A 75-year-old man presented to our clinic with painful bilateral lower extremity venous stasis and a dry scaling ulcer on the left lower extremity. He stated that he had been having pain and ulcerations in the lower extremities since 1955 when he sustained severe frostbite while serving in the military during the Korean War, which required 6 months of hospitalization.
The patient's medical history was positive for vascular insufficiency, peripheral vascular disease, obesity, erectile dysfunction, hypertension and chronic obstructive pulmonary disease (COPD). He has been a two-pack per day smoker for 30 years. The patient described his pain as a constant ache (8 out of 10 on a visual analog scale). Prior treatment included activity limitation, Unna boot, compression stockings, extremity elevation, whirlpool, debridement of ulcers and decreased salt intake.
Since the late 1960s, the patient had been taking increasingly frequent doses of propoxyphene (Darvon) and later acetaminophen with codeine to control his pain. His activities of daily living were severely limited. He had difficulty standing and walking. The patient was granted disability in 1988 because of his pain and venous stasis ulcers.
The patient was first seen in our primary care clinic in February 2008. He had a 5 cm by 5 cm round drying scaling ulcer with erythema of his left lower extremity. Segmental Doppler showed right and left lower extremity venous occlusive disease. He was placed in compression hose and was asked to follow up in our lower extremity preservation program, an appointment he did not initially keep. Because we were concerned about his frequent intake of acetaminophen and codeine and elevated liver enzymes, we changed his medication to ibuprofen 800 mg every 8 hours. He returned 6 months later with bilateral ulcerations, and again the lower extremity preservation program was consulted. He was referred to the vascular surgery clinic for bilateral venous reflux studies.
The studies demonstrated moderate to severe reflux from the bilateral common femoral veins, extending through the bilateral popliteal and posterior tibial veins and chronic, nonocclusive deep vein thrombosis throughout all deep veins bilaterally as well as in the greater saphenous veins. Ankle-brachial index was 1.1 on the right and 0.94 on the left. The patient was not a good candidate for surgical intervention because of his age, COPD and history of deep vein thrombosis. By this time his bilateral ulcers had healed, but he continued to complain of leg pain. It was recommended that he continue with compression therapy and return to the clinic in 1 year. Compression therapy was the treatment for 2 years. Ulcerations were noted intermittently.
In October 2010, the patient returned with a 2 cm by 4 cm ulceration on his left lateral ankle and 2+ pedal edema bilaterally. Although ibuprofen seemed to work as well as the acetaminophen with codeine for pain, the patient admitted to taking more than prescribed. We then added acetaminophen 650 mg four times daily. He was hesitant to use any topical treatment. As the patient was still complaining of pain and was extremely frustrated with his chronic condition, we initiated a trial of pulsed radiofrequency energy (Provant), which has been shown in several case reports to be of benefit in relieving chronic pain and healing of ulcers.1-3
The patient was advised to administer pulsed radiofrequency energy to his bilateral lower extremities twice daily for 30 minutes. Pulsed radiofrequency energy, emitted through an applicator pad, was placed directly onto the calf area. Initially over the first few weeks, the therapy did not seem effective, and the patient wanted to stop treatment, but with encouragement he continued the therapy. Three weeks later he began to note less pain, and his ulcerations were healing. By December of 2010, his pain was around 7 out of 10 daily, with no bad (10 out of 10) pain days.
In February of 2011, the vascular surgery clinic noted skin changes consistent with chronic venous stasis, but no open ulcerations. A 0.5 x 0.5 cm healing ulcer was noted on the left malleolus. He had palpable posterior tibial and dorsalis pedis pulses bilaterally. By March 2011, the pain had decreased to 3 out of 10 with no bad days. All ulcers remained healed. His medication intake decreased to just acetaminophen 650 mg four times daily and one aspirin (325 mg) daily for his heart. Pulsed radiofrequency energy is being continued to control the pain associated with his venous insufficiency and to prevent recurrence of ulcerations. The patient states that he can now stand and walk for longer periods of time and can perform all activities of daily living.
Chronic pain caused by vascular insufficiency often is severe and may diminish a patient's quality of life. Ulcerations, the most severe signs of the disease, have the greatest morbidity, and the cost of treatment is staggering. For some patients, the degree of discomfort interferes with necessary treatment, therefore pain should be controlled at every level using nonsteroidal anti-inflammatory drugs, topical analgesia and mild oral opioids or stronger opioids if necessary. Unfortunately, even with appropriate treatment, some patients still complain of debilitating pain. The negative effects of chronic pain on an individual's life have been well documented in the literature, and the cost of treatment for patients with venous stasis ulcers is staggering.4 Even with treatment many patients still suffer with pain and ongoing open wounds that often have severe personal and social consequences.5,6
Vascular insufficiency is a common problem in the general population; approximately 1% of individuals have active or healed leg ulcers caused by vascular insufficiency.7-9 Risk factors for chronic venous disease include female sex, advanced age, obesity, pregnancy, prolonged standing or sitting, inactivity, heredity and greater height.9 In chronic venous insufficiency, blood flow out of the leg to the heart refluxes back down into the veins and pools, causing venous hypertension and ultimately damage to the vessels. Primary valvular incompetence, present in 70% to 80% of patients with chronic venous disease, can be caused by trauma or deep vein thrombosis (up to 25%).9 Our patient's problems were long-standing and dated back to his severe frostbite injury. Vascular occlusion is a feature of severe frostbite and is caused by vasoconstriction, which decreases blood flow leading to complete stasis and clotting of red blood cells. Histologic studies have shown thromboses in the capillaries of tissues damaged by frostbite.10 Regardless of the cause of vascular insufficiency blood cannot exit the leg efficiently, and as this venous congestion persists chronic tissue damage results.
Manifestations of chronic vascular insufficiency include varicose veins, ulcers, edema, eczema, hyperpigmentation of the skin at the ankle, atrophie blanche and lipodermatosclerosis.9 Ulcerations are the most severe signs of the disease and have the greatest morbidity and mortality. Venous stasis ulcers represent a considerable burden on healthcare resources; McGuckin et al. estimated that treatment of venous ulcers costs 3 billion dollars a year in the United States.4
The initial physical signs of vascular insufficiency are leg pain that is described as aching, pressure, burning, itching or heaviness of the affected calves usually with activity. As the disease progresses, pain may occur even at rest.11 The prevalence of pain in this patient population ranges from 48% to 90% and has been associated with a poor quality of life.6 The importance of controlling pain cannot be overemphasized. For some patients, the degree of discomfort interferes with necessary treatment, such as compression dressing, which is the mainstay of management for venous stasis ulcers.12 Also, uncontrolled pain has been shown to impede the healing of wounds.13