laser therapy (EVLT) under the public health insurance scheme. Read also about swollen legs and ankles, leg cramps and restless legs.

---

References

1. Bradbury A, et al. What are the symptoms of varicose veins? Edinburgh vein study cross-sectional population survey. BMJ 1999;318(7180):353-6.
2. Rabe E, et al. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol 2012;31(2):105-15.
3. Eklöf B, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 2004;40(6):1248-52.
4. Labropoulos N, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38(4):793-8.
5. Gloviczki P, et al. The 2022 SVS/AVF/AVLS clinical practice guidelines for the management of varicose veins. J Vasc Surg Venous Lymphat Disord 2023;11(2):231-61.
6. Motykie GD, et al. Evaluation of therapeutic compression stockings in the treatment of chronic venous insufficiency. Dermatol Surg 1999;25(2):116-20.
7. Padberg FT Jr, et al. Structured exercise improves calf muscle pump function in chronic venous insufficiency. J Vasc Surg 2004;39(1):79-87.
8. Kakkos SK, Nicolaides AN. Efficacy of micronized purified flavonoid fraction (Daflon) on improving individual symptoms, signs and quality of life in patients with chronic venous disease: a systematic review and meta-analysis. Int Angiol 2018;37(2):143-54.
9. Martinez-Zapata MJ, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev 2020;11:CD003229.
10. Rasmussen LH, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011;98(8):1079-87.
11. Hamann SAS, et al. Five-year results of great saphenous vein treatment: a meta-analysis. Eur J Vasc Endovasc Surg 2017;54(6):760-70.