Post-Phlebitic Syndrome (Chronic Venous Insufficiency) C&P Exam Prep

Ankle-Brachial Index (ABI)

What it measures: Ratio of ankle blood pressure to brachial (arm) blood pressure; used primarily to assess arterial circulation and rule out peripheral arterial disease as a confounding or comorbid diagnosis

What to expect: A blood pressure cuff will be placed on your ankle and arm; a Doppler ultrasound probe will be used to detect pulse sounds. Normal ABI is 1.0-1.3. For venous insufficiency, ABI is typically normal (-0.8), which helps confirm the condition is venous rather than arterial in origin.

Pain considerations: Inform the examiner if cuff inflation causes significant pain or discomfort in the affected extremity, as this may indicate sensitivity consistent with your venous insufficiency symptoms.

Limb Circumference / Edema Assessment

What it measures: The degree and distribution of swelling in the affected extremity, assessed by visual inspection, palpation (pitting edema test), and sometimes tape measurement at standardized anatomical landmarks

What to expect: The examiner will press on the skin of your ankle, lower leg, or foot to check for pitting edema (an indentation that remains after pressure is released). They may compare both legs. They will also visually inspect for skin color changes, texture changes, and visible varicose veins.

Pain considerations: Describe any tenderness, tightness, or heaviness associated with the swelling, as these qualify as symptoms beyond mere appearance and affect the rating.

Skin/Dermatological Assessment

What it measures: Presence and severity of stasis pigmentation, stasis dermatitis (eczema), subcutaneous induration (fibrosis), and ulceration - all of which are specifically named in the DC 7121 rating criteria

What to expect: Visual inspection of the skin from the ankle to the lower leg; the examiner will note the presence, location, and extent of any skin discoloration, scaling, weeping, thickening, or open/healed ulcers. They will document whether these findings are beginning/early-stage or persistent/established.

Pain considerations: Stasis dermatitis and ulcers are often painful, itchy, or burning - describe these sensations specifically so the examiner documents the full symptom burden.

Transcutaneous Oxygen Tension (TcPO2)

What it measures: Oxygen levels in the skin, used to assess tissue perfusion and wound healing potential; more commonly used when ulceration is present or arterial disease is suspected

What to expect: A small electrode is placed on the skin of the foot; it heats slightly to dilate capillaries and measures oxygen diffusing through the skin. Values >40 mmHg suggest adequate healing potential.

Pain considerations: The test is generally painless, but inform the examiner of any hypersensitivity in the area being tested.

0%

Asymptomatic post-phlebitic syndrome with only visible or palpable varicose veins present; no pain, no edema, no skin changes, no functional impairment.

From 38 CFR: Veteran has dilated superficial veins visible on the lower extremity but reports no symptoms and has no objective findings beyond the visible/palpable veins.

10%

Symptomatic varicose veins with one or more of the following: aching or fatigue in the leg after prolonged standing or walking; symptoms relieved by elevation or compression hosiery; beginning stasis pigmentation; beginning eczema; intermittent edema.

From 38 CFR: Veteran reports leg aching and heaviness after standing at work for more than 30 minutes, relieved by sitting with leg elevated; early brownish discoloration around medial ankle noted on exam; mild pitting edema present at end of day but resolved in the morning.

20%

Persistent edema that is relieved by elevation; persistent stasis pigmentation; persistent eczema; persistent subcutaneous induration; intermittent ulceration.

From 38 CFR: Veteran has chronic brownish-purple discoloration of the bilateral lower legs from ankle to mid-calf, persistent daily swelling that requires leg elevation for 2+ hours to partially resolve, and reports two episodes of venous ulceration in the past year that healed with wound care.

30%

Persistent edema that is NOT completely relieved by elevation; stasis dermatitis with disfigurement; persistent ulceration; or a combination of severe findings across multiple categories.

From 38 CFR: Veteran has marked chronic edema that remains significantly swollen even after 6+ hours of leg elevation overnight, has a non-healing venous ulcer on the medial malleolus present for 3 months requiring weekly wound care, and has extensive lipodermatosclerosis (subcutaneous induration) throughout the lower leg.

100%

Massive, board-like edema with constant severe pain and extensive trophic skin changes; condition is effectively disabling with inability to ambulate or work; may include recurrent non-healing ulcers or severe complications.

From 38 CFR: Veteran cannot ambulate without wheelchair or walker due to massive bilateral lower extremity edema that is rock-hard (brawny edema/elephantiasis), has constant burning pain rated 8-10/10 even at rest, and has multiple simultaneous chronic venous ulcers that have been present for months without healing.

Edema (Swelling)

How to describe it: Be specific about timing, location, severity, and what relieves it. Specify whether swelling is present every day (persistent) or only some days (intermittent). Describe how much elevation is needed and whether it fully resolves the swelling. Quantify: 'My ankle is the size of a grapefruit by 3 PM every day. I elevate my leg above heart level for 3 hours before bed and wake up with it still somewhat swollen - it never completely goes away.'

Example: On my worst days, my entire left lower leg swells from my ankle to my knee. The skin feels tight and shiny. I cannot fit into regular shoes by midday and must wear specially fitted footwear. Even after elevating my leg all evening, I still wake up with visible swelling. The leg feels heavy and aching all day.

Examiner listens for: Whether edema is intermittent or persistent; whether elevation completely or only partially relieves it; bilateral vs. unilateral involvement; impact on footwear and mobility

Avoid: Saying 'my legs swell sometimes' without specifying frequency, severity, or that elevation does not fully resolve it. Do not say 'it goes away when I put my feet up' if in reality the swelling persists even after elevation.

Pain and Discomfort

How to describe it: Distinguish between aching/heaviness with activity (lower rating), constant pain at rest (higher rating), and burning or throbbing. Use a 0-10 scale for both typical and worst-day pain. Describe what triggers and worsens pain - standing, walking, heat. Describe what provides relief - elevation, compression, rest.

Example: On my worst days, my left leg throbs and burns constantly even when I am lying down with it elevated. I rate the pain 7 out of 10 at rest and 9 out of 10 after standing for more than 10 minutes. The pain keeps me awake at night. I cannot stand in line at a grocery store without needing to find something to lean on within 5 minutes.

Examiner listens for: Whether pain occurs only with activity or also at rest; severity using a numeric scale; impact on sleep and daily activities; whether it limits the distance the veteran can walk or time they can stand

Avoid: Saying only 'my leg aches sometimes.' Do not minimize rest pain. Do not fail to mention that pain disrupts sleep if it does. Do not say pain is only a 2/10 if on bad days it is significantly higher - report your typical worst-day experience.

Skin Changes (Stasis Pigmentation, Eczema, Induration)

How to describe it: Describe the location, extent, and duration of skin changes. Note whether changes are permanent (persistent) or only occur during flares (beginning). Describe any itching, scaling, weeping, or cracking. Indicate how long skin changes have been present.

Example: The entire lower third of my right leg, from ankle to mid-calf, has permanent dark brownish-purple discoloration that has been there for over two years and does not go away. The skin is thickened, leathery, and hard - like wood - especially around my ankle. During flares, the skin becomes red, extremely itchy, weeping, and painful. I scratch it in my sleep.

Examiner listens for: Duration (beginning vs. long-standing); whether changes are permanent or intermittent; location and body surface area affected; presence of itching, weeping, scaling; presence of palpable induration

Avoid: Not pointing out all affected areas during physical exam. Calling established, chronic, permanent skin changes 'sometimes I get a rash' - use the correct medical language: stasis pigmentation, stasis dermatitis. Do not forget to mention induration (hardening) if it is present.

Ulceration

How to describe it: Describe the history of all ulcers: how many episodes, how long each lasted, where on the leg, how they were treated, and whether any are currently open. Bring photographs and wound care records. Specify whether ulcers recur (intermittent) or have been continuously present (persistent).

Example: I have had four venous ulcers on my left inner ankle over the past three years. The most recent one was open for four months and required weekly wound care visits. Right now I have a 2 cm ulcer on my right medial malleolus that has been open for six weeks. It drains fluid daily and is painful to the touch and when I walk.

Examiner listens for: Number and frequency of ulcer episodes; duration (intermittent vs. persistent/non-healing); location and size; type of treatment required; current status (open vs. healed); impact on mobility

Avoid: Mentioning only current ulcers without documenting the history of prior ulcers. Saying an ulcer 'healed fine' without noting how long it took or how many times it has recurred. Not bringing wound care records or photographs.

Functional Limitation and Daily Activities

How to describe it: Describe specific activities you can no longer do or must modify because of your venous insufficiency. Quantify limitations: how far you can walk, how long you can stand, what you can no longer do at work. Describe how the condition affects sleep, self-care, employment, and social activities.

Example: On a bad day, I cannot stand for more than 5 minutes without severe leg pain and swelling. I can no longer do my job in retail, which requires standing for 8 hours. I had to move to a desk job and keep a footstool under my desk. I cannot go grocery shopping without using the motorized cart. I sleep with two pillows under my legs but still wake up with pain at 3 AM.

Examiner listens for: Specific functional limitations that map to the DBQ section on functional impairment; impact on occupational functioning; need for assistive devices; sleep disruption; restriction of recreational and social activities

Avoid: Saying 'I can get around OK' when in reality you have significantly modified your lifestyle to accommodate the condition. Not mentioning job modifications, use of compression garments, leg elevation requirements during the workday, or restrictions on travel and standing.

Treatment and Compression Therapy

How to describe it: List all treatments you use: compression stockings (class/pressure, how many hours per day), leg elevation (how often, how long), wound care, medications (diuretics, pentoxifylline, topical agents), vascular procedures. Emphasize that these treatments are ongoing and managing, not curing, the condition.

Example: I wear 30-40 mmHg medical-grade compression stockings every day, all day. Without them, my leg swells to the point I cannot put on shoes within two hours. Even with stockings I still swell by afternoon. I have to elevate my leg for at least 90 minutes per session multiple times per day. I take a water pill (furosemide) daily. Despite all this treatment, my symptoms are still significantly limiting my life.

Examiner listens for: Compliance with conservative treatment; effectiveness of treatment (partial vs. complete relief); extent of ongoing daily management required; need for medical-grade compression vs. over-the-counter; history of interventions (ablation, vein stripping, sclerotherapy)

Avoid: Do not arrive wearing compression stockings without telling the examiner how long you had them on, as they will artificially reduce visible edema. Do not say 'compression stockings help a lot' without specifying that they only partially control symptoms and that the condition persists despite their use.