The following content is intended for physicians and other clinicians. If you are a potential patient seeking information on varicose veins, visit our patient section to learn about the causes, symptoms of, and treatment options for varicose veins and spider veins

Diagnosing Venous Insufficiency

When evaluating a patient for venous insufficiency, physicians utilize several methods to examine the patient. Most physicians start with the patient’s presenting complaint and its history. Next, the physician may perform a physical exam followed by a duplex ultrasound evaluation.


  • Includes general medical and surgical information, as well as specific information about vascular disease
  • Onset of the problem
  • Predisposing or aggravating factors of symptoms
  • Patients are specifically asked about the common symptoms seen with venous insufficiency, such as leg heaviness, aching, itching, pain, fatigue, and swelling

Physical Examination

While a physical examination should not be used as the sole evaluation, there are several physical findings that are associated with venous reflux:

  • Asymmetry of the limbs (size, length, ankle diameter)
  • Scars (previous venous surgery or ulcers)
  • Skin changes
  • Lower limb swelling (edema)
  • Skin ulcers

A common physical exam that physicians may use to assess a patient is the Trendelenburg Exam. A physician may also perform a palpation of arterial pulses to confirm that there is not another underlying disease.

Venous Anatomy

Anatomic Classifications of the Venous System

The venous system can be broken down into four major classes. Insufficiencies can present in any of these veins, and treatment can vary depending on the classification. It is important to also understand the nervous system of the lower extremities before performing any laser vein treatment.

Deep Venous System

These are primary veins that drain venous blood from the lower extremity. They include:

  • Common Femoral
  • Deep femoral
  • External Iliac
  • Femoral
  • Popliteal
  • Tibial (Anterior and Posterior)
  • Peroneal

Deep veins are located within the muscle fascia which allows a high volume and pressure of blood to pass through the veins. They account for approximately 90-95% of venous blood return to the heart. Deep veins can form deep vein thrombosis, or DVT, which is a dangerous clot in the deep system.

Superficial Veins

Superficial veins serve to drain blood from the skin. Blood travels from the superficial veins through the perforator veins to the deep veins. Superficial veins are located near the surface of the skin, outside of the muscle fascia, and they account for approximately 5-10% of venous blood return to the heart. There are two primary superficial veins:

  • Small Saphenous Vein (SSV)
  • Great Saphenous Vein (GSV)

The great saphenous vein is the longest vein in the body, running medially from the dorsal vein in the foot up to the common femoral vein in the groin, where it empties. The point where the GSV empties into the common femoral vein is called the Saphenofemoral Junction (SFJ). A typical GSV contains an average of 7 valves throughout its entire length, and it is the most common superficial vein to develop venous reflux.

The small saphenous vein originates at the back of the ankle near the outer malleous bone, and usually runs up the back of the lower leg to the popliteal vein behind the knee.

Perforator Veins

Perforator veins connect superficial veins to deep veins. They contain one-way valves to direct the blood from the superficial system to the deep system. Perforators include:

  • Cockett Perforators
  • Boyd’s Perforators
  • Dodd’s Perforators
  • Hunterian Perforator

Boyd’s perforators are common sites for primary varicose veins. These veins connect the GSV to the posterior tibial vein. Hunterian perforators connect the GSV to the superficial femoral vein, and these are common causes of medial thigh varicosities.

Reticular Veins

  • Connect branch veins to any of the deep, superficial, or perforating veins