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Aching or heavy legs
Aching or heavy legs, a syndrome that should not be taken lightly
This article was written by Philippe Blanchemaison, vein specialist.
The “tired, aching or heavy” legs phenomenon is characterised by a feeling of heaviness and aching in the legs, particularly at the end of the day and in the summertime.
More than 1 out of 3 women complain of it and pregnancy is a period when women are particularly at risk. More than 18 million French people suffer from it. (1,2)
The intensity of the pain does not appear to be in proportion to the visible clinical signs: 40% of women with disabling heavy legs do not have any visible varicose veins* and conversely, 50% of varicose vein sufferers do not suffer from painful legs. (3)
Nevertheless “tired, aching or heavy legs” should be taken seriously as the problem can develop into really disruptive, or even disabling, pain that can have an affect on quality of life and on your working life on an everyday basis. (4) And, especially in the absence of an early diagnosis and treatment, complications may appear (varicose veins, leg ulcers**, phlebitis***, swelling, etc).
Heavy legs need to be taken care of in an appropriate manner according to how advanced the vein disorder is, but it is also preferable to intervene from the “aching” stage. A treatment combined with regular medical monitoring is the best guarantee for effectively preventing complications. (5)
*Permanent dilation of a vein which becomes visible underneath the skin in the form of a blue-coloured cord.
**Chronic wound of the leg that tends not to heal.
***Inflammation of a deep vein which forms a blood clot that obstructs the circulation.
Contents
An anatomical
and physiological reminder
In their normal state, arteries enable supplying the tissues and organs with elements, notably oxygen, that are essential for them to work correctly.
As for the veins, they enable the blood to return to the heart.
In the legs, the blood flows from the bottom upwards thanks to blood pressure and the tone of the vein walls. This flow of blood circulating in the veins and moving upwards towards the heart is known as the venous return.
Valves, acting like little one-way non-return flap valves, are laid out every 2 to 5 centimetres. They enable this blood flow to occur always in the same direction without the possibility of “going backwards” towards the bottom. Hence venous return is always in the same direction.
The calf muscles and the compression of the arch of the foot also play the role of a pump, notably during walking.
Artery
Valve
Varicosities
Vein
Varicose vein
Due to a slowing down of the circulation and venous hyperpressure...
The aching and tired legs syndrome is essentially due to the stagnation or slowing down of blood and increased blood pressure in the veins of the legs. These factors are inseparable in the appearance of clinical symptoms.
Dilation of the veins leading to the formation of varicose veins is associated with the loss of tone of the vein wall and the hyperpressure it is subjected to. The more the vein is dilated the more the pressure increases and the more the tone and elasticity are put to test.
If the veins dilate and the pressure increases, the valves gradually become deficient. They are no longer impenetrable, the blood thus stagnates in the lower part of the veins, provoking the feeling
of aching legs and increasing the risk of varicosities* and varicose veins.
The slowing down of blood flow and stagnation in turn increase the pressure and dilation. Hence a veritable vicious circle sets in.
In addition, substances are secreted under the effect of:
• Variations in body temperature,
• Stress and physical effort,
• A reduction in the fluidity of the blood.
They are active on the blood vessel walls (contraction or dilation) and provoke a rise in pressure in the veins.
*or telangiectasias. Dilation of superficial little blood vessels which form a network of fine blue or purplish lines on the surface of the skin, ranging from a few millimetres to several centimetres in length.
The constituents of the vein wall are also responsible
The alteration in tone and elasticity of the vein walls is responsible for the feeling of tired legs. It depends mainly on three of its constituents:
• Collagen fibres
They can tolerate dilation up to a certain point. Beyond this threshold limit, they “snap” and become torn. Their breakage considerably alters the tone of the wall.
• Elastin fibres
In their normal physiological state, they ensure the passive return to a normal diameter after dilation. Even though they are very resistant, they are sensitive to ageing. When they are damaged, the vein is unable to return to its normal diameter.
• Specialised cells
Contraction of the vein walls is carried out by 2 types of specialised cells: the muscle cells and the cells of the internal wall on contact with the flow of blood. The latter contain minuscule captors which are very sensitive to variations in pressure, certain hormones and the amount of oxygen in the blood.
When these captors are activated, they transmit information to the muscle cells of the wall which will thus dilate or contract the vein accordingly.
A loss of balance between these different components of the vein wall (alteration in the collagen and/or elastin fibres, activation of the wall captors) leads to permanent dilation of the vein which is experienced by a feeling of aching legs, then pain.
How do you identify the circulatory origin of "aching" legs? (4,5)
When you get feelings of discomfort in your legs, specific characteristics allow you to identify them and associate them with a venous pathology:
• The area where they appear
The discomfort is located on the inside and back areas of the calf and radiates upwards towards the hollow of the knee.
• The time when it occurs
It occurs more in the evening, at the end of the day, increased by standing for a long time, heat, summer, hot baths, hair removal using hot wax, etc.
• A period of increased discomfort
In 7 out of 10 cases the discomfort increases just before a woman has her period. It is also amplified during pregnancy from the 2nd quarter or when taking hormonal treatments (oestrogen or oestro-progestative contraceptives).
Women notice that they get spontaneous relief from the cold, winter, rest, putting their feet up and walking.
Aching legs are often accompanied by night cramps, restless legs syndrome*, swelling (oedema of the ankles) and varicosities.
Hence they really do alter the quality of life of those who suffer from it.
The clinical examination is therefore accompanied by thorough questioning on lifestyle, job, the development of the pain, how it feels and when it occurs.
Questioning is carried out standing up, undressed from the waist to the feet, then lying down and is completed by measuring the size of the ankles, calves and thighs.
*Restless legs syndrome can occur when you have been sitting down for too long (in a car, at a show, etc) or in the evening when you go to bed.
What is a venous doppler ultrasound?
The most advanced examination to carry out is an ultrasound scan combined with the Doppler: the Venous Doppler Ultrasound.
With the help of a transducer passed over the skin, it enables visualising blood flow in the veins and blood circulation in your ankles and hips to find and diagnose blood refluxes (Doppler) or exaggerated dilation (ultrasound).
It is a simple painless examination that does not take very long (approximately 15 minutes) and does not require any particular preparation.
The Doppler Ultrasound localises the reflux which may concern either superficial veins or deep veins.
According to where it is located and how significant it is, the appropriate care will thus be initiated accordingly.
The Venous Doppler Ultrasound also enables precisely detecting and localising obstructions of the vein caused by a blood clot (thrombophlebitis). An urgent blood fluidification treatment is thus required to reabsorb the blood clot.
In the event of any doubt regarding the venous origin of the pain it is possible you may be asked to wear support stockings or tights which, when they are well-adapted, enable improving heavy legs and carrying out a diagnosis.
For further information do not hesitate to talk to your GP.
Everyone may be concerned,
but in a very unequal way…
Even if men are concerned, they are much less so than women: women are twice as likely to suffer from venous insufficiency. (1,3)
The strongest risk factors are
• Heredity
50% of children born from a mother with venous insufficiency will suffer from it; if both parents are affected the risk rises to 90% for women. On the other hand, if there is no history of it in the family the risk of being affected by it is only 20%. (3,6)
• Standing working all day, walking very slowly
Hence some types of work are particularly exposed to it (tradesmen and women, nurses, waitresses, etc).
Prolonged periods of sitting are also bad as it obstructs venous return (long journeys by train or plane, sedentary jobs, etc). Generally speaking a sedentary lifestyle is an aggravating factor in venous insufficiency.
• Being overweight, obesity and a lot of fatty infiltration in the legs
The excess weight exercised by the body on the legs increases venous blood pressure and encourages a sedentary lifestyle.
• Hormones, especially female
Women are twice as concerned by it than men…
• Age
Ageing of the vein walls leads to a loss of tone and elasticity. 65% of people over 60 are concerned.
Pregnancy
This is a high-risk period. Venous circulation in the legs can be considerably perturbed. The risk of venous insufficiency increases with the number of pregnancies carried through to full term. There is a 23% risk during the first pregnancy whereas it increases to 31% by the 4th (1). Some varicose veins regress after pregnancy while others persist and thus require further attention.
The increase in volume of the uterus leads to compression of the main vein which enables blood to return to the heart, mainly during the 3rd quarter. But even from the first quarter, the special hormonal climate encourages a reduction in venous drainage and stagnation of blood in the veins.
Pregnancy hormones make the vein walls fragile and reduce the tone of the blood vessels. Oestrogen promotes swelling (oedemas) and progesterone modifies the walls and the dilation of blood vessels. (7)
In addition, the increase in weight, blood volume (20 to 30%) and vein pressure (x 2 or 3) all participate in increasing the pressure in the veins of the legs.
The valves are distanced from one another, one after the other, by stretching of the veins and no longer play their non-return role. (8)
Symptoms vary greatly from one woman to another and from one pregnancy to another: from a simple beauty issue to disabling pain. In addition, the symptom may regress a few weeks after the end of the pregnancy.
How is it cared for?
It all depends on how far the condition has developed
From simple lifestyle advice to a surgical intervention and veino-tonic drugs, there are many means available, without forgetting prevention…
Prevention is essential
It is based, wherever possible, on correcting aggravating factors:
• Lose weight if necessary.
• Take regular exercise.
• Practice “anti-heavy legs” exercises.
• Indulge in massages with the help of a special cream from ankle to knee: the aim is to increase blood return and encourage circulation from the bottom upwards.
• Physiotherapy may be indicated in the case of problems with joint mobility.
• Problems with the foot arches should be corrected by wearing special insoles…
Wearing support stockings and taking veino-tonic drugs may be recommended for women with a family history of the condition and/or after the second month of pregnancy.
Tips for tired and aching legs
• Elevate the end of the bed.
• Wear shoes with a low heel, neither too high nor too flat.
• Finish off your shower with cold water moving upwards from your ankles to your thighs.
• Avoid heat (prolonged exposure to the sun, hot baths, floor heating, etc).
• Gently massage your legs from bottom to top with a soothing refreshing leg gel.
• Walk or do a gentle fitness routine that encourages the circulation.
• Avoid tight clothing, socks that constrict, heels that are too high.
Several ways of relief can be envisaged
Fast relief and well-being can be obtained with a daily massage with the help of a soothing refreshing leg gel containing toning active ingredients.
Medical or physical treatments aim at strengthening the vein walls (veino-tonic drugs, exercises to strengthen leg muscles, thalassotherapy, electrotherapy, etc) or reducing the pressure exerted on vein walls (support stockings, hygiene, posture, massages, etc).
• Veino-tonics represent the treatment of vein walls requiring prolonged care to benefit from their protective vascular action. They have an anti-inflammatory action, stimulate tone and protect the elasticity of vein walls.
• Support with the help of stockings, tights or socks, is the basic treatment for any chronic venous insufficiency. The type, strength, location and duration should be specified by your doctor. Different models are available according to the strength of support required. A lot of progress has been made in the aesthetic appearance of these products. This means of support is reimbursed by Social Security under certain conditions (in France).
• Physiotherapy and exercises to strengthen leg muscles. The best activities are walking, swimming, cycling and cross-country skiing. Thermal Spas, massages and manual draining all supply precious help.
• At the varicose vein stage, sclerotherapy of the blood vessels or surgery will be discussed on a case by case basis. These techniques are carried out under local anaesthetic, without epidural anaesthesia or general anaesthetic and you return home the same day or the next day.
To find out more
What is chronic venous insufficiency? (6)
Chronic venous insufficiency is the consequence of various abnormalities: varicose veins, the after-effects of phlebitis, valve abnormalities, alterations in the pump function of the calf muscles, etc.
It is a veritable public health problem at a worldwide level as 1/4 to 1/3 of women have varicose veins. (1)
Chronic venous insufficiency develops in 3 evolving stages (3)
• Class 0: no symptoms (pain, cramps, heaviness with or without varicose veins.
• Class 1: minor chronic venous insufficiency.
Existence of symptoms (pain, cramps, heaviness) with or without the sign of venous stagnation: varicosities, oedema of the ankle, discreet stippling spots of the ankle.
• Classes 2 and 3: moderate or severe chronic venous insufficiency.
Appearance of painless signs, essentially unsightly: brown discoloration of the skin (ochre dermatitis), noticeable red stippling spots (purpura), thinning and white discoloration of the skin (white atrophy).
The existence of healed or open ulcers, combined with artery or nerve problems, provoking intense pain.
The care will be adapted to how serious the chronic venous insufficiency is after assessment according to its degree of severity and its cause.
1. Floury MC, Guignon N, Pinteaux A. “Données sociales 1996. La Société Française”. Éditions INSEE. 1996.
2. Blanchemaison Ph., Les lourdeurs de jambes, Phlébologie, 1995, 48, 4, 507-509.
3. Recommendations and medical references. “Anaes. Insuffisance veineuse chronique des membres inférieurs.” Le Concours Médical. Issue n° 42. December 1996.
4. Cazaubon M, Allaert FA. « Retentissement de la maladie veineuse chronique sur la qualité de vie ». 2003. Can be consulted on www.phlebologie.com.
5. Work group of the first meeting to discuss and reach a consensus on veino-tonic drugs: “Action des veinotoniques sur les symptômes de la maladie veineuse chronique.” 2003. Can be consulted on www.phlebologie.com.
Bibliographic references
6. Cazaubon M, Allaert FA. “La maladie veineuse est-elle une maladie évolutive ?” Le Quotidien du médecin. 19 January 2006. World Congress of the International Union of Phlebology. October 2005
7. Vin F, Allaert FA, Levardon M. “Influence of estrogens and progesterone on the venous system of the lower limbs in women.” J Dermatol Surg Oncol 1992; 18(10): 888-92.
8. Ramelet AA, Monti M. “Phlébologie. 4th edition.” Abrégés Masson.
9. Anaes. “Traitement des varices des membres inférieurs.” Department of Public Health, Evaluation Group. June 2004.
An anatomical and physiological reminder
Due to a slowing down of the circulation and venous hyperpressure…
The constituents of the vein wall are also responsible
How do you identify the circulatory origin of aching legs ?
Everyone may be concerned, but in a very unequal way…
How is it cared for?