Our protagonist, Tom, was a good guy, a traffic cop for many years. He loved working with children, playing the conductor, but hated long periods of “just standing there.” At first, he could do his job without difficulty, only occasionally suffering from boredom. Over time this changed and he noticed that his legs hurt towards the end of the workday. He thought little of it, just a fluke from work, until the swelling developed.
At the end of his average day, both ankles would be swollen and sore, relieved only by planting himself on his recliner and pulling up the footrest. His wife was not happy with his penchant for elevating his legs rather than helping around the house, but it was his greatest means of relief. And the swelling (and pain) didn’t improve, instead only got worse over time. Yet the pain never became crippling and he was able to ignore it.
The appearance of a dark area on his shins was disconcerting but symptomless. The skin in this area also stiffened slightly, imperceptibly, over the years. Tom was one of those guys who hated going to the doctor and did it reluctantly, revealing as little as possible. The subject of her legs was never brought up during her annual visit to her primary care provider, so the issue never came up. (Funny how it works: if your doctor doesn’t know about the problem, they can’t tell you something’s wrong!)
Tom suffered from a common disease, not a rarity only seen in medical journals. Estimates indicate that nearly one in 20 Americans experience changes associated with CVI, chronic venous insufficiency. Defined as the abnormal flow of blood within the veins of the lower leg, by which blood is returned by gravity to the feet. Normally, the valves inside our veins prevent this from happening, but when they malfunction, these vital fluids build up in the calf veins.
With CVI, an iron-containing substance may deposit in the skin, causing a brownish discoloration. Over time, this material, hemosiderin, builds up and poisons the epidermis (the outer layer of skin) in the lower calf region. Even the slightest trauma (or sometimes none at all) can produce an open, draining wound that does not heal, technically called a venous stasis ulcer.
Tom hit his shin on a broomstick and developed one of these sores. It didn’t look so bad at first and was nothing more than tender. He didn’t pay attention to it, even though he had to keep it covered because it was running away. Eventually, the woman couldn’t take it any longer (the smell!) and made an appointment at their primary care office. An antibiotic was prescribed (even though he didn’t feel infected….) and an ointment was distributed.
The ulcer had grown larger over time and the watery fluid produced required frequent dressing changes. Despite adding a home nurse to help with dressings, he saw no improvement in the size or appearance of the wound. And so on, relatively unchanged for months. Doesn’t heal, just draining, tender and painful.
A doctor who specializes in wound care understands the benefits of identifying the root of the problem. What condition prevents the good healing process from progressing? Without this vital information, the rate of closure is reduced, meaning fewer of these chronic wounds are healed. Tom’s ulcer was clearly due to CVI, the venous condition that plagued him for most of his adult life. In order for Tom’s wound to heal, the blood reflux had to be treated.
A specialized multi-layered medicated wrap was applied, not to the wound area, but to the entire lower leg, ankle and foot. This increases blood flow to the heart, in the direction it is supposed to go up, down the leg. This facilitates the healing process of the ulcer and the skin in general. In Tom’s case, healing did not progress fast enough and a cellular tissue product was used (in this case, lab-grown fake skin). When the cause is treated, many of these long standing chronic ulcers can be cured, just like Tom’s. Compression is the mainstay of treatment for many of these venous diseases. A difficult question is what kind of compression, with many methods available, some “old school” and other hi tech. Compression stockings are by far the most commonly prescribed method of treating the condition before there is any breakdown of the skin. These thick and heavy stockings that cover the foot, ankle and lower leg are made of an elastic material that causes compression of the limb. Unfortunately, while these garments are tight enough to be effective, they are too tight for most older people to put on. If the patient is successful (usually only with assistance), the garment is not comfortable to wear.
Motorized pneumatic systems (think giant inflating socks) are available and some of them are quite effective, but if they work well they are expensive. The most exciting development in the world of venous insufficiency therapies is a new compression device, essentially a lower leg sleeve. Velcro tabs allow the patient to control the amount of pressure on the leg. They are significantly more comfortable than prescription compression stockings and are more effective at healing the skin and reducing swelling.
Venous insufficiency ulcerations are the result of a long chain of events, beginning with the development of incompetent valves. This process can take years to occur, which means that it is possible to intervene in the process. The application of compression therapy of some type, used consistently, will prevent most if not all of the complications of this chronic condition.
Our healthcare system needs to better identify these people and prescribe some form of compression. It’s a perfect example of what preventative medicine can do. Although not everyone who has leg swelling progresses to a chronic ulcer, with enough signs and symptoms some form of compression therapy should be used. An apt cliché comes to mind: prevention is better than cure.
EDITOR’S NOTE Dr. Conway McLean is a podiatrist who now practices foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both areas, with a sub-specialty in foot orthotics therapy. Dr. McLean welcomes questions, comments and suggestions at firstname.lastname@example.org.