Toe elevation manoeuvre to assess venous reflux in comparison to manual calf compression and release

In the daily office setting, flow and reflux in leg veins is assessed to investigate patients with chronic venous disease. Valsalva manoeuvre and manual calf compression and release are frequent manoeuvres used to elicit blood flow in leg veins. Toe elevation manoeuvre (TEM) was proposed as a further alternative to provoke blood flow in veins. We compared both methods.

Patients consulting a venous office referring no previous treatment on their leg veins were evaluated with duplex ultrasound in the standing position. Age, body mass index, C of CEAP, venous clinics severity score, diameter of great saphenous vein and reflux duration at proximal thigh following TEM and manual calf compression and release were assessed.

In total, 53 legs were evaluated with both manoeuvres, applied in a randomised sequence. Reflux >0.5s was found in 40 legs (group "reflux") and no reflux in 13 legs (group "no reflux"). No significant difference was found following manual calf compression and release or TEM (2.11s vs. 2.31s in "reflux-group" and 0.11s vs. 0.13s in "no-reflux-group"), but good correlation was found between both with Pearson's test (r=0.72).

Both manoeuvres showed a good correlation with respect to reflux detection and reflux duration. The advantage of TEM is the easy and painless performance, low fatigability and independence from examiner.