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SALWA, Adam, GAJDZIŃSKA, Natalia, ROSTKOWSKA, Weronika, RUTKOWSKI, Wojciech, RZEPKA, Maciej, SZTUBA,
Karolina, PUCHAŁA, Justyna, RYMASZEWSKA, Katarzyna, STARZOMSKA, Dominika and BASIURA, Karolina. Can physical
exercise improve venous function in the context of chronic venous diseases? The impact of sport on varicose veins of the lower limbs
- a review. Quality in Sport. 2024;17:53793
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1
Can physical exercise improve venous function in the context of chronic
venous diseases? The impact of sport on varicose veins of the lower limbs -
a review
Adam Salwa, Natalia Gajdzińska, Weronika Rostkowska, Wojciech Rutkowski,
Maciej Rzepka, Karolina Sztuba, Justyna Puchała, Katarzyna Rymaszewska,
Dominika Starzomska, Karolina Basiura
Adam Salwa
ORCID 0009-0009-2534-7872
https://orcid.org/0009-0009-2534-7872;
asalwa97@gmail.com
Independent Public Health Care Institute of the Ministry of Internal Affairs and
Administration in Katowice,
ul. Wita Stwosza 41, 40-514 Katowice, Poland
Natalia Gajdzińska
ORCID 0009-0009-1072-2895
https://orcid.org/0009-0009-1072-2895;
gajdzinska.natalia@gmail.com
Independent Public Health Care Institute of the Ministry of Internal Affairs and
Administration in Katowice,
ul. Wita Stwosza 41, 40-514 Katowice, Poland
2
Weronika Rostkowska
ORCID 0009-0009-3759-9989
https://orcid.org/0009-0009-3759-9989;
weronika.rostkowska97@gmail.com
Narutowicz City Speciality Hospital at Krakow, ul Prądnicka 35-37; 31-202 Kraków
Wojciech Rutkowski
ORCID 0009-0004-7393-4231
https://orcid.org/0009-0004-7393-4231;
worutkowski@gmail.com
Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University in Katowice
ul. Ziołowa 45 / 47, 40-635 Katowice
Maciej Rzepka
ORCID 0009-0009-9005-817X
https://orcid.org/0009-0009-9005-817X
macrze0@gmail.com
ST. BARBARA SPECIALIZED REGIONAL HOSPITAL No.5,
Medyków Square 1, 41-200 Sosnowiec, POLAND
Karolina Sztuba
ORCID 0000-0003-4987-3833
https://orcid.org/0000-0003-4987-3833
k.sztuba96@gmail.com
SPZOZ District Railway Hospital in Katowice
Justyna Puchała
ORCID 0009-0002-6155-6670
https://orcid.org/0009-0002-6155-6670
Independent Public Health Care Institute of the Ministry of Internal Affairs and Administration in Katowice,
ul. Wita Stwosza 41, 40-514 Katowice
Katarzyna Rymaszewska
ORCID 0009-0006-1848-1991
https://orcid.org/0009-0006-1848-1991
Independent Public Health Care Institute of the Ministry of Internal Affairs and
Administration in Katowice,
ul. Wita Stwosza 41, 40-514 Katowice
Dominika Starzomska
ORCID 0009-0006-1607-2502
https://orcid.org/0009-0006-1607-2502
Independent Public Health Care Institute of the Ministry of Internal Affairs and Administration in Katowice,
ul. Wita Stwosza 41, 40-514 Katowice
Karolina Basiura
ORCID 00009-0002-2680-4114
https://orcid.org/0009-0002-2680-4114
2-nd Speciality Hospital in Bytom, ul. Stefana Batorego 15, 41-902 Bytom, Poland
3
Corresponding author.
Natalia Gajdzińska
ORCID 0009-0009-1072-2895
https://orcid.org/0009-0009-1072-2895; gajdzinska.natalia@gmail.com
Independent Public Health Care Institute of the Ministry of Internal Affairs and
Administration in Katowice, ul. Wita Stwosza 41, 40-514 Katowice
Abstract
Varicose veins, often linked to our upright posture, are dilated and twisted veins and are a sign of chronic venous
disease (CVD). They arise from vein degeneration, leading to blood flow issues and inefficiencies in the muscle
pump function. Venous diseases, including varicose veins and chronic venous insufficiency (CVI), are
widespread. Prevalence varies, with significant differences based on location and study methods. The incidence
of these conditions increases with age. CVI is mainly caused by venous hypertension due to blood reflux or
obstruction. Risk factors include hormonal changes, genetic predispositions, lifestyle habits (e.g., prolonged
sitting, smoking), and conditions like obesity and pregnancy. Regular exercise and a balanced diet help manage
CVD by reducing weight and improving blood flow. Effective activities include calf muscle exercises, while
high-pressure sports may worsen the condition. The 2023 guidelines stress the need for lifestyle changes,
including physical exercise, to better manage CVD.
Keywords: Varicose veins; Chronic venous disease; Chronic venous insufficiency;
Hormonal influence; Obesity; Physical activity.
Introduction: Varicose veins, a common form of chronic venous disease, arise from the
dysfunction of veins in the lower limbs due to increased pressure and impaired blood flow.
Regular physical activity and a balanced diet are crucial in managing and potentially
improving symptoms of this condition.
Material and methods: We have gathered the available materials and scientific reports,
analyzing and summarizing them in a single study.
Aim of study: We aimed to evaluate how physical activity and lifestyle changes impact the
progression and management of varicose veins and chronic venous disease.
4
Conclusion: The study underscores the significant role of physical activity and lifestyle
changes in managing varicose veins and chronic venous disease. By enhancing calf muscle
function and improving venous blood flow, these interventions can help reduce symptoms,
prevent disease progression, and potentially decrease the need for surgical treatments.
The definition.
Are varicose veins of the lower limbs a consequence of our evolution? It is somewhat
believed that evolution, and thus the adoption of an upright posture by our species, is an
inevitable factor causing the development of pathologies in the venous system of the lower
limbs. We can speak of varicose veins when a vein is dilated, lengthened, and tortuous [8,9].
Varicose veins are one of the symptoms of chronic venous disease. As a result of degenerative
changes in the venous vessels, blood flow is disrupted, leading to a reversal of flow direction
in the superficial system, with blood beginning to flow downward. Consequently, the blood
outflow generated by muscle contractions ("muscle pump") is less effective because, shortly
afterward, the blood accumulating in the superficial system quickly refills the deep system to
maximum pressure levels [4]. So, can more frequent activation of the muscle pump due to
physical activity worsen or improve the condition of the venous system in the lower limbs?
Epidemiology.
Venous diseases, including varicose veins and chronic venous insufficiency (CVI), are the
most frequently reported chronic conditions [3,30]. These two diseases are yet understudied
conditions in the general population. Estimations of the true prevalence of varicose veins have
varied widely from less than 1% to upwards of 70%, and between 1 and 40% for CVI,
depending on the population surveyed and the definition of disease [1]. Determining the
prevalence of chronic venous insufficiency is complicated due to the wide spectrum of
clinical symptoms of the disease, which can range from purely cosmetic blemishes to serious
complications such as venous stasis, ulcers, and venous embolism [2,30]. Epidemiological
studies conducted in Poland in the subject of varicose veins, covering over 40,000 patients,
indicate that the disease affects 61% of women and 38% of men in the adult population. Some
studies suggest smaller gender differences in disease prevalence, while others report the
opposite proportions. The most severe stage, active venous ulcers, affects less than 1% of the
population (up to 0.5% of adults in Poland), but is found in 3% of people over the age of 65.
[4]. A study conducted in the UK shows that half of the adult population has minor signs of
5
venous disease (50-55 percent of women; 40-50 percent of men), but fewer than half of these
individuals will have visible varicose veins (20-25 percent of women; 10-15 percent of men)
[5]. Thus, reviewing the current literature makes it difficult to precisely determine the age at
which symptoms of lower limb venous insufficiency and varicose veins appear. However,
studies conducted so far clearly show that the incidence of lower limb varicose veins
increases with age, due to the weakening of calf muscles and blood vessels [6,7,11].
Pathophysiology and risk factors.
The precise process of the pathogenesis of venous diseases leading to their insufficiency has
not been fully elucidated [14]. The anatomy of the venous system in the legs appears to play a
significant role in this disease. The venous vessels in the lower limb can be divided into two
main groups: the deep venous system and the superficial venous system. These two systems
are connected by perforating veins. In simple terms, the deep system is located "within the
muscles," while the superficial system is "under the skin," and it is primarily the superficial
system that is affected by chronic venous insufficiency [12]. The main pathophysiological
cause of clinical symptoms of chronic venous insufficiency (CVI) in the lower limbs is
venous hypertension [11]. It can be caused by reflux of blood in veins with damaged valves,
obstruction of venous flow, or both [10,12]. Varicose veins are therefore a symptom of
venous hypertension [13]. Researchers suggest that stasis of deoxygenated venous blood leads
to chronic hypoxia of the vessels and the development of an inflammatory process that can
affect their walls, causing damage [15]. Structural changes in the vein wall cause weakening
and dilation. Varicose veins show increased collagen type I, decreased collagen type III, and
disrupted smooth muscle cells and elastin. High levels of tissue inhibitors of
metalloproteinases, transforming growth factor β1, and fibroblast growth factor β contribute
to these changes [16].
Risk factors for varicose veins can be classified into four categories:
Hormonal- Female gender. Women aged 40-79 have a higher tendency to develop varicose
veins compared to men in the same age range, most likely due to the adverse effects of
estrogen on the venous system [16,17]. The direct effects of estrogen on the human vein wall
include more methylation of the ERα gene in older people, which suggests lower activity and
may contribute to aging of the blood vessels. 17β-estradiol affects how veins contract,
increasing the effect of ET-1 without causing them to widen, and it also inhibits Ca2+-
dependent vein constriction, indicating it might interfere with Ca2+ channels. High estrogen
6
levels in postmenopausal women are linked to more varicose veins and greater stretchiness of
veins [18].
Genetic- Current evidence shows a strong link between varicose veins and a positive family
history [16]. Genes such as desmuslin and thrombomodulin can directly influence vein
function, with mutations linked to the development and progression of varicose veins. While
some genetic studies using SNP (single nucleotide polymorphism) arrays have explored the
genetic role in varicose vein formation, most research has been qualitative and
epidemiological, and has not pinpointed specific susceptibility genes or variants [19].
Lifestyle- Prolonged standing or sitting is strongly correlated with the development of venous
hypertension, while smoking contributes to endothelial damage in the veins, including severe
form of CVD such as ulceration [16,29]. Additionally, some studies have identified diets low
in fiber-rich plant foods and resulting constipation as risk factors for varicose veins [17].
Acquired- Pregnancy significantly influences the onset and progression of varicose veins in
women. The alterations in the venous system during pregnancy are linked not only to
hormonal changes but also to the compression of the iliac veins by the expanding uterus.
Studies revealed that the likelihood of developing varicose veins grew with each advancing
week of pregnancy [20]. According to the study results, the most reported risk factor
worsening venous system issues is overweight and obesity, cited by 93% of respondents [21].
The link between obesity and varicose veins can be explained by several biological
mechanisms. First, abdominal obesity can increase intra-abdominal pressure, potentially
hindering venous return from the lower limbs or causing venous dysfunction, which can lead
to varicose veins. Second, obesity is frequently associated with dyslipidemia, which may raise
blood viscosity and cause hemodynamic issues. Lastly, obesity can trigger inflammatory
factors that negatively impact the vascular wall [22].
Physical activity.
Many factors can contribute to the development or worsening of chronic venous disease.
Besides unsightly visible veins, the presence of varicose veins is associated with painful
symptoms, aching, swelling, itching, skin changes, ulceration, thrombophlebitis, and
bleeding [23,30]. The safest management, though not a cure, for varicose veins is
graduated compression stockings. Wearing these stockings may reduce venous reflux
while they are worn, but the reflux resumes once they are removed [24]. Surgical
treatments such as high ligation and stripping are commonly used but come with
drawbacks, including scarring, risk of recurrence and extended recovery periods [24,31].
Valvuloplasty targets problems with deep venous valves but has its limitations. Minimally
7
invasive methods, like endovenous laser therapy and sclerotherapy, provide promising
alternatives, though there is still a risk of recurrence [24,25]. Can physical activity reduce
the frequency of postoperative recurrences of chronic venous disease or even slow the
progression of the condition before surgical treatment?
Regular physical activity combined with a balanced diet helps reduce weight, addressing
the significant risk factor for CVD, which is overweight and obesity. Additionally, it
improves blood flow in the lower limbs by enhancing muscle pump function and
improving hemodynamics. Venous return is primarily driven by the natural muscle pumps
in the lower limb: the foot, calf, and thigh pumps, while the calf muscle pump is very
effective for blood flow because it can hold a lot of blood, generate high pressures, and is
located in the lower part of the leg where venous pressure is highest [27]. Studies show
that a short, supervised calf exercise program can greatly improve blood flow in patients
with leg ulcers caused by valve issues and weak calf muscles. After 7 days of calf
exercises with a 4-kg pedal machine, patients had a significant increase in calf muscle
endurance and better blood ejection, with venous volume and ejection fraction rising by
67.5% and 62.5%, respectively. While venous reflux, which indicates valve problems, did
not change, the exercise significantly reduced leftover blood in the veins by 25% and the
proportion of residual blood by 28.6%, suggesting reduced venous hypertension [27].
As mentioned earlier, ineffective functioning of the calf muscle pump leads to incomplete
emptying of the lower limb veins, causing blood stagnation and resulting in venous
hypertension [26]. Beneficial effects are seen from exercises that activate the lower limb
muscles, ranging from simple activities such as toe flexion and extension, rotational foot
movements, and calf raises, to regular walking and sports activities like running,
gymnastics, and recreational cycling. Conversely, sports that increase pressure in the veins,
such as weightlifting, strength training, or even competitive cycling, seem to have a
negative impact [26,27]. It is not without reason that the 2023 guidelines for managing
chronic venous disease published in ‘Polish Journal of Surgery’ recommend increasing
awareness and encouraging patients to adopt lifestyle changes, including regular physical
exercise, as they play a crucial role in modifying the course of the disease. [28]
Conclusion.
In conclusion, varicose veins and chronic venous disease, potentially influenced by
evolutionary changes in posture, present significant challenges in terms of prevalence and
8
management. Effective treatment strategies include both lifestyle modifications and
targeted physical activities, which improve venous circulation and reduce symptoms.
Regular exercise, especially calf muscle activation, along with a balanced diet, plays a
critical role in mitigating disease progression and enhancing overall venous health. The
integration of these strategies into patient care is essential for better management and
prevention of chronic venous disease. It is important to remember that despite the
seemingly minor nature of varicose veins, this condition can progress to chronic venous
insufficiency, which carries significant morbidity. If left untreated, varicose veins can lead
to serious complications.
Authors contribiution:
Conceptualization: Natalia Gajdzińska, Adam Salwa
Methodology: Adam Salwa, Weronika Rostkowska
Software: Maciej Rzepka, Wojciech Rutkowski
Check: Natalia Gajdzińska, Adam Salwa
Formal Analysis: Adam Salwa, Justyna Puchała
Investigation: Weronika Rostkowska, Natalia Gajdzińska
Resources: Dominika Starzomska, Justyna Puchała, Katarzyna Rymaszewska
Data curation: Adam Salwa, Maciej Rzepka
Writing- rough preparation: Natalia Gajdzińska, Adam Salwa
Writing- review and editing: Wojciech Rutkowski, Karolina Sztuba
Visualization: Adam Salwa, Weronika Rostkowska, Karolina Basiura
Supervision: Karolina Sztuba, Dominika Starzomska, Karolina Basiura
Project administration: Adam Salwa
Receiving fundings: no fundings was received.
All authors have read and agreed with the published version of manuscript.
Funding statement:No financial support was received.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Our work did not involve direct human subject
research or obtaining their consent for participation in the study.
9
Data Availability Statement: Since this is a review paper, our work does not contain
new data or analyses. Consequently, there are no databases or data accessibility to outline.
The details and conclusions presented in this review are derived from previously
published studies, which can be accessed through their respective sources as mentioned in
the references section.
Conflict of interest:The authors declare no conflict of interest.
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