1. General considerations
2. History
3. Inspection
4. Palpation
5. Cough impulse test
6. Trendelenberg test
7. Perthes' test

General considerations

• 2 sets of veins, deep and superficial. "Deep veins" means deep to the fascia.
• Flow is superficial veins to deep veins.
• Arise by: calf pumps up, pushing blood out into superficial veins. Superficial veins then dilate, spreading their own valves apart, so the superficial veins become torturous.
• Walking with a pressure tourniquet on leg
  • If competent valves, gets better as walk.
  • If incompetent valves between deep and superficial, no effect.
  • If DVT, gets more painful as walk [since exit is blocked]. 
• Can optionally use a Doppler after physical examination.

History

Inspection

• Pt stands, both legs completely visible.
• Inspect from anterior of thighs to lateral of legs (long saphenous vein).
• Inspect back of calves (short saphenous vein).
• Venous ulcers. See Venous ulcer exam.
• DDx from femoral hernia, since varicose veins:
  • Are blue.
  • Disappear when lie flat.
  • Show a positive cough impulse.

Palpation

• Tenderness (thrombophlebitis).
• Hard (thrombosis).

Cough impulse test

• Pt stands.
• Dr's fingers held over saphenofemoral opening [medial to femoral vein].
• Pt. coughs.
• If saphenofemoral incompetent, cough makes a fluid thrill.

Trendelenberg test

• Pt lies flat, leg is elevated.
• Tie tourniquet around thigh at saphenous opening.
• Pt stands.
• If normal valve at tourniquet site, will see filling from below tourniquet.
• Take off tourniquet: if incompetent valve there, will have a sudden filling from above when remove tourniquet.
• Can repeat procedure down the leg, until find the incompetent valve.
• Note: there's a different Trendelenberg test for proximal myopathy of hip.

Perthes' test

• Similar to Trendelenberg test.
• Release a bit of tourniquet, but pt raises up and down on toes after releasing.
• If perforating calf veins have competent valves, calf pump will function, making varicosities less tense.