Pathogenesis of venous ulceration in relation to the calf muscle pump function

Air plethysmography has been used to quantitate venous reflux by measuring the average filling rate of the veins (venous filling index; in milliliters per second) on standing from the supine position, the ejection fraction of the calf muscle pump as a result of one tip-toe movement, and the residual volume fraction after 10 tip-toe movements. Thirty normal limbs, 110 limbs with primary varicose veins, 34 limbs with reflux in the deep veins but without occlusion, and 31 limbs with deep venous occlusion, with or without reflux, have been studied. An increase in the incidence of ulceration occurred with increasing values of reflux and decreasing values of the calf muscle pump ejection fraction. A poor ejection fraction was the primary cause of venous ulceration in limbs with minimal reflux. A good ejection fraction, however, significantly reduced the incidence of ulceration in limbs with marked reflux (p less than 0.05). The residual volume fraction, which expresses the combined effect of venous reflux and ejection fraction with rhythmic exercise, showed a good correlation with the incidence of ulceration and the measurements of ambulatory venous pressure (r = 0.81). The air-plethysmographic measurements completely assess the calf muscle pump function and provide an accurate method to identify the predominant hemodynamic factor (ejection fraction, reflux, or both) responsible for the clinical picture of the patient.