What is the role of palpation in the physical exam of varicose veins and spider veins (telangiectasia)?

Updated: Feb 28, 2018
  • Author: Robert Weiss, MD; Chief Editor: William D James, MD  more...
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Answer

The entire surface of the skin is lightly palpated with the fingertips because dilated veins may be palpable even where they are not readily observed. Palpation helps to locate both normal and abnormal veins. After light palpation to identify superficial vascular abnormalities, deeper palpation helps to elucidate the causes and sources of the superficial problems.

Palpation begins with the anteromedial surface of the lower limb (the territory of the long saphenous vein), proceeds to the lateral surface (collateral varicose veins of large trunks and nonsaphenous varicose veins), and finally focuses on the posterior surface (territory of the short saphenous vein) of both lower limbs. The location, size, shape, and course of all varicosities are noted, and the diameter of the largest vessel is measured as accurately as possible.

Both distal and proximal arterial pulses should be palpated. An ankle-brachial index is useful if any suspicion of arterial insufficiency exists.

The arch of the long saphenous vein may be palpable in some patients who do not have varicose veins, but it is particularly well appreciated in patients with truncal reflux at the saphenofemoral junction. It is best palpated 2 fingerbreadths below the inguinal ligament and just medial to the femoral artery. If reflux is present, a forced coughing maneuver may produce a palpable thrill or sudden expansion at this level.

The short saphenous vein may be palpable in the popliteal fossa in some slender patients. Other normal superficial veins above the foot usually are not palpable even after prolonged standing.

Palpation of an area of leg pain or tenderness may reveal a firm, thickened, thrombosed vein. These palpable thrombosed vessels are superficial veins, but an associated deep vein thrombosis may exist in up to 40% of patients with superficial phlebitis. When completely thrombosed, the popliteal vein (a continuation of the femoral vein as it passes behind the knee and into the calf) may sometimes be palpated in the popliteal fossa, and the same is true of the common femoral vein at the groin. Palpation for deep thrombosis is not reliable because the vast majority of cases of deep vein thrombosis do not produce any palpable abnormality.

Varices of recent onset are easily distinguished from chronic varices by palpation. Newly dilated vessels sit on the surface of the muscle or bone; chronic varices erode into underlying muscle or bone, creating deep boggy or spongy pockets in the calf muscle and deep palpable bony notches, especially over the anterior tibia.

Palpation often reveals fascial defects in the calf along the course of an abnormal vein at sites where superficial tributaries emerge through openings in the superficial fascia. Incompetent perforating veins may connect the superficial and deep venous systems though these fascial defects, but the finding is neither sensitive nor specific for perforator incompetence.


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