You probably already know
Nurses are the group most likely to arrive having already worked out what is wrong. Twelve hours on a hard floor, the legs that are done by hour eight, the ankles at the end of a shift, the veins that turned up in your thirties. Most have been in compression for years.
What most have not had is the leg actually mapped — and that is the gap, because compression manages the symptom and changes nothing about the cause.
The mechanism, briefly
Blood gets back up the leg by way of the calf muscle pump: every step squeezes the deep veins and drives blood upward, and a ladder of one-way valves stops it falling back between steps. The pump needs walking. Standing largely in one place, shift after shift, leaves those valves loaded by gravity with no relief, and over years enough of them fail that the leg below carries pressure it was not built for.
That pressure is the disease. It forces fluid into the tissue — the swelling. It pushes red cells into the skin, which break down and leave the brown staining around the ankle. Left long enough in some people it ends in a venous ulcer.
You know this. The useful part is what follows from it.
Why compression is not the answer, only the holding pattern
Graduated compression genuinely works while it is on, and it is the right baseline. It is also, frequently, sold at a pressure too low to do much — which is worth knowing if you have been buying stockings for a decade and wondering why your legs still hurt.
But the valve does not repair. No stocking, cream, supplement or amount of elevation restores it. Compression counteracts the consequences; closing the refluxing vein removes the cause. That is the whole distinction, and it is why the first real step is a scan rather than a stronger stocking.
What happens
A standing duplex ultrasound — performed upright, because gravity is the load being tested and a scan on a bed can miss significant reflux entirely. Painless, about half an hour. It shows which vein segments are refluxing, for how long, and how far the problem extends.
That map decides everything: whether treatment is needed at all, which vein, and by which method. It is also what most insurers require.
Because this is a pain practice as well, the back gets examined in the same appointment. Patient handling is one of the best-documented causes of occupational back injury there is, and it is a waste of a trip to have only the legs looked at.
Dr. D’Alessio is board-certified in Physical Medicine & Rehabilitation.
Treatment
Office-based, under local anaesthetic. Radiofrequency ablation for a larger refluxing vein, Varithena® microfoam where the vein is tortuous or branched, sclerotherapy for the surface vessels afterwards. You walk out — walking is part of the recovery — and drive yourself home.
The heaviness and aching usually improve before the appearance does, because they come from the pressure, and the pressure drops immediately.
On benefits
Hospital, union and public-employee plans frequently include out-of-network benefits. Whether yours does, what it covers and what you would owe are verified and explained before anything is scheduled.