The prevalence of lowerlimb venous symptoms in recent epidemiological surveys

Eberhard RABE, Prof Dr. med
Department of Dermatology
University of Bonn

The prevalence of lowerlimb venous symptoms in recent epidemiological surveys

by E. Rabe, Germany

The clinical class, “C”, of the clinical, etiological, anatomical, pathophysiological (CEAP) classification divides cases into symptomatic and asymptomatic, with symptoms including aching, pain, tightness, skin irritation, heaviness, and muscle cramps, particularly if they are exacerbated, eg, by heat or during the course of the day, or relieved with leg rest or elevation. In recent epidemiological studies, it could be shown that these symptoms are very frequent in the general population and may not be specific for venous disease. Their prevalence increases with age and is higher in women. However, these symptoms are significantly associated with venous pathology and their frequency also increases with higher “C” stages. Venous symptoms in individuals without clinical signs of chronic venous disorders may indicate hidden structural or functional venous pathology, such as postthrombotic changes or obesity-induced venous obstruction. However, other reasons for leg symptoms, such as orthopedic disease or a psychogenic component, should not be neglected

Medicographia. 2015;37:16-19 (see French abstract on page 19)


Chronic venous disorders of the lower limbs are amongst the most common diseases all over the world.1,2 in contrast to older studies, recent epidemiological studies have used the clinical, etiological, anatomical, pathophysiological (CEAP) classification to make results more comparable.2-9

The CEAP classification of chronic venous disorders, in its updated version from 2004, gives clear definitions of venous findings and specifies venous symptoms.10 All clinical classes can be asymptomatic (A) or symptomatic (S). Symptoms include aching, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints attributable to venous dysfunction.10 The subjective symptomatic course can point to a venous etiology, particularly if the abovementioned symptoms are exacerbated, eg, by heat and/or the course of the day, or relieved with leg rest and/or elevation.11

Lower-limb symptoms may be associated with venous pathology, but may not be specific for venous disease. Van der Velden recently found that other leg diseases like arterial occlusive disease, knee or hip arthrosis, or spinal disc herniation may be associated with identical symptoms as venous disease.12 in the Edinburgh Vein Study, Bradbury found that the correlation of trunk varices with venous symptoms is weak13 and that venous symptoms do not correlate well with venous reflux.14 How- ever, Darvall showed a worsening of health-related quality of life with the number of reported venous symptoms.15 The aim of the paper is to review venous symptom findings in recent epidemiologic studies that used the CEAP classification.

Table I. Leg symptoms in the Bonn Vein Study I.

Modified from reference 4: Rabe E et al. Phlebologie. 2003;32:1-14. © 2003,
Schattauer GmbH.

The Bonn Vein Study

The Bonn Vein Study investigated 3072 participants aged between 18 and 79 years, selected by a simple random sample from population registers of the city of Bonn and two rural townships.4 The overall prevalence of varicose veins was 23.2% (19.8% in men, 25.8% in women), and of chronic venous insufficiency (C3 to C6) 17% (15.4% in men, 18.3% in women). A total of 56.4% of the participants claimed leg symptoms assignable to chronic venous disorders in the prior 4 weeks (Table I).4 Venous symptoms were more frequent in the female population (62.1%) compared with the male population (49.1%). A total of 53.9% of the rural population and 57.9% of the city population had venous symptoms. The prevalence of symptoms increased with age and with the clinical class according to the CEAP classification. Venous symptoms were present in 43.4% of the C0 population, whereas 85.1% of the C4 population were symptomatic.

The San Diego Population Study

The San Diego Population Study investigated 2408 men and women, aged between 29 to 91 years, who were employees, retirees, or spouses of a large state university. This population was randomly selected within strata by age, sex, and ethnicity.6 in the whole population, 23.3% had varicose veins (15% in men, 27.7% in women).5 Trophic changes were present in 6.2% of the population (7.8% in men, 5.3% in women). As a part of the standard interview, participants were asked if they had any kind of venous symptoms in the past or present. The most frequent symptom was aching (17.7%), followed by cramping (14.3%), tired legs (12.8%), and feeling of swelling (12.2%) (Table II).6

Symptoms were more common in the female population compared with the male population. Except for restless legs, all symptoms increased with the severity of the disease. The prevalence of all symptoms, except of restless legs, was significantly higher in participants with trophic venous changes.

The Italian Study

In Italy, Chiesa and coworkers published the 24-cities cohort study on venous diseases, including 4457 women and 730 men aged 18 to 90 years.7 The participants were selected during spring and summer 2003 by advertising on television, in newspapers, and by leaflets in 24 italian cities. Only 22.7% had no clinical signs of chronic venous disease (CVD). A total of 64.8% had telangiectasias or reticular veins, 29.4% had varicosities other than saphenous veins, and 13.6% saphenous varicose veins. in the C3 class, 13.6% had edema, 13.4% venous eczema, and 8.6% preulcer skin changes like white atrophy and dermatoliposclerosis, or healed or active venous ulcers. Venous symptoms were reported in 96.3% of the women and 90.1% of the men. The authors suspected that this high prevalence might be partly due to the method of recruitment for the study.7 There were no differences in prevalence by age or by region of living for most of the symptoms. The most frequent complaints were tired legs (77.5%) and heavy legs (75.5%). Except for tingling sensation, women reported symptoms significantly more often than men (Table III, page 18).7

Table II
Table II. Percentage of participants with leg symptoms in the San Diego Population
Study by visible disease.

Abbreviations: CVD, chronic venous disease; C1, telangiectasias or reticular veins; VV, varicose
veins; TC, trophic changes.
Modified from reference 6: Langer RD et al. Arch Intern Med. 2005;165(12):1420-1424. © 2005,
American Medical Association.

The Polish Study

In this multicenter cross-sectional study, 803 participating primary care physicians in Poland screened 40 095 consecutive patients using a standardized interview and assigned them to clinical class, “C”, according to the CEAP classification.8 Of the participants, 16% were men and 84% were female. The age ranged from 16 to 97 years with a mean of 44.8 years. A total of 51.1% were assigned to C0, 16.5% to C1, 21.8% to C2, 4.5% to C3, 4.6% to C4, 1% to C5, and 0.5% to C6.

Table III
Table III. Percentage of participants with leg symptoms in the Italian
24-cities cohort study.

Modified from reference 7: Chiesa R et al. Eur J Vasc Endovasc Surgery. 2005;
30:422-429. © 2005, Elsevier Ltd.

in patients assigned to the clinical levels C1 to C6, symptoms like heaviness, cramps, and aching were very frequent compared with those assigned to C0 (heaviness 73.7% vs 23.3%, cramps 57.5% vs 20.0%, aching 75.7% vs 27.5%, respectively). in the chronic venous disorder group (CEAP C1 to C6), in most cases the symptoms intensified at the end of the day (73.4%), during standing position (67.4%), and during summer time (66.1%), compared with the C0 patients, where this dynamic could only be observed in the minority of participants (24.6%, 20.0%, 19.5%, respectively). in the chronic venous disorder population, the symptoms were chronic in 23.8%, whereas this was only the case in 4.4% of the C0 group.

The Brazilian Study

From March 1998 to December 2000, in the cities of Sorocaba and Campinas, 2104 consecutive patients from general ambulatory departments in the University Hospital and from the Public Health Centers were screened for venous disease and assigned to the “C” classofCEAP.9 They were asked about the presence of subjective symptoms such as feelings of heaviness in the legs, edema, tired legs, burning feet, and paresthesia. in the female age group of 14 to 22 years, 12.29% were symptomatic, in the age group of 23 to 48 years, 37.53% had venous symptoms, and in those older than 48 years, 62.7% were classified as symptomatic. in the male population, only 13.97% were classified as symptomatic.

The Vein Consult Program

The most recent data derive from the Vein Consult Program (VCP).2 The VCP is a large international observational prospective survey that has been carried out on the initiative of the Union Internationale de Phlébologie (international Union of Phlebology) to raise awareness of CVD, thanks to an unrestricted grant from Servier, France. A total of 6232 general practitioners in Western, Central, and Eastern Europe, Latin America, and the Middle East screened 91 545 consecutive patients for the presence of chronic venous disorders. The mean age was 50.6 years, with 16.4% of all participants in an asymptomatic C0 class and 19.7% with venous symptoms, but no clinical signs of chronic venous disorders (C0s). A total of 21.7% had reticular veins or telangiectasias, 17.9% were in class C2, 14.7% in C3, 7.5% in C4, 1.4% in C5, and 0.7% in C6. The majority of the population screened had venous symptoms, the most prevalent being heavy legs (72.4%) and pain (67.7%) (Table IV).

In the majority, symptoms increased at the end of the day. Venous symptoms were more prevalent in the female population and the prevalence increased with higher “C” classification.


Recent epidemiologic studies show that venous symptoms defined in the updated CEAP classification are very common in the general population.10 These symptoms, eg, feeling heaviness, swelling, and pain in the legs, are more prevalent in the female population compared with the male population. They increase with age and are more frequent in higher clinical stages of chronic venous disorders, except for restless legs and similar complaints. These symptoms increase during the course of the day and with warm temperatures in the chronic venous disorder population.2,8,12

Table IV
Table IV. Percentage of participants with leg symptoms in the Vein
Consult Program (unpublished data).

These symptoms are not limited to venous disease alone. As Van der Velden showed, similar symptoms may also be present in other pathologies, such as orthopedic back and knee diseases, and arterial occlusive disease.12 However, in these cases the typical dynamics with increased intensity during the course of the day and during warm periods may not be present.8,12

Even in the C0 patients without any clinical signs of CVD so-called venous symptoms may be present. it is possible in these cases that the symptoms are definitely not of venous origin and therefore may have an alternative cause. However, the clinical level C0 does not mean that no venous pathology exists. One such example is of postthrombotic patients with obstruction or valve incompetence in the deep venous system, but without varicose veins, edema, or skin changes. in these patients, the symptoms are even part of the Villalta Score to classify postthrombotic syndrome.16 Feelings of heaviness, swelling, or pain, like venous claudication, may also be symptoms of primary or secondary iliac vein obstruction without visible signs of chronic venous disorders.17 in addition, obese patients may develop a functional venous disease without reflux, but with nonpermanent iliac vein obstruction during sitting periods.18 They may also develop venous symptoms without clinical signs of chronic venous disorders. We have to consider that there may also be a psychogenic component of leg symptoms, as reported by Amsler and coworkers in 7.3% of the Bonn Vein Study symptomatic participants.19

1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15:175- 184.
2. Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez Quesada F; VCP Coordinators. Epidemiology of chronic venous disorders in geographically diverse populations: Results from the vein consult program. Int Angiol. 2012;31:105-115.
3. Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh vein study. J Epidemiol Community Health. 1999;53:149-153.
4. Rabe E, Pannier-Fischer F, Bromen K, et al. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie. Phlebologie. 2003;32:1-14.
5. Criqui MH, Jamosmos M, Fronek A, et al. Chronic venous disease in an ethnically diverse population: The San Diego population study. Am J Epidemiol. 2003; 158:448-456.
6. Langer RD, Ho E, Denenberg JO, Fronek A, Allison M, Criqui MH. Relationships between symptoms and venous disease: The San Diego population study. Arch Intern Med. 2005;165(12):1420-1424.
7. Chiesa R, Marone EM, Limoni C, Volonté M, Schaefer E, Petrini O. Chronic venous insufficiency in italy: The 24-cities cohort study. Eur J Vasc Endovasc Surg. 2005;30:422-429.
8. Jawien A, Grzela T, Ochwat A. Prevalence of chronic venous insufficiency in men and women in Poland: multicenter cross-sectional study in 40095 patients. Phlebology. 2003;18:110-122.
9. Scuderi A, Raskin B, Al Assal F, et al. The incidence of venous disease in Brazil based on the CEAP classification. Int Angiol. 2002;21:316-321.
10. Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg. 2004;40:1248- 1252.
11. Eklof B, Perrin M, Delis KT, et al. Updated terminology of chronic venous disorders: The VEiN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49(2):498-501.
12. Van der Velden SK, Shadid NH, Nelemans PJ, Sommer A. How specific are venous symptoms for diagnosis of chronic venous disease? Phlebology. 2014: 29(4):580-586.
13. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318:353-356.
14. Bradbury A, Evans CJ, Allan P, Lee AJ, Ruckley CV, Fowkes FG. The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: The Edinburgh Vein Study. J Vasc Surg. 2000;32(5): 921-931.
15. Darvall KA, Bate GR, Adam DJ, Bradbury AW. Generic health-related quality of life is significantly worse in varicose vein patients with lower limb symptoms independent of CEAP clinical grade. Eur J Vasc Endovasc Surg. 2012;44(3):341- 344.
16. Kahn SR. Measurement properties of the Villalta scale to define and classify the severity of the post-thrombotic syndrome. J Thromb Haemost. 2009;7:884.
17. Neglén P, Raju S. Balloon dilation and stenting of chronic iliac vein obstruction: technical aspects and early clinical outcome. J Endovasc Ther. 2000;7:79- 91.
18. Göstl K, Obermayer A, Hirschl M. Pathogenese der chronisch venösen insuffizienz durch Adipositas – Aktuelle Datenlage und Hypothesen. Phlebologie. 2009;38:108-113.
19. Amsler F, Rabe E, Blattler W. Leg symptoms of somatic, psychic, and unexplained origin in the population-based bonn vein study. Eur J Vasc Endovasc Surg. 2013;46:255-262.

Keywords: CEAP classification; chronic venous disease; chronic venous disorder; venous symptom