Symptoms and Treatment of Varicose Veins in the Back of the Knee
Varicose veins in the popliteal fossa (back of the knee) typically present with pain, aching, heaviness, cramping, throbbing, restlessness, and swelling that worsens after prolonged standing and improves with leg elevation. 1
Symptoms
Localized Symptoms
- Pain, burning, itching, and tingling at the site of varicose veins
- May be unilateral or bilateral
- Symptoms often worse at end of day, especially after prolonged standing
- Relief typically occurs when sitting and elevating legs
Generalized Symptoms
- Aching and heaviness in the legs
- Cramping and throbbing sensations
- Restlessness in the legs
- Swelling (edema)
- Women report symptoms more frequently than men
Warning Signs of More Serious Venous Disease
- Changes in skin pigmentation
- Eczema
- Infection
- Superficial thrombophlebitis
- Venous ulceration
- Loss of subcutaneous tissue
- Lipodermatosclerosis (chronic inflammation, fibrosis, and skin contraction)
- Rare but possible: significant external hemorrhage from vein perforation
Diagnostic Approach
Physical Examination
- Visible bulging veins in popliteal area
- Assess for edema, skin changes, or ulceration
- Document using CEAP classification (Clinical, Etiology, Anatomy, Pathophysiology)
Imaging
- Venous duplex ultrasonography is the gold standard when:
- Venous disease is severe
- Interventional therapy is being considered
- Need to document valvular reflux
Treatment Options
Conservative Management (First-Line)
- Compression therapy (20-30 mmHg gradient stockings)
- First-line treatment for pregnant women
- Trial for at least 3 months before considering interventional approaches 2
- Leg elevation when resting
- Lifestyle modifications:
- Avoid prolonged standing and straining
- Regular exercise
- Wear non-restrictive clothing
- Weight loss if obese
- Address cardiovascular risk factors
Pharmacological Options
- Phlebotonics (available as dietary supplements)
- Horse chestnut seed extract may provide symptomatic relief
- Long-term studies are lacking
Interventional Treatments
When conservative measures fail and valvular reflux is documented, interventional treatment should be offered 1:
Endovenous Thermal Ablation
Sclerotherapy
- Suitable for smaller veins (2.5mm or larger)
- Agents include hypertonic saline, sodium tetradecyl, polidocanol
- Complications: phlebitis, new telangiectasias, pigmentation
Surgical Options
- Ligation and stripping
- Phlebectomy (multiple small incisions)
- Modern techniques use smaller incisions to reduce scarring and blood loss
- Generally reserved for cases not suitable for endovenous procedures
Post-Treatment Care
- Continue compression therapy (20-30 mmHg)
- Walking for 15-20 minutes immediately after procedures
- Follow-up ultrasound to confirm successful vein closure
Risk Factors to Consider
- Family history of venous disease
- Female sex
- Older age
- Increased intra-abdominal pressure (obesity, pregnancy, chronic constipation)
- Prolonged standing
- Previous deep vein thrombosis
- Arteriovenous shunting
Treatment Algorithm
- Start with 3-month trial of conservative management (compression, elevation, lifestyle changes)
- If symptoms persist, obtain venous duplex ultrasound to document reflux
- For documented reflux in veins >4.5mm, proceed with endovenous thermal ablation
- For smaller veins (2.5-4.5mm), consider sclerotherapy
- For visible bulging varicosities after treating primary reflux, consider phlebectomy
- Maintain compression therapy after procedures
Remember that while varicose veins may cause discomfort and cosmetic concerns, they rarely lead to significant complications unless left untreated for extended periods.