Physical examination The patient should stand during the physical examination, preferably on a bench or chair. Visualization, palpation, percussion, and auscultation should be performed in sequence, with special emphasis on the first two steps. Edema shows functional changes of early venous disease. The circumference of the limb should be measured at specific anatomic points to objectively show the degree of edema. Changes in skin pigmentation should be described especially above the ankle, which indicates severe venous insufficiency. An associated desquamative skin disease may be present. Venous ulcers are usually found in the boot area (the area above the medial ankle), the location of the lower three major penetrating veins, which are subject to the greatest hydrostatic pressure. The size and depth of the ulcer and the growth of granulation tissue are to be recorded. The limb should be palpated to assess the compliance of the subcutaneous tissue edema. More advanced chronic venous insufficiency has a woody sensation on palpation. The temperature of the skin should be felt and if the skin temperature is elevated, this suggests deep cellulitis. In more obese patients some of the superficial varicose veins are not easily visible, so palpation is the best way to identify such superficial varicose veins. A circular subcutaneous defect found on palpation of the lower leg usually indicates an incompetent dilated feeder vein. This area should be marked on the skin or diagrammed prior to surgery to indicate the location of the area from the medial ankle. The purpose of auscultation is primarily to identify the presence of arteriovenous fistulae in areas of significant superficial varicose veins of the lower extremity. If present auscultation usually reveals a continuous murmur. If the Doppler probe is placed at the superficial varicose vein a pulsating arterial component can be detected. This can also result in an increase in skin temperature. Tourniquet test The main purpose of the tourniquet test on physical examination is to identify the level of valvular insufficiency in the superficial venous system and to determine if the deep venous system is involved. The method is described in detail in textbooks or other websites and will not be repeated here. It should be noted that with the widespread use of Doppler ultrasound, these traditional functional tests are rarely used in China or Europe. Venous imaging studies Although a detailed physical examination can reveal a great deal of useful clinical information, vascular imaging techniques can be of great help in the management of venous disease. Current studies are broadly divided into physiological and anatomical examinations. Venography and Doppler scans can provide detailed anatomic detail, including images of veins, penetrating veins, identification of obstructive lesions, and assessment of segmental venous reflux. Physiologic information can be obtained from a variety of volumetric tracings. Treatment Non-surgical treatment Non-surgical treatment therapy has been used for decades as the basic treatment for chronic venous insufficiency and venous ulcers. Elevation of the foot above the thigh while the patient rests in a seated position and elevation of the foot above the heart in supine position is generally accepted as an effective treatment for CVI and venous ulcers. However this is a short term treatment. The main objective of non-surgical treatment is to maintain the patient’s normal activity and to promote healing of the ulcer and prevent its recurrence. The use of bandages was proposed by the Hebrew prophet Isaiah in the eighth century B.C. In 1676 Weismen introduced the use of stockings made from the skin of dogs for the treatment of venous ulcers, and in the 1950s Jobst invented gradient compression for venous ulcers during activity. However, he observed that his leg symptoms were reduced when he was standing upright in a swimming pool, so he designed the first pair of gradient compression socks to simulate the force exerted on his legs by the pool water. Sixty years later, this gradient compression therapy is still the basic treatment for chronic venous insufficiency. Other compression treatments including the use of medical elastic bandages wrapped around the affected limb in a sequential manner can also serve as gradient compression therapy. However, the tightness of the bandage (i.e., the force of compression) is not easy to control for the general population, and too tight a compression can lead to ischemia in the limb due to arterial compression, as well as worsening symptoms due to the reversal of the pressure gradient (high pressure at the upper end and low pressure at the lower end) caused by the wrapping. At the same time, the bandage can easily loosen on its own, leading to compression failure. It is now advocated to wear medical compression stockings, which are both reliable and easy to use. Medical compression stockings are available in various sizes and pressure levels: short leg (below the knee), long leg (up to the thigh) and pantyhose by size. According to the pressure, there are low pressure (prevention type around 18mmHg, K1): it is suitable for the daily health care prevention of people with high incidence of varicose veins and thrombosis. Medium pressure (treatment type around 20-30mmHg, K2): suitable for the treatment and prevention of superficial varicose veins, thrombosis, swelling of lower limbs, etc. High pressure (therapeutic type around 30-40mmHg, K3): suitable for obvious varicose veins of lower limbs, stagnant venous blood flow, phlebitis, severe varicose veins in pregnancy, after saphenous vein stripping, after sclerotherapy of varicose veins, calf ulcers, post-thrombosis syndrome of deep veins of lower limbs, irreversible lymphedema, etc.