Examination checklist

    Varicose veins examination

    A 22-step mark sheet for examining varicose veins — standing inspection, skin changes of venous hypertension, cough impulse and saphena varix, tourniquet and Trendelenburg tests, handheld Doppler — with the CEAP classification.

    Surgery
    Vascular
    All colleges

    Mark sheet

    22 steps · 22 marks

    #StepWellPartlyNot
    1. 1Greets the examiner and the patient, introduces self and obtains consent1½0
    2. 2Exposes both legs from the groin to the toes with underwear on1½0
    3. 3Examines the patient standing, from the front, side and back1½0
    4. 4Describes the distribution of varicosities — great saphenous (medial leg and thigh) or small saphenous (posterior calf) territory1½0
    5. 5Looks for thread veins, reticular veins and corona phlebectatica around the ankle1½0
    6. 6Inspects for skin changes — oedema, haemosiderin pigmentation, venous eczema, lipodermatosclerosis, atrophie blanche1½0
    7. 7Looks for active or healed ulcers in the gaiter area1½0
    8. 8Looks for scars of previous surgery, injections or deep vein thrombosis1½0
    9. 9Looks for a swelling in the groin (saphena varix)1½0
    10. 10Palpates the varicosities for tenderness, hardness (thrombophlebitis) and fascial defects1½0
    11. 11Palpates for pitting oedema1½0
    12. 12Palpates the saphenofemoral junction (2–3 cm below and lateral to the pubic tubercle) for a cough impulse1½0
    13. 13Taps the distal varicose vein and feels for a transmitted impulse at the junction (tap test)1½0
    14. 14Palpates the saphenopopliteal junction in the popliteal fossa1½0
    15. 15Lies the patient down, elevates the leg to empty the veins, and applies a tourniquet just below the saphenofemoral junction (tourniquet test)1½0
    16. 16Stands the patient up and observes whether the varicosities stay empty (junction incompetence) or fill (incompetence below)1½0
    17. 17Repeats the tourniquet test at lower levels to localise the incompetent point1½0
    18. 18Uses a handheld Doppler at the saphenofemoral and saphenopopliteal junctions for reflux lasting over 0.5–1 second1½0
    19. 19Palpates the peripheral pulses and asks for the ABPI1½0
    20. 20Examines the abdomen and pelvis for a mass causing secondary varicosities1½0
    21. 21Examines the other leg1½0
    22. 22Presents the findings with the CEAP class1½0

    Summary of findings

    I examined the legs of a 50-year-old market woman, standing. There are tortuous, dilated veins along the medial aspect of the right leg and thigh in the distribution of the great saphenous vein, with corona phlebectatica at the ankle. There is brown pigmentation and eczema in the gaiter area with induration of the lower leg (lipodermatosclerosis), but no ulcer. There is no saphena varix, but there is a palpable cough impulse and a positive tap test at the saphenofemoral junction. On the tourniquet test the varicosities stay empty with the tourniquet at the upper thigh and fill rapidly when it is released, indicating saphenofemoral junction incompetence. Handheld Doppler confirms reflux at the junction. Peripheral pulses are all palpable. The left leg and abdomen are normal. These findings are in keeping with primary right great saphenous varicose veins with skin changes — CEAP C4b.

    CEAP clinical classification

    ClassDescription
    C0No visible signs
    C1Thread (telangiectasias) or reticular veins
    C2Varicose veins (3 mm or more)
    C3Oedema
    C4aPigmentation or eczema
    C4bLipodermatosclerosis or atrophie blanche
    C4cCorona phlebectatica
    C5Healed venous ulcer
    C6Active venous ulcer

    The full CEAP adds Etiology (primary, secondary, congenital), Anatomy (superficial, deep, perforator) and Pathophysiology (reflux, obstruction).

    Differential diagnoses

    PictureConsider
    Groin swelling that disappears on lyingSaphena varix (thrill on coughing) versus femoral hernia
    Varicose veins with a swollen leg and previous DVTPost-thrombotic syndrome (secondary varicose veins)
    Unilateral varicosities in a young person with a birthmark and limb hypertrophyKlippel–Trénaunay syndrome — avoid stripping the superficial veins
    Varicosities of the vulva or back of the thigh in womenPelvic venous reflux (ovarian vein incompetence)
    Varicosities with a pelvic or abdominal massCompression — pregnancy, fibroids, tumour

    Investigations

    • Venous duplex ultrasound — the standard: site and extent of reflux, deep venous patency, perforators
    • ABPI before compression
    • Pelvic ultrasound or CT venography for suspected pelvic or iliac vein problems
    • Bloods only as indicated (thrombophilia screen in unexplained DVT)

    Treatment

    See Varicose veins with venous ulcer.

    Examiner questions

    References

    • O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.
    • National Institute for Health and Care Excellence. Varicose veins: diagnosis and management (CG168). London: NICE; 2013.

    Updated September 18, 2026