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Venous insufficiency and saphenous vein reflux
When the valves inside your leg veins stop closing, blood pools in the lower leg instead of returning to the heart. The pressure that builds is what swells the ankle, aches the calf and eventually marks the skin.
What the saphenous veins do
The saphenous veins are the long superficial veins of the leg. The great saphenous runs up the inner leg from the ankle; the small saphenous runs up the back of the calf. Both carry blood upward against gravity, helped by the calf muscle squeezing on every step and by one-way valves that stop what has been pushed up from falling back down.
When those valves weaken, that is exactly what happens. Blood flows backward, which is called venous reflux, and settles in the lowest part of the leg. Pressure rises inside the vein. The vein stretches. Stretching pulls the next valve apart, which lets more blood back, which raises the pressure again. The condition feeds itself, which is why it rarely stays where it started.
Signs you might notice
- Ankles or lower legs that swell, worse by the evening
- Legs that feel tired, heavy or achy after standing
- Visible varicose veins, or clusters of fine spider veins
- Burning, cramping or throbbing in the calf
- Skin above the ankle that has darkened or hardened
- Restless legs at the end of the day
- A wound on the lower leg that will not close
- Discomfort that eases when you put your legs up
The timing is the giveaway. Venous symptoms are better in the morning, after a night with your legs level with your heart, and worse by evening once gravity has had a day to work. Pain that behaves the opposite way, worst on the first steps out of bed, points somewhere else entirely and is more often plantar fasciitis.
What raises the risk
Family history is the strongest single factor, and it is the one nobody can do anything about. Age, pregnancy, extra body weight, previous blood clots, smoking and long hours standing or seated all add to it. Nurses, teachers, hairdressers, retail and restaurant staff carry more of this than most, because the calf pump only works when the calf is working.
Why it matters to your feet
Poor venous return does not stay a cosmetic problem. It shows up as ankle swelling, heaviness, irritated skin and wounds that heal slowly, and those are the symptoms that bring people to a podiatrist rather than a vein clinic. Patients often arrive convinced the problem is their arch or their shoes.
If you have diabetes, or you already have circulation problems or a history of foot wounds, catching this early is part of protecting the limb. Poor venous return and diabetic circulation problems compound each other, and the combination is how a small sore becomes a serious one. Our wound care program exists for the cases that get that far.
How it is diagnosed
The visit starts with examination and history: what the legs, ankles and feet look like, which veins are visible, and what your symptoms do across a day. If reflux is suspected, a duplex ultrasound maps blood flow and shows which vein segments have failed.
That map decides everything that follows. A failing great saphenous vein is a different problem from surface veins that simply look bad, and treating the visible veins while the underlying one keeps refluxing is how people end up back where they started a year later.
What treatment looks like
It depends entirely on what the ultrasound shows. Conservative management with compression and activity changes is enough for many patients. Where a specific vein has failed, closing it is usually the answer, whether by injection or by sealing it from the inside. Advanced cases occasionally need surgical treatment or referral.
The full range, including sclerotherapy, endovenous laser therapy and radiofrequency ablation, is set out on our vein treatment page.
Common questions
Is venous reflux the same as venous insufficiency?
Effectively, yes. Venous reflux describes the backward flow; venous insufficiency describes the condition that flow creates. You will hear both, plus chronic venous insufficiency once it has been present a long time.
Why are my ankles fine in the morning and swollen by evening?
Gravity. Overnight your legs are level with your heart and the pooled blood drains away, so the swelling settles. Through the day it builds again. That pattern is one of the clearest signs the cause is venous rather than structural.
Can this cause a wound that will not heal?
Yes. Sustained pressure damages the skin around the ankle, and a venous leg ulcer can open from a knock that would otherwise have healed. Any wound on the lower leg that has not improved in two weeks should be looked at, and any wound on a diabetic foot should be seen promptly rather than watched.
Will compression stockings fix it?
They manage it rather than fix it. Compression supports the calf pump and reduces pooling, which usually improves how the legs feel, but it does nothing to the failed valve causing the problem. For many patients that trade is worth it. For others, closing the vein is the more durable answer.
Does it get worse if I leave it?
Usually. Pressure stretches the vein, stretching pulls the next valve open, and more reflux raises the pressure again. How fast that runs varies a great deal between people, but it is progressive rather than self-limiting, and the skin changes at the ankle are the part that is hardest to reverse once established.
Have your legs mapped
If your ankles swell most days, or the skin above one has started to change colour, an ultrasound will tell you exactly which vein is responsible.