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The Anatomy and Physiology of the Venous Foot Pump
The Anatomical Record
Abstract
The presence of a venous pumping mechanism in the foot may be significant for venous return in the lower extremities. However, there has been a lack of conclusive research in the area to date and controversy still exists over the detailed anatomy and physiologic mechanism of the venous foot pump. A full understanding of the anatomy and physiology of the venous foot pump is essential for designing effective interventions for the prevention, treatment, and management of venous disease in the lower limbs. This article highlights and discusses the relevant literature relating to the anatomy and physiology of the venous foot pump. In addition, the plantar aspects of 10 cadaveric feet were dissected. These dissections revealed the presence of a previously unreported secondary deep plantar arch and/or deep system of venous connections in the foot and facilitated a more detailed description of the patterns of doubling and branching of the primary veins of the foot. The results of these dissections are discussed within the context of previous work in the field with the aid of detailed diagrams of the dissected feet and may provide a backdrop for the physiology of the venous foot pump and its potential role in lower limb circulation. This is discussed in the last section of the article, which also highlights existing controversy regarding the role of weight bearing and muscular contraction as the dominant mechanisms for venous pumping in the foot.
... В 2010 г. на основании исследования John V. White et al. [20], Gavin J. Corley et al. было проведено более детальное изучение анатомии венозной системы стопы и сформировано понятие о плантарном сплетении, которое до сих пор рассматривалось лишь в общем контексте венозного возврата из нижних конечностей. Хотя описание венозной системы стопы в данном исследовании напоминало предыдущие, были и значимые новые наблюдения [23]. ...
... Это анатомическое исследование обеспечило более детальное понимание физиологии венозной помпы стопы и ее потенциальной роли в кровообращении нижних конечностей: исследователями был обнаружен диссонанс между механическим воздействием веса и сокращением мышц стопы на формирование венозного потока. Исходя из этого, авторы предположили, что исключительно анатомического изучения стопы недостаточно для формирования представления о физиологии ее венозной помпы [23,24]. ...
... На основании предыдущего исследования все те же B.J. Broderick, G. Corley, исследовали физиологию венозного оттока от стопы с целью изучения роли воздействия веса и работы мышц стопы на функцию венозной помпы [24]. Рисунок 5. Принципиальная схема вен стопы с указанием латеральных и медиальных подошвенных вен, плюсневых вен, глубокой подошвенной венозной дуги и задних большеберцовых вен [23,24] Для этого было проведено исследование 10 человек по следующей схеме -в положении лежа и стоя проводились различные манипуляции: быстро создавалась кратковременная максимально возможная нагрузка на одну из конечностей; производилось резкое максимально сильное сгибание пальцев стопы; подвергались электростимуляции мышцы стопы; производилась переменная пневмокомпрессия стопы. ...
The growing interest in chronic venous diseases of the extremities reflects their increasing prevalence in modern society, particularly among lower socioeconomic groups. Over the past 75 years, significant research has expanded our understanding of venous return physiology within the inferior vena cava system. However, when examining this topic, the understanding of the anatomy and physiology of the venous pump in the lower extremities appears fragmented. Key components are often considered in isolation, leading to an overemphasis on certain structures, such as the musculovenous pump of the calf and the venous valve system, while other essential elements like the venous pump of the foot and the role of fascia are underestimated or overlooked. Moreover, insufficient attention has been given to the interplay between the components of the venous return system and how they integrate into the mechanics of the step cycle. The venous return mechanism is predominantly examined in two scenarios – upright walking andlying down – while the more common body positions in modern industrial society, such assitting and standing, remain inadequately studied. The purpose of this literature review isto synthesize data from domestic and international sources to trace the evolution of concepts surrounding the anatomy and physiology of the foot’s venous pump. It aims to consolidate available information, highlight the significance of the foot venous pump in the overall venous return system, and underscore the connection between venous return function and the mechanics of the step cycle.
... Several mechanisms return the venous blood accumulated in the lower limbs to the heart, including the activation of the diaphragm pump, the plantar venous pump, and the muscle pumps of the calf and thigh [2,13]. Venous return in the foot is ensured by the plantar venous pump, which propels a quantity of venous blood at each step (in push phase) to both the deep and superficial venous system [14][15][16][17][18]. Therefore, the foot pump should be considered as a real impulse-aspiration system, providing the first push of venous blood in the lower limbs during walking [19,20]. ...
... The maximum score was 28 because item 5 had a possible score of 2 if scored "yes", 1 if scored "partially" and 0 if scored "no" or "unable to determine." For all other items, "yes" was scored 1 and "no" and "unable to determine" were scored 0. Based on the risk of bias assessment scores, studies were classified as very high quality/very low risk of bias (26-28), good quality/low risk of bias (20-25), fair quality/fair risk of bias (15)(16)(17)(18)(19) or poor quality/high risk of bias (� 14) [43]. Higher scores indicated less risk of bias than lower scores. ...
... They also affect kinetic (e.g., reduction in the peak and mean ankle eversion moments) and kinematic (e.g., reduction in peak rearfoot eversion or tibial internal rotation) variables and muscle activity (e.g., increase in tibialis anterior and peroneus longus electromyographical amplitudes: EMG) [32, 59,60]. There was also evidence reported of the relationship of foot and ankle movements to venous return in the lower limb, where combined active movement produced the highest flow velocities [15,61,62]. This would explain the influence of orthotics use on the increased venous return or the decreased edema formation. ...
This systematic review evaluated the literature pertaining to the effect of shoes on lower limb venous status in asymptomatic populations during gait or exercise. The review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed-NCBI, EBSCO Host, Cochrane Library and Science Direct databases were searched (March 2019) for words around two concepts: shoes and venous parameters. The inclusion criteria were as follows: (1) the manuscript had to be published in an English-language peer-reviewed journal and the study had to be observational or experimental and (2) the study had to suggest the analysis of many types of shoes or orthotics on venous parameters before, during and/or after exercise. Out of 366 articles, 60 duplications were identified, 306 articles were analyzed, and 13 articles met the eligibility criteria after screening and were included. This review including approximately 211 participants. The methodological rigor of these studies was evaluated with the modified Downs and Black quality index. Nine studies investigated the effect of shoes on blood flow parameters, two on venous pressure and two on lower limb circumferences with exercise. Evidence was found that unstable shoes or shoes with similar technology, sandals, athletic or soft shoes, and customized foot orthotics elicited more improvement in venous variables than high-heeled shoes, firm shoes, ankle joint immobilization and barefoot condition. These venous changes are probably related to the efficiency of muscle pumps in the lower limbs, which in turn seem to be dependent on shoe features associated with changes in the kinetics, kinematics and muscle activity variables in lower limbs during gait and exercise.
... The foot was once thought to have little influence on the physiological return of blood from the leg, and venous return from the foot was thought to occur under muscle pump activity only [11][12][13][14]. The work of Gardner and Fox [11,15] reported on the role of the foot in venous return, describing and proposing a compression hydraulic pump. ...
... The work of Gardner and Fox [11,15] reported on the role of the foot in venous return, describing and proposing a compression hydraulic pump. The pump requires compliance of the soft tissues surrounding the foot veins, which are embedded in dense fibro-fatty tissue [11,13] within deep fascia accompanied by arteries [4,5]. Deep fascia has a significant role in venous return from constraining the muscles and vessels [4,5,16]. ...
... Although the lateral plantar vein is suggested to be particularly important as it is larger with fusiform sinuses, it is also more likely to weightbear than medial veins [5]. Recent studies have confirmed that venous throughput is increased through the tibial, peroneal and popliteal veins on weightbearing when compared to lying supine with the foot loaded with force [13]. Both intrinsic muscle activity and weightbearing compression of the foot have been reported as being equally significant in expelling blood into the deep veins of the calf [13]. ...
The gait cycle has been modelled for energetics and musculoskeletal health and disease, but little has been published in relation to the function of gait as a mechanism in maintaining haemodynamic homeostasis through the lower limb. Blood returns from the lower limb drawn to the heart by the low pressure at the vena cava through hydrodynamic forces. Resisting these hydrodynamics forces are gravitational and frictional forces. The deficit between the forces acting for venous return from the lower limb by hydrodynamics and those acting against antegrade flow, is filled by extrinsic mechanical mechanisms including the respiratory pump, skeletal muscle pumps and the foot pump. The efficiency of the lower limb skeletal muscle pump and foot pump are likely linked to gait kinetics and kinematics. A model is proposed that attempts to expand upon previous gait models of the foot pump as part of the kinetic and kinematic events that occur during gait, whilst also developing the argument that the foot pump needs to be divided into passive-pressure phases, and combined active-muscular/passive-pressure phases during gait. This model suggests that non-weightbearing arch profiles will have little influence on the combined active/passive-pressure phases of the foot pump, while the ability to develop compliance and stiffness within the foot at the requisite periods of the gait cycle is likely to influence foot pump efficiency.
... The deep venous system of the foot forms a venous plexus that is composed by a lateral vein, a medial vein, and a deep plantar arch. The lateral and medial plantar veins are usually doubled and course either intramuscularly or in between the plantar muscles from a lateral position distally to a medial position near the ankle, where they drain into the paired posterior tibial veins [93]. The deep plantar arch and the lateral and medial plantar veins receive blood from superficial veins located in the sole of the foot and from the metatarsal veins [85,93]. ...
... The lateral and medial plantar veins are usually doubled and course either intramuscularly or in between the plantar muscles from a lateral position distally to a medial position near the ankle, where they drain into the paired posterior tibial veins [93]. The deep plantar arch and the lateral and medial plantar veins receive blood from superficial veins located in the sole of the foot and from the metatarsal veins [85,93]. The plantar deep venous system is connected with the superficial veins on the dorsum of the foot via several perforator veins. ...
... The anatomical design of the deep plantar system, characterized by the presence of paired veins flanking an artery and joined together by connective tissue, and by the close relation between these veins, the plantar muscles and the metatarsophalangeal joints, is well suited to enhance venous blood flow during weight bearing and ambulation. These imply that the foot pump expels the blood through a double mechanism: contact of the foot with the ground, resulting in extension of the tarsal arch and metatarsophalangeal joints associated with compression of the deep veins and the calcaneous plexus, and by contraction of the plantar muscles surrounding the blood reservoir of the deep venous system [88,[93][94][95]. The foot pump empties during the stance phase of the gait, as a result of weight-bearing, and pushing off action, and refills during the swing phase, when the foot is cleared from ground contact. ...
Chronic venous disease (CVD) is a chronic condition that is associated with venous hypertension, vein’s valves damage, venous obstruction, and calf muscle pump impairment. This blood circulatory condition is also characterized by important inflammatory changes affecting the skin, the subcutaneous tissue and the muscles, which are probably triggered by blood stasis and venous edema. With disease progression, severe ulcerative skin damage might occur, which when present represent the more severe stage of this condition. CVD has a significant economic, social and health impact, mostly due to raised morbidity and chronicity.
The treatment of patients with CVD might focus on both the symptoms and secondary changes of the disease, such as edema, skin and subcutaneous changes or ulcers. Usually, initial treatment of CVD patients involves a non-invasive, conservative treatment to reduce symptoms, treat secondary changes, and help prevent the development of secondary complications and the progression of the disease. Complementary, some interventional or surgical treatments can be undertaken.
There are several conservative treatments to treat and prevent complications associated with CVD that have been described in the literature, like manual lymphatic drainage (MLD) and compression, physical exercise, intermittent pneumatic pressure, kinesio taping, electrical muscle stimulation, transcutaneous electrical nerve stimulation, hydrotherapy, and health education. Most of these techniques are complementary to compression therapy or pharmacological treatment.
This chapter will address the role of physical therapists in the management of CVD. The chapter will begin by reviewing the basic physiopathology of CVD, including the role of calf muscle pump. The CEAP classification system and the chronic venous severity score will be presented, as these are main tools for clinical assessment of CVD severity. In the remainder of the chapter will address the physiological effects and recommendations for treating CVD of MLD, based on our clinical experience and own research.
... Their physiology was proven in further studies using phlebography and duplex sonography [21][22][23][24] . In either case, the effect unfolds through a combination of passive and active moieties, which gave rise to the name venous hand or foot pump [25][26][27] . For the foot pump, the passive effect consists of weight bearing during the stance phase and the stretching of the plantar surface during roll-off, draining the contained blood volume proximally. ...
... In the hand, the superficial veins, both palmar and dorsal, pass over prominent bony structures and are compressed onto them during fist clenching 24,28 . Synergistically with this passive moiety, the blood from the deep intermuscular veins in both regions is actively transported centrally by muscle pumps 27 . Since their development, there have been numerous studies on the use of intermittent pneumatic compression (IPC) devices, the Vascular Impulse Technology therapy (VIT therapy) being one form of these. ...
Soft-tissue conditioning due to posttraumatic oedema after complicated joint fractures is a central therapeutic aspect both pre- and postoperatively. On average, 6–10 days pass until the patient is suitable for surgery. This study compares the decongestant effect of vascular impulse technology (VIT) with that of conventional elevation. In this monocentric RCT, 68 patients with joint fractures of the upper (n = 36) and lower (n = 32) extremity were included and randomized after consent in a 1:1 ratio. Variables were evaluated for all fractures together and additionally subdivided into upper or lower extremity for better clinical comparability. Primary endpoint was the time in days from hospital admission to operability. Secondary endpoints were total length of stay, oedema reduction, pain intensity, complications, and revisions. The time from admission until operability was reduced by 1.4 (95% CI − 0.4; 3.1) days in the mITT analysis (p = 0.120) and was statistically significant with 1.7 (95% CI 0.1; 3.3) days in the as-treated sensitivity analysis (pAT = 0.038). Significantly less pain and a faster oedema reduction were found in the intervention group. Due to rare occurrences, nothing can be concluded regarding complications and revisions. Administration of VIT therapy did not lead to a significant reduction in time until operability in the whole population but was superior to elevation for soft-tissue conditioning and pain reduction. However, there was a significant reduction by 2.5 days (95% CI 0.7; 4.3) in the subgroup of lower extremity fractures. VIT therapy therefore seems to be a helpful tool in the treatment of posttraumatic oedema after complex joint fractures of the lower and upper extremity, especially in tibial head and lower leg fractures.
... In the 1970s, a venous plexus was demonstrated for both, venous return from the foot and from the hand, and the physiology of both was proven in further studies using phlebography and duplex sonography [21][22][23][24]. In either case, the effect unfolds through a combination of passive and active moieties, which gave rise to the name venous hand or foot pump [25][26][27]. In case of the foot pump, the passive effect consists of weight bearing during the stance phase and the stretching of the plantar surface during roll-off, draining the contained blood volume proximally. ...
... Synergistically with this passive moiety, the blood from the deep intermuscular veins in both regions is transported actively centrally by muscle pumps [27]. Since their development, there have been numerous studies on the use of intermittent pneumatic compression (IPC), the Vascular Impulse Technology therapy (VIT therapy) being one form of it. ...
Introduction
Soft tissue conditioning due to posttraumatic oedema after complicated joint fractures is a central therapeutic aspect both pre- and postoperatively. Six to ten days are passing on average until the patient is suitable for surgery. The aim was to compare the decongestant effect of vascular impulse technology (VIT) with that of conventional elevation.
Materials and Methods
In this monocentric RCT, 68 patients with joint fractures of the upper (n = 36) and lower (n = 32) extremity were included and randomised after consent in a 1:1 ratio. The variables were evaluated for all fractures together and additionally subdivided into upper or lower extremity for better clinical comparability. The primary endpoint was the time in days from hospital admission to operability. Secondary endpoints were total length of stay, oedema reduction, pain intensity, complications and revisions.
Results
The time from admission until operability was reduced by 1.4 (95% CI: -0.4; 3.1) days in the mITT analysis (p = 0.120), being statistically significant with 1.7 (95% CI: 0.1; 3.3) days in the as-treated sensitivity analysis (pAT = 0.038). Significant less pain was found in the intervention group and a significantly faster oedema reduction. Due to rare occurrences, nothing can be derived in regard to complications and revisions.
Conclusion
Administration of VIT therapy did not lead to a significant reduction in the time until operability but was superior to elevation in regard of soft tissue conditioning and pain reduction. Thus, it seems like a helpful tool in the treatment of posttraumatic oedema after complex joint fractures of the lower and upper extremity, especially in tibial head and lower leg fractures.
... Несколько механизмов возвращают венозную кровь, скопившуюся в нижних конечностях, к сердцу, включая активацию мембранного насоса, подошвенного венозного насоса и мышечных насосов икр и бедер [49]. Венозный возврат в стопу обеспечивается подошвенным венозным насосом, который при каждом шаге (в фазе толчка) подает некоторое количество венозной крови как в глубокую, так и в поверхностную венозную систему [51][52][53]. Именно поэтому ножной насос следует рассматривать как настоящую импульсно-аспирационную систему, обеспечивающую первый толчок венозной крови в нижние конечности во время ходьбы [54,55]. Таким образом, одной из стратегий улучшения функции вен может быть воздействие непосредственно на стопу с помощью определенных видов обуви (например, ортопедических стелек, сандалий, обуви без каблука). ...
The article provides a review of the literature on the role of compression knitwear in the complex treatment of chronic venous disease (CVD). The pathogenesis of CVD and its complications is analyzed, with the consequent need to follow a precisely calibrated pressure profile (graduated compression) when choosing compression knitwear. Based on the literature data, it has been shown that it is precisely a strictly selected pressure gradient that guarantees the flow of blood to the heart, and not in the opposite direction or the distribution of blood through the superficial veins. Correct graduated compression reduces venous hypertension, improves the functioning of the musculoskeletal pump, facilitates venous return and improves lymphatic drainage, exerting positive physiological and biochemical effects affecting the venous, arterial and lymphatic systems. It is necessary to take into account the fact that patients with a pronounced violation of venous outflow have increased skin sensitivity, a tendency to atopic reactions, irritations and various discomfort when wearing compression knitwear. This often leads to its irregular use, which increases the duration of treatment. Thus, the effectiveness of compression therapy can only be ensured by high-quality compression knitwear, confirmed by clinical studies, having international certificates of conformity and a wide range of sizes, allowing to select compression knitwear for each patient individually. An impressive evidence base is provided, including both international clinical trials and domestic observations, attesting to the compliance of mediven® elegance compression knitwear with RAL-387 quality standards. CVD and flat feet are related conditions. With flat feet, the muscles of the lower leg suffer greatly, which are forced to be under increased stress while working with increased stress. It is their work that ensures the normal outflow of venous blood. To reduce the risk of developing CVD with flat feet, it is recommended to use orthopedic insoles in combination with compression knitwear, which reduces the load on the legs and helps slow down the development of varicose veins. The combined use of orthopedic insoles and compression knitwear will reduce pain, swelling and heaviness in the legs, create comfort, increase confidence when walking, ensure proper foot position due to their design, improve the functioning of the shin muscles and, as a result, venous outflow.
... During walking, there is a dynamic interplay between the foot and lower leg veins and between the foot and calf muscle pumps, which is facilitated by the above-mentioned unique valve orientation in the foot perforators. This interplay can be compromised if the foot is deformed or improper footwear is used [38][39][40][41][42]. ...
Veins of the lower extremity can be categorized into three hierarchically ordered groups: the epifascial, the interfascial, and the deep ones. In the past, the interfascial veins, e.g., the great saphenous vein, were categorized as superficial veins. But nowadays, experts recommend regarding these veins as a separate group because of their unique topography and clinical relevance. In order to better understand the venous anatomy of the lower limbs, which is highly variable, one should also comprehend their embryological development. Venous embryogenesis in the lower limb consists of three stages. During the first stage the primitive fibular vein is the main vein of the extremity. During the second stage it is replaced by the axial vein and finally by the femoral vein. In some adult individuals this embryonic or fetal venous anatomy is still present. Unfortunately, current anatomical textbooks and atlases, as well as traditional cadaver dissections, are not very useful regarding these issues. Therefore, undergraduate teaching of anatomy can be challenging. New educational tools, such as ultrasonography, seem indispensable to teach the anatomy of these veins properly.
... These veins then contribute to the formation of the deep venous arch. From this point, the medial and lateral plantar veins arise, converging behind the medial malleolus to form the posterior tibial veins [1,4,6,26,27]. ...
Plantar vein thrombosis (PVT) is an underdiagnosed condition affecting the deep plantar veins, with challenging clinical diagnosis, often presenting with non-specific symptoms that mimic other foot pathologies. This study assessed the magnetic resonance imaging (MRI) features of patients diagnosed with PVT to contribute to the understanding of this condition. We performed the comprehensive analysis of a substantial dataset, including 112 patients, with a total of 130 positive MRI scans (86 of the forefoot and 44 of the ankle) presenting with PVT. Upon evaluating all the veins of the feet, we observed a higher frequency of involvement of the lateral plantar veins (53.1%) when compared to the medial veins (3.8%). The most affected vascular segments in the forefeet were the plantar metatarsal veins (45.4%), the plantar venous arch (38.5%), and the plantar communicating veins (25.4%). The characteristic findings on MRI were perivascular edema (100%), muscular edema (86.2%), venous ectasia (100%), perivascular enhancement (100%), and intravenous filling defects (97.7%). Our study provides valuable insights into the imaging evaluation of PVT and shows that MRI is a reliable resource for such diagnosis.
... The plantar surface of the foot distorts under GRF during gait, allowing the heel and forefoot to behave like 'compression pumps', expelling blood into calf veins together with the action of plantar intrinsic muscles [25,26]. With each step, GRFs act on deep plantar veins like a hydraulic pump, with the valves in the perforating veins preventing reflux to the deep foot veins during offloading [21]. ...
The foot and calf muscle pump, collectively known as the venous muscle pump, plays a crucial role in the circulatory system (veins, arteries, and lymphatics), particularly in the return of blood from the lower extremities to the heart. Further, the venous muscle pump is crucial to lymphatic health and essential in chronic edema/lymphedema management. This article will highlight the significance of the venous pump and review the functional anatomy and physiology of the foot and calf, integrating the connection to venous and lymphatic health. The complementary importance of mobility, exercise, and breathing will also be explored.
... Strand contents may therefore be secreted into the strands' extracellular matrix, and from there can probably be pushed forwards when neighbouring muscles contract. Exploitation of mechanical work by neighbouring structures is a common physiological principle, including transportation of glandular secretions [56][57][58]. A mechanical dependency could also explain the identified anatomical differences between male and female frogs (e.g. ...
Intraspecific chemical communication in frogs is understudied and the few published cases are limited to externally visible and male-specific breeding glands. Frogs of the family Odontobatrachidae, a West African endemic complex of five morphologically cryptic species, have large, fatty gland-like strands along their lower mandible. We investigated the general anatomy of this gland-like strand and analysed its chemical composition. We found the strand to be present in males and females of all species. The strand varies in markedness, with well-developed strands usually found in reproductively active individuals. The strands are situated under particularly thin skin sections, the vocal sac in male frogs and a respective area in females. Gas-chromatography/mass spectrometry and multivariate analysis revealed that the strands contain sex- and species-specific chemical profiles, which are consistent across geographically distant populations. The profiles varied between reproductive and non-reproductive individuals. These results indicate that the mandibular strands in the Odontobatrachidae comprise a so far overlooked structure (potentially a gland) that most likely plays a role in the mating and/or breeding behaviour of the five Odontobatrachus species. Our results highlight the relevance of multimodal signalling in anurans, and indicate that chemical communication in frogs may not be restricted to sexually dimorphic, apparent skin glands.
... The lateral plantar vein is positioned between the flexor digitorum brevis muscle and quadratus plantae. The medial plantar vein courses between the abductor hallucis and the flexor hallucis brevis muscles [9,10]. The deep plantar venous anatomy is shown in Figure 1. ...
Plantar vein thrombosis is a venous disorder affecting deep plantar veins that can manifest with non-specific localized pain, plantar foot pain, swelling, and sensation of fullness. Plantar veins are not routinely assessed during sonographic scans for deep venous thrombosis, which makes plantar venous thrombosis a commonly missed diagnosis. This paper provides a comprehensive review of the venous anatomy of the foot and imaging findings of plantar venous thrombosis as well as discusses the current literature on the topic and its differential diagnoses.
... Malfunction of any of these mechanisms can lead to chronic venous insufficiency (CVI). 1 The foot venous pump is located near the foot arch and is also termed the plantar venous pump (PVP). [2][3][4] The PVP is composed of deep plantar lateral and medial veins, constituting a reservoir of 15 to 25 mL. 3 The PVP empties at each stance phase of the gait cycle, first with weightbearing (Fig 1, A and B) and then with plantar muscle contraction for propulsion (Fig 1, C). 6,7 The hemodynamics of the PVP remain a topic of research with many open questions. Other investigators have studied the PVP via activating it using different compression mechanisms such as muscular exercises, intermittent pneumatic compression (IPC), and micromobile foot compression devices. ...
Background:
The plantar venous pump PVP, composed of deep plantar veins, is the most distal contributor to venous return from the lower limbs. There is still a pressing need to assess how plantar muscles contraction and gait affect its function, how foot stato-dynamic disorders FSD can contribute to venous insufficiency, and how it can be optimally stimulated.
Objective:
Our first objective is to compare venous blood hemodynamics in lower limb between healthy subjects having FSD and healthy subjects without FSD to understand the influence of foot morphology in the performance of the PVP. Our second objective is to evaluate whether the PVP function varies modifying plantar pressures.
Patients/methods:
Fifty-two healthy volunteers - twenty-six feet with normal arch (control group) and twenty-six feet with dysmorphy (thirteen flat feet, thirteen hollow feet) - were included. Strain-gauge plethysmography was performed 8 cm above the medial malleolus during different conditions of PVP stimulations: (1) with toe flexions, (2) with Intermittent Pneumatic Compression (IPC) with and without insole, (3) with 3 km/h-speed walking on a treadmill barefoot, with shoes, and with shoes and insoles. From the strain-gauge plethysmography, we measured venous blood ejection fraction (EF,%). From the pressure sensor placed at midfoot on the plantar arch during IPC, we obtained maximal pressure (N/cm2).
Results:
Toe flexion allowed ejecting in average 20% of the total venous volume in both groups whereas IPC and gait generated mean EF superior to 100% of the available venous volume. The Pmax applied at midfoot during IPC was lower than the pressure set. No significant difference of EF and Pmax was observed between the two groups. The mean EF was not significantly impacted in pronator and supinator walkers compared to subjects with normal walking dynamics. Wearing shoes did not significantly impact the mean EF whereas wearing insoles during gait significantly increased venous return in feet with plantar dysmorphy.
Conclusion:
This clinical study is the first one to assess the PVP function in 52 healthy volunteers with and without foot stato-dynamic disorders. The study showed that wearing shoes did not significantly impact the PVP efficiency while wearing morphological adapted insoles significantly improved the venous return in dysmorphic feet. In this sample of healthy volunteers, the differences observed between control group and feet with FSD were not significant.
... Although differences exist regarding the vessel dimensions, this anatomical-functional organization was confirmed by Corley et al. 8 and Ricci et al. 9 Moreover, unlike what F. Lejars suggested in 1890, demonstrated that, strictly speaking, the foot venous pump is essentially intermuscular and located deeply at the level of the foot arch and can be called Plantar Venous Pump PVP. Indeed, it is mainly composed of deep plantar lateral and medial veins which constitute a blood reservoir of about 15-25 mL. 5 Uhl, Corley et al., Ricci et al., and others studying PVP all showed that it empties at each gait cycle with weightbearing and plantar muscle contractions following these three steps: (1) high compliance of large caliber plantar veins as well as relaxation of plantar muscles allow PVP filling during the swing phase of the gait. ...
Background:
The role of the plantar venous pump (PVP) on venous return is evident but the effects of the foot morphology have never been characterized properly.
Method:
52 healthy volunteers-26 with normal plantar arch (control) and 26 with dysmorphic plantar arch (in two subgroups: 13 flat feet, 13 hollow feet)-were included. Using Doppler ultrasound, we measured the diameter and the peak systolic velocity in the large veins of the lower limb after PVP stimulation by manual compression and bodyweight transfer.
Result:
The mean peak systolic velocity of the studied veins varied from 12.2 cm/s to 41.7 cm/s in the control group and from 10.9 cm/s to 39.1 cm/s in the dysmorphic plantar group. The foot arch morphology did not affect significantly the venous blood flows, except in the great saphenous vein during manual compression.
Conclusion:
The plantar morphology did not induce a significant increase of venous blood velocity resulting from PVP stimulation.
... Mediante el uso de instrumental que permite un fresado óseo a bajas revoluciones por minuto y una menor agresión a los vasos y nervios, junto a una mínima incisión quirúrgica, se permite disminuir de forma significativa las complicaciones en los pacientes diabéticos (5) . Además, al permitir la carga inmediata mediante un zapato posquirúrgico, se logra la elevación de la cabeza con la consecuente disminución de la presión a nivel plantar que, junto a la activación del sistema de retorno venoso, facilita la curación de las úlceras (17) . En nuestro caso, mediante la realización de esta técnica, conseguimos la curación de la totalidad de las úlceras plantares en un tiempo medio de 3,3 semanas. ...
... This is augmented by the foot pump, which concurrently expels a column of blood of 100mmHg during weight bearing through a normal gait cycle. 64,65 When a needle is introduced into a dorsal foot vein and the intravenous pressure is measured, the pressure during quiet standing corresponds to the weight of the blood column and the right heart, which is between 80 and 100mm depending on the body height. When the subject starts walking, the intravenous pressure will drop to 20-30mmHg as a sign of a normal calf muscle pump. ...
The following supplement is a rare example of a paper that combines clinical experience and theoretical knowledge on textiles used in compression therapy. The authors' intention is to propose a decision support system for choosing specific compression devices, which can be adjusted to counteract the individual signs and symptoms in an optimally adopted way. The document concentrates on compression devices which can be self-applied by the patients—compression stockings and adjustable wraps. The acronym ‘S.T.R.I.D.E.’, incorporating both textile characteristics and clinical presentation, stands for: Shape, Texture, Refill, Issues, Dosage and Etiology. The intent of the mnemotechnical value is to highlight that successful compression includes more than dosage alone. In addition to dosage, etiology and patient presentation need to be incorporated, including a patient's physical ability to use compression effectively as part of the daily routine, thereby promoting adherence.
The suggested algorithms provide a valuable guide to stride across the important, but still underestimated field of medical compression therapy and will help to put the prescription of a specific product on a more rational basis. Enjoy reading!
Hugo Partsch Emeritus Professor Medical University of Vienna, Austria
... The plantar muscle pump is activated with each step during walking, especially during the heel contact and stance phases of the gait cycle, when venous return is stimulated by a weight bearing compression of the plantar veins and muscular contraction around the veins. 21,22 The footwear tested in our study is assumed to improve the blood circulation by strengthening the lower limb foot and/or calf muscle pumps, since the design of the insole tested stimulates activation of the foot muscles. Nevertheless, there is a need for further investigation of the beneficial effect on venous flow of the footwear tested and its applications, since there are many factors affecting the pregnant body, demonstrated by a significant difference between PSV in the experimental and control groups at the first data collection session, before the test footwear had been worn. ...
Background
During pregnancy, a number of changes affecting venous blood flow occur in the circulatory system, such as reduced vein wall tension or increased exposure to collagen fibers. These factors may cause blood stagnation, swelling of the legs, or endothelial damage and consequently lead to development of venous disease.
Objectives
The aim of this study is to evaluate the effect of special footwear designed to improve blood circulation in the feet on venous blood flow changes observed during advancing phases of pregnancy.
Methods
Thirty healthy pregnant women participated in this study at 25, 30, and 35 weeks of gestation. Participants were allocated at random to an experimental group (n = 15) which was provided with the special footwear, or a control group (n = 15). At each data collection session, Doppler measurements of peak systolic blood flow velocity and cross-sectional area of the right popliteal vein were performed using a MySonoU6 ultrasound machine with a linear transducer (Samsung Medison). The differences were compared using Cohen’s d test to calculate effect size.
Results
With advancing phases of pregnancy, peak systolic velocity in the popliteal vein decreased significantly in the control group, whereas it increased significantly in the experimental group. No significant change in cross-sectional area was observed in any of the groups.
Conclusions
Findings in the experimental group demonstrated that wearing the footwear tested may prevent venous blood velocity from reducing during advanced phases of pregnancy. Nevertheless, there is a need for further investigation of the beneficial effect on venous flow of the footwear tested and its application.
... Venous return estimated from stroke volume and popliteal vein diameter was similar between treatment conditions, indicating that the Korvit system has minimal effects on the venous foot pump. This finding was expected, given that the Korvit system mainly stimulates the forefoot and heel, rather than the arch of the foot where the venous network is more concentrated (Corley et al. 2010). ...
Walking is a complex locomotor process that involves both spinal cord reflexes and cortical integration of peripheral nerve input. Maintaining an upright body position requires not only neuromuscular activity but also cardiovascular regulation. We postulated that plantar mechanical stimulation might modulate autonomic nervous system activity and, thereby, impact blood pressure adaptation during standing. Methods
Twelve healthy subjects underwent three randomly ordered 45-min 70°-saddle tilt tests while the plantar surfaces of the feet were stimulated using specially engineered Korvit boots in the following modes: (1) no stimulation, (2) disrupted stimulation, and (3) walking mode. Orthostatic tolerance time was measured for each trial. During testing, we obtained an electrocardiogram and measured blood pressure, skin blood flow, and popliteal vein cross-sectional area. We estimated central hemodynamics, baroreflex sensitivity and heart rate variability. ResultsOrthostatic tolerance time was not found to differ significantly between test conditions (37.2 ± 10.4, 40.9 ± 7.6, and 41.8 ± 8.2 min, for no stimulation, disrupted stimulation, and walking mode, respectively). No significant differences between treatment groups were observed for stroke volume or cardiac baroreflex sensitivity, both of which decreased significantly from baseline during tilt testing in all groups. Cardiac sympathetic index and popliteal vein cross-sectional area increased at the end of the tilt period in all groups, without significant differences between treatments. Conclusions
Plantar mechanical stimulation is insufficient for immediate modulation of cardiac sympathetic and parasympathetic activity under orthostatic stress.
... Patients are strongly encouraged to maintain normal physical activity and to ambulate freely while undergoing VLU treatment. Frequent calf muscle and pump action(16) and the increased limb perfusion that accompanies exercise can only improve the ulcer environment and promote healing. action and the increased limb perfusion that accompanies exercise can only improve the ulcer environment and promote healing.It is well known that there are three factors that contribute to failure of wounds to heal in a timely manner: compromised perfusion resulting in diminished tissue oxygen levels; invading flora and host immunological impairment. ...
In order to assess the impact of comorbidities and identify factors that accelerate the healing rate of venous leg ulcers we performed an extensive, retrospective analysis of our experience in a diverse population. From June, 2006 to June, 2014, 897 patients with 1249 venous leg ulcers were treated at Lake Wound Clinics. Treatment protocols utilized the standard regimen of wound cleaning, debridement and compression bandaging. Wound cleaning, autolytic debridement, packing and dressing of venous leg ulcers utilized aqueous solutions of hypochlorous acid (HCA) rather than the standard normal saline. This protocol caused all ulcers to close completely. Comorbidities that delayed healing included uncontrolled or poorly controlled diabetes mellitus, advanced peripheral artery occlusive disease (PAD), active smoking, use of steroid medications and/or street drugs, large initial ulcer size and significant depth. Other factors, including advanced age, recurrent venous ulceration, stasis dermatitis, lipodermatosclerosis, morbid obesity and infection with one or more multidrug resistant organisms did not delay closure. From this experience we conclude that venous leg ulcer care protocols that clean, debride, pack and dress with hypochlorous acid solutions can reduce the effects of some comorbidities while accelerating healing times. Additional benefits are described.
... Auch die Atemmechanik wirkt gleichsinnig, trägt also zur "vis a fronte" bei [23], allerdings ist auch hier keine Korrelation zwischen Atemfrequenz und Klappenschlusszyklus zu finden [40,41]. Als wesentliche Antriebsmechanismen werden die peripheren Muskel-und Gelenkpumpen beschrieben [16,21,23], allerdings gibt es auch dazu kritische Stimmen [24], zumal ihre Funktion von aktiven Bewegungen abhängig ist. Bei aktiver Muskulatur tragen sie sicherlich zum venösen Rückstrom bei, in absoluter körperlicher Ruhe fällt dieser Mechanismus jedoch aus. ...
The superficial venous system is basically different from the deep venous system. The superficial veins run independently from the arteries, they lie on the fascia and are partly separated from the subcutaneous connective tissue by their own fascia. This applies particularly to the great saphenous vein and the small saphenous vein. The great saphenous vein opens into the communicating femoral vein in the region of the saphenous opening of the fascia lata. The small saphenous vein continues into the thigh as the femoro-popliteal vein and finally opens into the great saphenous vein as the posterior accessory saphenous vein. The region of the opening into the great saphenous vein has many valves and side branches the most important of which are an ostial valve which is only sometimes present and the terminal valve. The latter is situated between the actual junction and the most proximal side branch. Even this is not constant and is found in only four out of five cases.
Substantial advances occurred in phlebological practice in the last two decades. With the use of modern diagnostic equipment, the patients' venous hemodynamics can be examined in detail in everyday practice. Application of venous segments for arterial bypasses motivated studies on the effect of hemodynamic load on the venous wall. New animal models have been developed to study hemodynamic effects on the venous system. In vivo and in vitro studies revealed cellular phase transitions of venous endothelial, smooth muscle, and fibroblastic cells and changes in connective tissue composition, under hemodynamic load and at different locations of the chronically diseased venous system. This review is an attempt to integrate our knowledge from epidemiology, paleoanthropology and anthropology, clinical and experimental hemodynamic studies, histology, cell physiology, cell pathology, and molecular biology on the complex pathomechanism of this frequent disease. Our conclusion is that the disease is initiated by limited genetic adaptation of mankind not to bipedalism but to bipedalism in the unmoving standing or sitting position. In the course of the disease several pathologic vicious circles emerge, sustained venous hypertension inducing cellular phase transitions, chronic wall inflammation, apoptosis of cells, pathologic dilation, and valvular damage which, in turn, further aggravate the venous hypertension.
Thermal comfort plays a crucial role in the performance and well-being of mountaineers, especially in extreme environments. The aim of this study was to develop a reliable protocol to assess the thermal comfort of mountaineering boots, with a specific focus on temperature variations in different regions of the foot and their correlation with physiological factors. Two different models of mountaineering boots were tested at two different environmental temperature (-15 • C and-30 • C). The mean skin temperature, measured according to International Standards BS EN ISO 9886:2004, was used as an indicator of overall thermal comfort. Physiological factors such as heart rate (HR), body mass index (BMI) and body surface area (BSA) were also measured to understand their relationship to thermoregulation. Kruskal-Wallis and Pearson's ProductMoment correlation tests were performed to investigate whether there was a statistically significant relationship. The results showed significant differences in foot temperature among the Testers, indicating variations in the perception of thermal comfort. The correlation analysis showed a strong positive relationship between mean skin temperature and HR, highlighting the influence of physiological factors on thermal comfort. In addition, the analysis showed that the dorsum and hallux areas had the largest temperature variations, suggesting the occurrence of vasoconstriction and potential discomfort. This study represents a preliminary approach to establishing a reliable protocol for assessing the thermal performance of cold protective footwear.
Objective
The aim of this study was to compare the outcomes and complications of selected patients treated with endovenous laser ablation (EVLA) or ambulatory phlebectomy for foot varicose veins.
Methods
From October 2016 to February 2022, selected patients undergoing EVLA (using 1470-nm with radial-slim or bare-tip fibers) or phlebectomy of foot varicose veins for cosmetic indications were analyzed, and the outcomes were compared. Patients were classified according to the Clinical, Etiologic, Anatomical, and Pathophysiological (CEAP) classification. Anatomic criteria provided the basis for the decision to perform EVLA or phlebectomy. Clinical and ultrasound assessments were performed on postoperative days 7, 30, and 90 for visualization of the sapheno-femoral and sapheno-popliteal junctions and the deep venous system. Disease severity was graded with the Venous Clinical Severity Score (VCSS), and quality of life was measured with the Aberdeen Varicose Vein Questionnaire (AVVQ) before and after treatment. Treatment outcomes were evaluated based on changes in VCSS and AVVQ scores. The groups were also compared for procedure-related complications. Data were statistically analyzed in SPSS v. 20.0 using the χ², Student t test, Mann-Whitney test, Wilcoxon test, and analysis of variance. The results were presented as mean (standard deviation or median (interquartile range).
Results
The study included 270 feet of 171 patients. Mean patient age was 52.3 (standard deviation, 13.1) years, ranging from 21 to 84 years; 133 (77.8%) were women. Of 270 feet, 113 (41.9%) were treated with EVLA and 157 (58.1%) with phlebectomy. The median preoperative CEAP class was 2 (interquartile range, 2-3) in the phlebectomy and EVLA groups, with no statistically significant difference between the groups (P = .507). Dysesthesia was the most common complication in both groups. Only transient induration was significantly different between EVLA (7.1%) and phlebectomy (0.0%) (P = .001). The two approaches had an equal impact on quality of life and disease severity.
Conclusions
Treatment complications were similar in phlebectomy and EVLA and to those previously described in the literature.
Das Venensystem der Extremitäten ist ständigen hydrostatischen Druckveränderungen ausgesetzt und muss neben der Volumenspeicherung auch Funktionen im Stoffaustausch übernehmen. Die Kenntnis über diese physiologischen Mechanismen helfen im klinischen Alltag bei der Diagnostik von Venenerkrankungen und bei der Auswahl der Therapieform. Im ersten Teil der Fortbildungsreihe wird die Funktion der Venen durch vier Grundbausteine: Venenanatomie, Herz-Kreislaufsystem/Zwerchfellpumpe, Wadenmuskelpumpe und Fußpumpe definiert. Die Kombination aus Zwerchfellpumpe mit der Wadenmuskel und Fußpumpe als funktionelle Einheit stellt einen komplexen Mechanismus für den Venenrückfluss dar. //The venous system is constantly subject to changes in hydrostatic pressure in the extremities as the body changes position. In addition to storing blood volumes, the venous system also plays an important role in the exchange of substances. In the first part of the training series, the function of the veins is defined by four basic elements: vein anatomy, cardiovascular system/diaphragmatic descent, the foot pump, and the calf muscle pump. Venous valves are duplications of the intima, and valve cycles consist of an opening, equilibrium, and closing phase. The vascular width of a vein is regulated by neural-humoral controls so that a sympathetically induced adrenergic stimulation mediates venous constriction. The calf muscle pump is divided into proximal and distal parts whose haemodynamic effects differ. In the foot there is a medial and a lateral plantar vein, with the lateral plantar vein playing a crucial role (foot pump) in mobilizing blood volume due to its size and venous capacity. The function of the diaphragmatic descent on the venous return in the supine position without movement of the lower extremity depends on the degree of filling of the inferior vena cava. In combination with the calf muscle pump and foot pump, this results in a complex functional unit. In everyday clinical practice, knowledge of the physiological mechanisms of venous return helps in the diagnosis of venous diseases, and in the selection of the correct therapeutic approach.
Eine Vielzahl epidemiologischer Studien zur CVI hat nicht-modifizierbare Risikofaktoren wie Alter, weibliches Geschlecht, Familienanamnese und Anzahl der Schwangerschaften sowie
modifizierbare Risikofaktoren wie Adipositas, Nikotinkonsum und Zwangshaltungen (langes Stehen oder Sitzen) für die Entstehung und das Fortschreiten der Erkrankung zum Gegenstand. Da die Berufsausübung einen erheblichen Anteil unserer täglichen Aktivzeit in Anspruch nimmt, muss deren Auswirkung auf die modifizierbaren Risikofaktoren für eine CVI besondere Beachtung geschenkt werden. Neben der ätiologischen Erklärung relevanter Symptome Betroffener und symptomatischer Therapieansätze, muss grundsätzlich auch eine Intervention in die berufliche Exposition des Venensystems als Behandlungsinstrument
in Betracht gezogen werden. Die Autoren gehen den Fragen nach, inwieweit die berufliche Exposition das Entstehen einer chronischen Venenerkrankung fördert bzw. welche berufsbedingten Risikofaktoren deren Entstehung begünstigen und stellen den Zusammenhang zwischen den Ergebnissen und den pathophysiologischen Grundlagen dar.
The Valve-Muscular Pump (MVP) of the lower limb, a kind of peripheral heart, is principally activated during walking, by the succession of gait phases. The pump has three parts, which work in a coordinated way. The foot pump, due to the compression of the predominating lateral plantar vein during the contact on the ground (40% of gait event), “eject” 20-30 cm3 of blood into the posterior tibial vein and, in alternative, in the anterior tibial, peroneal and saphenous veins connected by perforators. The distal calf pump, activated during dorsiflexion of the ankle (passive 20% and active 40% of gait event), when the calf muscles are stretched and their distal part descends within the fascial sheath. This movement acts like a piston which expels venous blood in proximal direction. The proximal calf muscle pump due to sural and gastrocnemius muscles rich in venous sinuses that are strongly squeezed during the impulse phase of the step. During dorsiflexion of the ankle (passive or active) space is given to the blood coming from the foot pump (due to weight bearing), that will feed in prevalence the posterior tibial veins. These two systems are “in series”: the foot pump cannot expel the blood into the deep veins if these are not regularly emptied. The proximal pump, at the opposite, is very strong and can void a high volume of blood in the popliteal vein, even in the absence of a favourable gradient as it works “in parallel”.
One of the most widely recognized and fortunately infrequent complications of major surgery is having a patient develop thromboembolism and die after an elective procedure. Patients should be evaluated for risk factors for thromboembolism before surgery, and measures should be taken to reduce this risk. This article will present the various risks for thromboembolism and suggest the means to prevent or avoid this complication. Special emphasis will be placed on one of the most common errors in cosmetic surgery that increase the risk of thromboembolism: the failure to have the patient stop the use of estrogens at least 4 weeks before surgery and 2 weeks after surgery.
The superficial venous system of the leg starts with the epifascial veins, i.e. the various subcutaneous venous networks, the accessory saphenous veins, superficial epigastric vein, the superficial iliac circumflex vein, and the external pudendal veins. These flow into the two intrafascial veins, the great and the small saphenous veins. These, in turn, enter the deep venous system, the great saphenous vein constant in the saphenous hiatus, the small saphenous vein in just over two thirds of cases in the popliteal fossa. In addition, numerous connections exist between the superficial and the deep venous system by the perforating veins. The superficial veins communicate with each other by communicating veins. In the superficial veins numerous parietal valves are found, mostly with two, in smaller and smallest veins also with only one valve leaflet. At the entrance of the great saphenous vein into the femoral vein, there may also be an ostial valve. The wall of the superficial veins has the typical three-layered structure with a tunica intima, a tunica media and a tunica externa. The tunica intima comprises, at least in the great saphenous vein, an internal elastic membrane. In the tunica media, longitudinally arranged bundles of smooth musculature are found inside, followed by dense bundles of circularly arranged smooth musculature. In the tunica externa longitudinal muscle fiber bundles can also be found. Both the great and the small saphenous vein lie in their own fascial sheath, the floor of which is formed by the crural fascia or the fascia lata and their superficial leaf by the respective saphenous fascia. Within these saphenous compartments the respective veins are laterally anchored by saphenous ligaments. About 60 large-volume, clinically significant perforating veins connect the superficial with the deep venous system. At least one flap in each perforating vein prevents backflow from the deep venous system.
Venous developmental anatomy and embryology are fundamental to understanding venous disorders. Embryologic signaling has now been defined to establish differentiation of the circuit into arterial and venous components. The venous system is the most varied system in the human body. Clinical impact of developmental anomalies is reviewed. The currently accepted terms of venous dysfunction, anatomy, and clinical syndromes associated with congenital vascular malformations are presented.
Ein Kapitel über die funktionelle Anatomie des Venensystems muss notwendigerweise mit der Funktion des Venensystems beginnen.
Understanding the potential risks and complications of stem cell-assisted fat transfer is essential. Patients have the right to be informed and the physician has the duty to inform the patient of these possible risks and complications. Being aware of the complications can help the physician to avoid some of them and allow the physician to timely treat the complication. The author presents the risks and complications with measures to prevent the problem and suggestions on how to treat some of the problems. There is a thorough discussion of the risk of fat tissue embolization that has only recently been described to involve the lungs with possible fatal results. © 2014 Springer-Verlag Berlin Heidelberg. All rights are reserved.
Venous return from the foot is worthy of interest for both research and clinical purposes. This review summarizes the available knowledge of venous return from the foot with a special focus on research and clinical implications. The anatomy and physiology of venous return are described with an emphasis on the differences between standing and walking and the interplay between the venous systems of both the foot and the calf. Selected conditions of clinical interest are discussed and mechanistically interpreted, including the distinctive localization of leg ulcers, the corona phlebectatica, the possible independence of dilatation of the veins of the foot from refluxing varices, and the arteriovenous fistulae of the foot. From this perspective, the practice of using a postoperative lower-leg bandage is also discussed. Little attention has been devoted to the veins of the foot: surgeons begin the saphenectomy where the foot ends and echographists do not extend their exploration distally to the malleolus. Even anatomists have been more interested in the arteries of the foot, rather than the veins, as demonstrated by the more detailed description of arteries in anatomical tables. Finally, experts in hemodynamics focus on the calf to explain the mechanism of the limb pump, leaving the blood in the foot "und rained." However, as shown in the present bibliography, a few well-conducted classic studies have clarified the anatomical and functional characteristics of venous circulation in the foot, although some areas of uncertainty still exist. The main concepts concerning the anatomy and physiology of venous return from the foot will be revisited in this article, followed by observations of clinical interest and hypotheses for research and daily practice.
A thorough understanding of venous anatomy and physiology is foundational to the diagnosis and management of venous disease. Compared with the arterial system, there is significantly greater developmental variation in the venous system. The veins of the lower extremity include the superficial and deep veins, which are defined by their respective relationships to the muscular fascia. Perforating veins traverse the muscular fascia to connect superficial and deep veins. Communicating veins connect veins within the same venous compartment, either deep to deep or superficial to superficial. The deep veins of the lower extremities primarily drain muscles and are encompassed by muscular fascia. The veins located between the skin and the muscular fascia are considered superficial veins. Superficial veins drain the cutaneous microcirculation. The pelvic venous system is a complex transitional outflow pathway between the lower extremities, the pelvic structures, and the inferior vena cava. The terminology used to describe lower-extremity, pelvic, and abdominal vasculature conforms to published international standards.
This review aims to summarize present knowledge of foot venous return, with a special interest in clinical and research implications.
It is based on the latest available publications on foot anatomy and hemodynamics.
Five systems are described: the superficial veins of the sole, the deep veins of the sole (with particular attention to the lateral plantar vein), the superficial dorsal plexus, the marginal veins and the dorsal arch and the perforating system. The Foot Pump: The physiology of venous return is briefly described, with an emphasis on the differences between standing and walking and the interplay of the foot and calf venous systems.
The hypothesis that the foot and calf venous systems may be in conflict in several clinical conditions (localization of leg ulcers, corona phlebectatica, foot vein dilatation, arteriovenous fistulas of the foot, foot-free bandaging) is presented, briefly discussed, and mechanistically interpreted.
Foot venous return could be more important than is commonly thought. Certain clinical conditions could be explained by a conflict between the mechanisms of the foot pump and the leg pumps most proximal to the foot, rather than by generic pump insufficiency, with possible effects on treatment and compression strategies.
This study investigated the hemodynamic properties of the plantar venous plexus (PVP), a peripheral venous pump in the human foot, with Doppler ultrasound. We investigated how different ways of introducing mechanical changes vary in effectiveness of displacing blood volume from the PVP. The contribution of the PVP was analyzed during both natural and device-elicited compressions. Natural compressions consisted of weight bearing on the foot and toe curl exercises. Device-elicited compressions consisted of intermittent pneumatic compression (IPC) of the foot and electrically elicited foot muscle contractions. Ten healthy participants had their posterior tibial, peroneal, anterior tibial, and popliteal vein blood flow monitored while performing these natural and device-elicited compressions of the PVP supine and in an upright position. Results indicated that 1) natural compression of the PVP, weight bearing and toe curls, expelled a significantly larger volume of blood than device-elicited PVP compression, IPC and electrical stimulation; 2) there was no difference between the venous volume elicited by weight bearing and by toe curls; 3) expelled venous volume recorded at the popliteal vein under all test conditions was significantly greater than that recorded from the posterior tibial and peroneal veins; 4) there was no significant difference between the volume in the posterior tibial and peroneal veins; 5) ejected venous volume recorded in the upright position was significantly higher than that recorded in the supine position. Our study shows that weight bearing and toe curls make similar contributions to venous emptying of the foot.
Presented is a physiological study of the plantar venous plexus in the context of venous return. It is accepted that the plantar venous plexus acts as a peripheral venous pump, capable of emptying blood from the foot into the posterior tibial veins. Controversy still exists, however, over the precise physiological mechanism which is responsible for completely emptying the deep plantar veins of the foot. This study was designed to investigate whether weight bearing or muscular contraction was the dominant mechanism involved. This was achieved by comparing blood flow measurements taken from the posterior tibial and popliteal veins while performing specific foot exercises. Measurements were taken using Doppler ultrasound. Neuromuscular electrical stimulation was also used to study the blood flow obtained by artificially inducing contraction of the plantar venous plexus.
We performed a prospective randomised controlled trial of a new mechanical method of prophylaxis for venous thrombo-embolism in 60 patients undergoing knee replacement surgery. The method uses the A-V Impulse System to produce cyclical compression of the venous reservoir of the foot. The overall incidence of deep-vein thrombosis was 68.7% in patients receiving no prophylaxis and 50% in those using the device. The difference was not significant. There was, however, a reduction of the extent of thrombosis in the treated group. There were 13 major calf-vein thrombi and six proximal-vein thrombi in the control group compared with only five major calf-vein thrombi in the treated group. This difference was significant (p = 0.014). No patient developed clinical features of a pulmonary embolism.
We performed a randomised controlled study to compare heparin with the A-V Impulse System in the prevention of deep-vein thrombosis (DVT) in 132 consecutive patients undergoing total hip replacement. After the operation, all patients had compression stockings, 65 were treated with calcium heparin and 67 with the intermittent plantar pump. DVT was diagnosed by Doppler ultrasound and thermography, followed by phlebography. There were 23 cases of DVT (35.4%) in the heparin group, with 16 major and seven minor thromboses. In the impulse pump group there were nine cases (13.4%) with three major and six minor thromboses. The differences for all thromboses and for major thromboses were both significant at p < 0.005. In the heparin group there was one fatal pulmonary embolism and nine patients (13.8%) had excessive bleeding or wound haematomas, as against none in the impulse pump group.
A prospective, randomized study was conducted to assess the efficacy of pulsatile pneumatic plantar compression for prophylaxis against deep venous thrombosis after total knee arthroplasty performed with use of regional anesthesia. One hundred and twenty-two patients (164 knees) who were scheduled to have a unilateral or a one-stage bilateral total knee arthroplasty were separately randomized to be managed with either aspirin alone or the pulsatile pneumatic plantar-compression device and aspirin. The prevalence of deep venous thrombosis was 27 per cent (twenty-two of eighty-one knees) in the group treated with pneumatic plantar compression compared with 59 per cent (forty-nine of eighty-three knees) in the patients managed with aspirin alone (the control group) (p < 0.001). A significant difference was also noted in the group that had had a unilateral arthroplasty (a prevalence of 27 per cent [eleven of forty-one knees] in the group treated with pneumatic plantar compression, compared with 67 per cent [twenty-six of thirty-nine knees] in that treated with aspirin alone; p < 0.006) and in the group that had had a one-stage bilateral procedure (a prevalence of 28 per cent [eleven of forty knees] in the group treated with pneumatic plantar compression, compared with 52 per cent [twenty-three of forty-four knees] in that treated with aspirin alone; p < 0.03). No proximal thrombi were noted in any patient who used the pulsatile pneumatic plantar-compression device, while the prevalence of proximal thrombosis in the popliteal or femoral veins was 14 per cent (twelve of eighty-three knees) in the group treated with aspirin alone (p < 0.0003). In the group treated with a unilateral procedure and aspirin alone the prevalence of proximal thrombosis was 13 per cent (five of thirty-nine knees; p < 0.02), while in the group treated with a bilateral procedure and aspirin alone it was 16 per cent (seven of forty-four knees; p < 0.01). Only in the patients who had had a unilateral procedure was use of the compression device associated with significantly less edema postoperatively than was use of aspirin alone. The change between the preoperative and postoperative circumferences of the thigh and leg was significantly less (9 +/- 4.1 millimeters [mean and standard deviation] less for the thigh [p < 0.01] and 6 +/- 3.9 millimeters less for the leg [p < 0.049]) with the compression device than with aspirin alone. In addition, there was significantly less mean drainage (98 +/- 61.1 milliliters) in the group treated with a unilateral procedure and pneumatic compression, compared with that treated with a unilateral procedure and aspirin alone (p < 0.041). An internal timer of the compression device was used to assess the compliance of the patient with use of the device, and a relationship between deep venous thrombosis and the total duration of treatment with the device was found. The patients in whom deep venous thrombosis did not develop used the device for a mean of 96 +/- 23.4 hours (range, sixty to 164 hours) postoperatively, or 19.2 +/- 5.1 hours a day, while those in whom thrombosis developed used it for a mean of 67 +/- 21.1 hours (range, twenty-six to 101 hours), or 13.4 +/- 4.3 hours a day (p < 0.001). No untoward effects were noted in any patient who used the device. This study confirms the safety and efficacy of pulsatile pneumatic plantar compression and aspirin compared with aspirin alone and supports the use of mechanical compression for prophylaxis against deep venous thrombosis and for reduction of edema in patients who have had a total knee arthroplasty. In addition, we found a direct relationship between compliance with the use of this device and its efficacy in reducing deep venous thrombosis.
To evaluate the calf muscle pump function using an air plethysmograph (APG) applied to the lower leg of subjects during three different tiptoe exercises.
A controlled trial design was selected to compare the hemodynamic effects of three exercise conditions on a group of able-bodied, healthy patients.
Testing was performed in an outpatient clinic at a rehabilitation hospital.
Patient groups were selected from a convenience sample of 10 healthy volunteers with normal venous capacitance and no reflux, determined through impedance pleythysmography before the study.
Three exercise conditions undertaken by each subject consisted of loaded and unloaded lower leg muscle contractions produced by (1) voluntary contraction (VOL), (2) electrical stimulation of the gastocnemius-soleus and tibialis anterior muscles (ES), and (3) combined ES and VOL (ES/VOL).
Hemodynamic measurements of venous filling index upon standing from the supine (VFI), ejection fraction (EF), ejection volume (EV), residual volume (RV), and residual volume fraction (RVF) were recorded after each protocol. These results were used to compare the lower leg hemodynamic effects of the treatments.
Combined ES/VOL single tiptoe exercise produced the highest EV (97.8mL), followed by VOL (80.6mL) and ES (51.7mL) (p < .0008). The EF was also highest for combined ES/VOL (73.1%), followed by VOL (64.5%) and ES (37.8%) (p < .0001). Ten tiptoe ES exercises produced the highest RV (96.2mL), followed by ES/VOL (44.7mL) and VOL (28.2mL) (p < .0001). RVF was also highest in the ES group (71%), followed by ES/VOL (33.4%) and VOL (22.8%) (p < .0001).
Periodic single ES-induced calf muscle contractions produced significant muscle pump function and could be used to improve venous blood flow and reduce stasis in the lower leg. Continuous ES-induced contractions, on the other hand, could improve lower leg peripheral perfusion while eliciting the physiologic venous muscle pump. Higher RV and RVF after 10 ES-induced contractions in this sample of healthy subjects with normal VFI may be caused by an increase in arterial blood perfusion after repeated ES-induced contractions.
We conducted a prospective, randomized trial to compare the safety and effectiveness of the A-V Impulse System foot pump with that of low- molecular-weight heparin for reducing the prevalence of deep-vein thrombosis after total hip replacement. Of 290 patients who were to have a primary total hip replacement, 143 were randomized to receive enoxaparin (forty milligrams daily) for seven days after the operation and 147, to use the foot pump for seven days. The primary outcome measure was the prevalence of deep-vein thrombosis, as determined by venography on the sixth, seventh, or eighth postoperative day. Secondary outcome measures included transfusion requirements, intraoperative blood loss, postoperative drainage, blood-loss index, appearance of the site of the wound according to a subjective visual- analog scale, and swelling of the thigh. The patients' compliance with the regimen for use of the foot pump was monitored with an internal timing device, and their acceptance of the device was assessed with a questionnaire. Symptoms consistent with pulmonary embolism were investigated with ventilation-perfusion scanning. The patients were contacted later for detection of symptoms of venous thromboembolism that may have occurred during the first three months after discharge from the hospital. Venography was performed on 274 patients: 136 who used the foot pump and 138 who received enoxaparin. Deep-vein thrombosis was detected in twenty-four (18 per cent) of the patients who used the foot pump compared with eighteen patients (13 per cent) who received enoxaparin (95 per cent confidence interval for the difference in proportions, -3.9 to +13.0 per cent). Thrombosis in the calf was found in seven patients (5 per cent) in the former group compared with six patients (4 per cent) in the latter (95 per cent confidence interval for the difference, -4.2 to +5.8 per cent), and proximal thrombosis was observed in seventeen patients (13 per cent) in the former group compared with twelve patients (9 per cent) in the latter (95 per cent confidence interval for the difference, -3.5 to +11.1 per cent). None of these differences was significant. No patient in either group had major proximal deep-vein thrombosis; all proximal thrombi were isolated entities involving the femoral valve cusp and were of unknown importance. One patient who used the foot pump had a non-fatal pulmonary embolism. One patient who received enoxaparin had a symptomatic deep-vein thrombosis during hospitalization. Two patients (one from each group [0.7 per cent]) were readmitted to the hospital because of a symptomatic deep-vein thrombosis despite normal venographic findings at the time of discharge. There was no difference in the transfusion requirements or the intraoperative blood loss between the two groups. There were more soft- tissue side effects in the patients who received enoxaparin than in those who used the foot pump: there was more bruising of the thigh and oozing of the wound (p < 0.001 for each), postoperative drainage (578 compared with 492 milliliters; p = 0.014), and swelling of the thigh (twenty compared Southampton University Hospitals, NHS Trust, Southampton S016 6YD, United Kingdom [email protected]
/* */ with ten millimeters; p = 0.03). Of 124 patients who used the foot pump and were asked about the acceptability of the device, fourteen (11 per cent) said that it was uncomfortable, twenty-one (17 per cent) reported sleep disturbance, and four (3 per cent) stated that they had stopped using the device. Conversely, ten (8 per cent) found it relaxing. We concluded that the foot pump is a suitable alternative to low-molecular- weight heparin for prophylaxis against thromboembolism after total hip replacement and that it produces fewer soft-tissue side effects. Tolerance of the device is a problem for some patients.
Approximately 14%-20% of patients with critical lower limb ischemia are unsuited for distal arterial reconstruction and face major distal amputation. Distal venous arterialization is a unique procedure in which the venous bed is used as an alternative conduit for perfusion of peripheral tissues. Eighteen patients with stage IV Fontaine critical lower limb ischemia underwent venous arterialization. Preoperative angiographic findings confirmed the absence of any below-knee continuous arterial vessels. The most distal satisfactory artery was used for proximal bypass anastomosis, and venous valves were destroyed with Parsonnet probes, cutting balloons, Fogarty catheters, and valvulotomes under radiologic guidance. All patients underwent intra- and postoperative angiography of the venous grafts and the distal venous bed. Primary and secondary graft patencies were 66% and 72%, respectively, at a mean follow-up of 25 months. The limb salvage rate was 83% overall and 75% at 2-year follow-up. Vascular imaging is essential in selecting and following up patients and in determining the appropriate intraoperative procedure.
The pattern of popliteal blood flow following electrical calf muscle stimulation and activation of the venous foot pump were studied using duplex ultrasound scanning in volunteers. The increase in velocity was of a similar magnitude for both methods, but the pattern was different, suggesting that the venous foot pump may not empty the soleal venous sinuses. Dynamic venography confirmed this hypothesis.
The gross anatomy of the deep plantar veins has been examined in 14 cadaveric feet in order to assess their function as a ‘venous foot pump’.The lateral plantar vein was found to be larger than the medial and is double in its proximal segment. Both plantar veins contain valves which face proximally and have a convoluted and intermuscular course. These features suggest that the deep plantar veins act as a pump that empties during contraction of the intrinsic foot muscles during the stance phase of gait.
In a prospective, randomised controlled trial, the efficacy of the A-V Impulse System in the prevention of deep-vein thrombosis was investigated in 84 patients who had undergone total hip replacement. The incidence of venographically proven, and clinically significant postoperative deep-vein thrombosis was 40% in the control group and 5% in the treatment group (p less than 0.001). No adverse reactions were recorded.
The deep veins of the leg and their associated perforating veins provide the major conduits for the return of blood from the legs to the heart. In health intrinsic valves maintain a one-way flow of blood from distal to proximal leg.
To describe and illustrate the different deep veins, their relationship to each other, and to the superficial venous system. Of particular interest is the demonstration of the deep plantar plexus and its relationship to the anterior and posterior tibial veins and to the greater and lesser saphenous veins. The valvular system, which protects them from the effects of gravity, is also illustrated.
The various deep veins as well as their tributaries and perforating veins are described in detail and illustrated with simple line drawings. These depictions help clarify the relationships between the paired veins and the higher single veins.
Hopefully this unified approach to the various groups of deep veins will allow a better understanding of their form and function.
The deep venous system is an integrated group of veins beginning in the deep venous plexus of the foot and terminating in the lower pelvis. Following contraction of the foot, calf, and thigh muscles the blood flows from a multitude of high pressure veins to a single low pressure vein.
Mechanisms of venous outflow from the leg and foot have not been clearly defined. The purpose of this study was to evaluate the anatomy and physiologic mechanism of the plantar venous plexus and its impact on venous drainage from the tibial veins.
Fifty phlebograms that contained complete foot and calf films were reviewed. On lateral films, the number of veins in the plantar venous plexus and its tibial outflow tract were counted. The length and diameter of the longest vein in the plantar venous system and the length of the foot arch were measured. The ratio of the length of the plantar venous plexus to the arch length was calculated. The presence or absence of valves within the plexus was recorded. Plantar venous plexus outflow was evaluated by an duplex ultrasonographic scan of the posterior tibial, anterior tibial, and peroneal veins during intermittent external pneumatic compression of the plantar surface of the foot.
The plantar venous plexus was composed of one to four large veins (mean, 2.7 veins) within the plantar aspect of the foot. The diameter of these veins was 4.0 +/- 1.2 mm. The veins coursed diagonally from a lateral position in the forefoot to a medial position at the level of the ankle, spanning 75% of the foot arch. Prominent valves were recognized within the plantar veins in 22 of 50 patients. The plexus coalesced into an outflow tract of one to four veins (mean, 2.5 veins) that flowed exclusively into the posterior tibial venous system. Small accessory veins that drained the plantar surface of the forefoot flowed into either the posterior tibial or peroneal veins. This pattern of selective drainage of the plantar venous plexus was confirmed by duplex imaging. Mechanical compression of the plantar venous plexus produced a mean peak velocity in the posterior tibial veins of 123 +/- 71 cm/sec, in the anterior tibial veins of 24 +/- 14 cm/sec, and in the peroneal veins of 29 +/- 26 cm/sec.
The plantar venous plexus is composed of multiple large-diameter veins that span the arch of the foot. Compression of the plantar venous plexus, such as that which occurs during ambulation, is capable of significantly increasing flow through the posterior tibial venous system into the popliteal vein. Its function may be integral to venous outflow from the calf and priming of the more proximal calf muscle pump.
The aim of this study was to explore the option of stimulating calf muscle contraction through externally applied neuromuscular electrical stimulation (NMES) and to measure venous blood flow response to this stimulation.
Ten patients with class 6 chronic venous disease (CEAP clinical classification) were recruited. Measurements of peak venous velocities in the popliteal vein were recorded by Duplex scanning in response to six test conditions; 1. Standing, 2. Voluntary calf muscle contraction, 3. Standing with NMES applied, 4. Standing with compression bandaging applied to the leg, 5. Voluntary calf muscle contraction with compression bandaging applied to the leg, 6. Stationary with compression bandaging applied to the leg and NMES applied. Comfort assessment was completed using visual analogue scales at each test stage and on study completion each patient completed a short structured interview to determine comfort and acceptability of NMES. Statistical analyses were carried out using SPSS, Version 9. Non-parametric testing was used in all analyses using the Wilcoxon Signed Ranks Test for paired samples.
There was a significant increase in venous velocities on voluntary contraction of the calf muscle (median resting vel 7.3 cm/s; voluntary contraction median 70 cm/s) and with the introduction of NMES, both with compression (median velocity 15 cm/s, p = 0.005 Wilcoxon) and without compression (median velocity 13 cm/s, p = 0.005 Wilcoxon). The greatest increase with NMES was when combined with compression bandaging. All patients reported the stimulus as an acceptable treatment option with 90% reporting NMES as comfortable.
Healing rates in venous ulceration with the application of compression bandaging remain between 50 and 70%. This study shows a positive haemodynamic response to NMES. Further research is needed to quantitatively measure the effect of NMES on ulcer healing.
Our objective was to overview the effectiveness of intermittent pneumatic compression (IPC) devices to prevent deep vein thrombosis (DVT) in postoperative patients, using meta-analysis methodology. We searched the Medline, metaRegister of Controlled Trials, and Cochrane database for studies published between 1970 and October 2004. Our inclusion criteria were: 1) randomized controlled trial of IPC versus no prophylaxis, 2) at least 20 patients per group, 3) at least one diagnostic DVT imaging test in all patients, and 4) clinical follow-up for at least the duration of hospitalization. A total of 2,270 patients were included in 15 eligible studies: 1,125 and 1,145 in the IPC and no prophylaxis group, respectively. The included studies formed a total of 16 treatment groups and were conducted in orthopedic (5), general surgical (4),oncologic (3), neurosurgical (3) and urologic (1) patient populations. In comparison to no prophylaxis, IPC devices reduced the risk of DVT by 60% (relative risk 0.40, 95% CI 0.29 - 0.56; p < 0.001). Contemporary randomized trials should be undertaken to test the utility of IPC in hospitalized medical patients as well as combined pharmacological plus IPC prophylaxis in both medical and surgical patients.
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in Medicine and Biology Society, 2008. p 1411-1414.