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Journal of Physical Therapy and Health Promotion 2016, Vol. 4 Iss. 1, PP. 29-33
- 29 -
DOI: 10.18005/PTHP0401005
Calf Strengthening Exercise for Post Partum Women
with Varicose Veins
Omar Farouk Helal*1, Ali Abdel Monsef Thabet2, Ahmed Mohamed Elsodany3, Mohamed Mohamed Ibrahim Ali4,
Anwar Abdelgayed Ebid5, Shamekh Mohamed El-Shamy6
1Physical Therapy Department, College of Applied Medical Sciences, Umm Al Qura University, Kingdom of Saudi Arabia
2Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Egypt
3Department of Basic Science, Faculty of Physical Therapy, Cairo University, Egypt
4Department of Physical Therapy for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo University,
Egypt
5Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt
6Department of Physical Therapy for Disturbance of Growth and Development in Children and its Surgery, Faculty of Physical
Therapy, Cairo University, Egypt
*1dr.mon5@hotmail.com; 2alithabet2005@yahoo.com; 3ahmed_sodany@hotmail.com; 4egy.dr2010@yahoo.com;
5anwarandsafa@yahoo.com; 6shamekhmohammed@yahoo.com
Abstract-Background: Varicose veins are common among pregnant women. In addition to them not being visible, they can be very
discomforting. Objective: This current study’s goal was to explore the impact of calf muscle exercises on varicose veins in
postpartum women. Methods: Forty postpartum females, ranging from ages 26 to 36, with varicose veins on the lower limbs
participated in this study. The patients were randomly divided into two groups: group (A) performed calf muscle strengthening
exercises in addition to using compression stockings; group (B) were considered the control group and used only the compression
stocking. All participants received their usual medications as prescribed by their physician. Before and after treatment, venous
duplex ultrasound scanning was conducted in order to measure the inner diameter of the great saphenous vein (IDGSV) at the knee
and ankle. Results: In comparison to control group (B), there was a significant decrease (p > 0.0001) in the IDGSV at both the ankle
and knee in the exercise group (A). Conclusion: Calf muscle exercise is an influential remedying modality for women with
postpartum varicose veins.
Keywords- Calf Strengthening Exercise; Varicose Veins; Post Partum
I. INTRODUCTION
Varicose veins are a recalcitrant medical problem that affects millions of people worldwide. It is very common in women
over the age of 30, with the percentage between 20 to 40%, which may be due to the impact of pregnancy and possible
hormonal fluctuations [1, 2].
A varicose vein is a swollen surface vein that may appear anywhere in the body. It occurs to a defect in the valves or a
decrease in the venous wall elasticity and leads to inverse blood flow and enlargement of surface veins. This abnormal process
most commonly occurs in the sapheno-popliteal and sapheno-femoral junctions, as well as in the perforating veins that join the
superficial and deep venous systems along the entire leg length where there is inadequate venous return [3].
During pregnancy, women are at high risk of developing varicose veins and the prevalence may reach 40%. After delivery,
the saphenous system on their legs and thigh are most commonly affected and many women will spend years searching for a
cure to this problem [4].
The high prevalence of varicose veins among pregnant women may be related to several factors and changes that occur
during pregnancy, including an increase in fluid volume that causes the veins to enlarge, an alteration in venous smooth muscle
tone due to high progesterone levels, obstruction of the lower limb venous return by the mechanical pressure of the gravid
uterus, decreased plasma osmotic pressure and finally, from a hereditary predisposition. The isolated or cumulative effects of
these factors during pregnancy promote venous distension and the origination of valvular incompetence [5].
The interaction of the central and peripheral venous pump along with competent venous valves entails successful venous
return and maintains an efficient peripheral pump mechanism that overcomes the gravity retrograde effect and the hydrostatic
pressure that resists the upward venous flow [6]. Lower extremity venous hypertension will develop as a result of the increase
in lower limb residual venous volume that occurs with impaired and inefficient pumping action of the calf muscle in
accordance with the involvement of venous valvular insufficiency [7].
Symptoms of varicose veins range from itching, leg swelling, leg aching pain, night cramps, paraesthesia, tiredness,
heaviness, and prominent palpable and tender varicosities, all of which may lead to anxiety, depression, high morbidity, but
most importantly, a negative effect on quality of life [8].
Journal of Physical Therapy and Health Promotion 2016, Vol. 4 Iss. 1, PP. 29-33
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DOI: 10.18005/PTHP0401005
Conservative intervention, laser therapy, injection sclerotherapy, and surgery are treatment options for varicose veins.
During pregnancy, there are many factors limiting proper treatment of varicose veins. Injection therapy is potentially
hazardous for the fetus, while vascular surgery is limited to the first and second trimester, and vein stripping is usually
postponed for some time [9, 10].
Calf muscle strengthening exercises is an effective treatment of varicose veins. It increases the skeletal muscle fibre size,
prompts calf muscle pumping function, and restores venous hemodynamic, therefore, keeping the legs healthy and comfortable
[11].
Padberg et al. [12] conducted a study to investigate the effect of a six-month calf strengthening exercise program on calf
muscle pump function, dynamic calf muscle strength, venous reflux, and quality of life. An improvement in calf muscle pump
function and dynamic strength was concluded. They recommended future research on exercise interventions in patients with
varicose veins.
Van Uden et al. [13] studied the impact of chronic venous insufficiency (CVI) on gait and calf muscle endurance. In
patients with severe chronic venous insufficiency, their results revealed a disturbance in gait parameters and reduction in calf
muscle endurance. They recommended further studies to explore the role for gait and strength training in the treatment of CVI.
To examine the influence of contrast baths and calf muscle exercises, Helal et al. [14] carried out a study on 70 patients
with varicose veins. They concluded that contrast baths and strengthening exercises are both efficacious and safe methods in
enhancing venous return in patients with varicose vein.
Consequently, calf muscle strengthening exercises are a safe and non-invasive method for treating varicose veins in
postpartum women, which may reduce their suffering, improve their quality of life, and alleviate the associated depression.
While much is known about different aspects of varicose vein treatment ranging from conservative intervention passing to
surgical intervention, there are currently no evidence-based studies exploring the effect of calf strengthening exercise on
postpartum varicose veins. By measuring changes in the inner diameter of the great saphenous vein (IDGSV), the aim of this
study was to explore the effects of calf muscle exercises on postpartum varicose veins, which is concluded to greatly impact
the improvement of varicose veins [8, 9, 11].
II. SUBJECTS, MATERIALS AND METHOD
A. Subjects
Forty postpartum women, ranging from ages 26 to 36 and a body mass index (BMI) < 29 kg/m2, referred to the Physical
Therapy Department of Al-Noor Hospital suffering from primary varicose veins and competent sapheno-femoral junctions that
developed during pregnancy and signed the standard informed consent form to participate in the study. The exclusion criteria
included: currently pregnant, ankle-brachial index (ABI) measurements > 1.0, diabetic, any local leg condition such as
dermatitis, vein ligation, gangrene, or recent skin graft, severe leg arteriosclerosis or other ischemic vascular disease, restricted
ankle mobility, massive leg oedema, and extreme leg deformity.
The study purpose and procedures were explained, and the patients were randomly divided into two groups. Group (A)
performed calf muscle exercises on the Minitalus device in addition to using the compression stockings. Group (B) was the
control group and only used the compression stockings. Group randomisation was achieved by asking the patient to choose a
piece of paper with either the letter (A) or (B) written inside, with (A) being the exercise group and (B) the control group. All
participants were instructed to keep taking their usual physician-prescribed medications.
B. Materials
To measure IDGSV at the knee and ankle, venous duplex ultrasound scanning (Sonoline-Versa Plus, Siemens, Germany)
was undertaken [15].
A Minitalus device (Easytech, Italy) in Fig. 1, for the rehabilitation and prevention of ankle injuries was used for specific
calf muscle strengthening exercises. The specific action of this device is based on the principle of adjustable elastic resistance
and it is used for the rehabilitation of the ankle and associated muscular groups. The device enables patients to perform plantar
flexion exercises against elastic strap resistance. Each elastic strap has a traction adjuster, which allows the adjustment of the
force required from the elastic reaction. The Minitalus stretched elastic straps have a definite resistance during plantar flexion,
which equals 16 Nm-2.
Compression stockings (open toe thigh high 8-18 mmHg compression support stockings, Covidien TED) were used to aid
venous return, compress the surface veins, and prevent skin ulceration [16].
Journal of Physical Therapy and Health Promotion 2016, Vol. 4 Iss. 1, PP. 29-33
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DOI: 10.18005/PTHP0401005
Fig. 1 Minitalus device
C. Procedure
In the exercise group (A), the total session time of calf muscle exercise on the Minitalus device was 30 minutes. With the
exercises completed three times per week for six weeks, each patient did three sets of planter flexion in six minutes, with six
minutes rest between consecutive sets. Initially, the maximum number of planter flexion in six minutes was determined.
During the first three weeks, the patient performed half the maximum number of planter flexions, proceeding to the maximum
in the following three weeks. The exercise was performed from a long sitting position with a pillow under the knee, allowing
slight knee flexion for optimum calf muscle isolation, and the foot resting on the Minitalus foot support [17].
In the control group (B) as well as the exercise group (A), the patients were instructed to wear the compression support
from the time they woke up to the time they went to bed.
For each patient, the long saphenous veins were evaluated from a relaxed supine position. The veins were evaluated with
frequent Valsalva manoeuvres and calf compressions [18]. Without being notified about which group the patient belonged to,
the duplex ultrasound scans were performed by the same specialist at the same time of day.
D. Statistical Analysis
SPSS software was used to conduct statistical analysis. Each patient’s age, weight, and height was collected and analysed
using unpaired t-tests. Paired t-tests were used to compare pre- and post-treatment mean IDGSV in both groups. The unpaired
t-test was used to compare pre-treatment and post-treatment mean values of group (A) versus group (B). A p-value < 0.05 was
considered significant and p < 0.0001 as highly significant.
III. RESULTS
Forty women with a mean age of 31.3 ± 1.13 years and BMI of 25.5 ± 2.7 (kg/m2) participated in this study. There were not
significant age, weight, and height differences between the two groups. The mean difference (MD) of pre-treatment IDGSV at
both the ankle and knee did not differ significantly between both groups, indicating a clear homogeneity between the two
groups (see Table 1). On the contrary, the MD of post-treatment IDGSV at both the ankle and knee revealed a significant
difference between both groups, indicating a significant decrease in IDGSV in group (A), but not in group (B).
TABLE 1 THE COMPARISON BETWEEN PRE AND POST-TREATMENT MEAN VALUES OF THE IDGSV OF BOTH GROUPS
IDGSV (mm)
Group (A)
Mean ± SD
Group (B)
Mean ± SD
MD
Percentage of
Improvement
t-value
p-value
Significance
Ankle Level
(Normal=2.35)
Pre
treatment
2.90±0.064
2.88±0.072
0.02
0.00 %
0.925
0.361
No
Significance
Post
treatment
2.38±0.037
2.85±0.069
0.47
16.5%
13.625
0.0001
High
Significance
Knee level
(Normal=3.10)
Pre
treatment
3.45±0.025
3.44±0.024
0.01
0.00 %
1.439
0.158
No
Significance
Post
treatment
3.23±0.058
3.42±0.033
0.19
5.60 %
13.145
0.0001
High
Significance
As shown in Table 2, in exercise group (A) there was a highly significant decrease in the IDGSV at the ankle, while in the
control group (B), the IDGSV mean difference was not statistically significant at the ankle. Similarly, as shown in Table 3, a
Journal of Physical Therapy and Health Promotion 2016, Vol. 4 Iss. 1, PP. 29-33
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DOI: 10.18005/PTHP0401005
highly significant decrease in the IDGSV at the knee was observed in group (A), whereas the difference between the pre-
treatment and post-treatment mean values of the IDGSV at the knee were not significant in group (B).
TABLE 2 CHANGES IN IDGSV BETWEEN BOTH GROUPS (A AND B) AT ANKLE LEVEL
Ankle Level
IDGSV (mm)
(Normal=2.35mm)
Pre
treatment
Post
Treatment
MD
Percentage of
Improvement
t-value
p-value
Significance
Group (A)
Mean
2.90
2.38
0.52
18%
26.97
0.0001
High
Significant
SD
0.064
0.037
Group (B)
Mean
2.88
2.85
0.03
1.04 %
1.84
0.082
No significant
SD
0.072
0.069
TABLE 3 CHANGES IN IDGSV BETWEEN BOTH GROUPS (A AND B) AT KNEE LEVEL
Knee Level
IDGSV (mm)
(Normal=3.10mm)
Pre-
treatment
Post-
treatment
MD
Percentage of
Improvement
t-value
p-value
Significance
Group (A)
Mean
3.45
3.23
0.22
6.40 %
16.80
0.0001
High
Significance
SD
0.025
0.058
Group (B)
Mean
3.44
3.42
0.02
0.60 %
1.91
0.071
No
Significance
SD
0.025
0.033
IV. DISCUSSION
Because vascular surgery is limited to the first and second trimester and vein stripping is usually postponed for some time,
the concept of the current study was to examine the effect of calf muscle exercises on varicose veins in postpartum women in
order to overcome many factors limiting many alternative medical interventions for this problem during pregnancy [9, 10]. The
results of our study revealed a reduction in the IDGSV at both the ankle and knee after six weeks of a calf strengthening
exercise program, greatly impacting the improvement of varicose veins. In contrast, there were no significant improvements in
the IDGSV at the ankle and knee in the control group.
In comparison to the effects of compression stocking alone, the combination of calf muscle exercise and compression
stocking was more effective in reducing the IDGSV at both the ankle and knee since MD of post-treatment IDGSV at both the
ankle and knee revealed a high significant difference between both groups.
This effect may be related to the interaction of the central and peripheral venous pump along with the competent venous
valves, enabling successful venous return and maintaining an efficient peripheral pump mechanism. The pumping action of the
three muscles of the lower limb, the foot, calf, and thigh predominates the venous return. Because of its position in the lower
limb, the calf muscle can generate high capacitance and pressures responsible for the most efficient action for venous return
[12]. The lower limb residual venous volume will increase when the calf muscle function is impaired, resulting in the
inefficient pumping action of the calf muscle in accordance with the presence of venous valvular regurgitation, raising the
ambulatory venous pressure, and consequently, development of venous hypertension [19].
Our findings are in accordance with other studies that found that strengthening calf muscle exercises are effective in the
treatment of varicose veins. Helal et al. [14] concluded that both contrast baths and strengthening calf muscle exercises are
effective methods for the treatment of varicose veins. In addition, Clarke et al. [20] reported a positive effect of neuromuscular
electrical stimulation (NMES) on lower limb venous velocities subsequent to calf muscle contraction. Van Uden et al. [13]
found an improvement in gait parameters and increased calf muscle endurance after a selected program of gait training.
Padberg et al. [12] concluded that after six months of a physical therapy strengthening program, the improvement in venous
haemodynamic was as a result of amelioration of calf muscle pump function. Kan and Delis [21] also showed amelioration in
the venous haemodynamic and calf muscle endurance after an isotonic calf muscle-strengthening program.
V. CONCLUSION
The combination of calf muscle exercise and compression stocking is a useful physical therapy remedying modality in
reducing the IDGSV, which has a great impact on the improvement of varicose veins. It can be effectively and safely used as a
Journal of Physical Therapy and Health Promotion 2016, Vol. 4 Iss. 1, PP. 29-33
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DOI: 10.18005/PTHP0401005
treatment option for women with postpartum varicose veins as it overcomes factors limiting many alternative medical
interventions for this problem.
RECOMMENDATION
A six-week calf muscle exercise program is a highly recommended physical therapy modality for women with post partum
varicose veins. Because the long-term effect of the exercise program was not directly investigated in this study, the women are
advised to continue the exercise for an extended period of time for prolonged care and maintenance of healthy veins. Further
studies need to be conducted in order to investigate the effect of the exercise program on venous reflux and the diameter of the
short saphenous vein (SSV), as well as the possible correlation between BMI and IDGSV.
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Omar Farouk Helal, born in UAE in 1972, completed his PhD at the age of 35 years from Cairo University. He is an
Associate Professor in the Department of Physical Therapy, director of Alumni Committee and member in Academic
Accreditation Committee in the College of Applied Medical Sciences, Umm Al-Qura University. Omar has served on
roughly thirty conference and workshop. He has published about 15 papers in Cardiopulmonary and Geriatrics
Rehabilitation and directs multiple research programs focused on the exercise intensity and geriatrics care.
