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Restless Legs? Vein Treatment Might Help

A female in her mid 40’s presents to Dallas Vein Institute without visible signs of vein disease. One of her primary complaints is having restless legs at night. She describes incessant urges to move her legs when she lies down that only subside when her calves and thighs are massaged, making it difficult to fall asleep on a regular basis.

An ultrasound test reveals that the patient has clinically significant backflow (reflux) in her greater saphenous vein (GSV) and small saphenous vein (SSV) in both legs that is suspected to be contributing to her restless leg symptoms. During a follow-up appointment, the patient receives a quick vein closure procedure to close down her diseased veins, and immediately experiences major improvement in her restless leg symptoms and her quality of sleep.

While it’s less common that an individual has symptomatic vein disease without readily visible cosmetic signs, this case demonstrates that hidden vein disease is sometimes responsible for unexplained symptoms like restless legs.

 

Restless Legs: Syndrome or Vein Symptom?

When severe, restless legs can cause frequent discomfort and sleep loss, taking a major toll on quality of life. While affected individuals tend to recognize that they have restless leg symptoms, many aren’t aware that their symptoms could be related to vein disease - even when they have visible varicose veins.

Restless leg syndrome (RLS) is a condition characterized by a persistent urge to move the legs, usually caused by an uncomfortable or unpleasant sensation. The medical severity of restless legs can range from occasional episodes brought on by stress to nightly sleep disruption.¹ Because restless legs produce an atypical sensation that varies from person to person, individuals with restless legs tend to have a hard time describing what they feel. Patients of ours have used a variety of phrases to describe the sensations they experience with their restless legs, such as:

Jittery, pulling, creepy-crawly, worms moving, electric current, shock-like feeling, pain, burning, heebie jeebies, tearing, throbbing, tight feeling, grabbing sensation, itching bones, crazy legs, fidgets, soda bubbling in the veins

A formal diagnosis of restless leg syndrome is made when an individual’s symptoms (1) begin or worsen during periods of rest, (2) are partially or totally relieved by movement, and (3) are worse at night than they are during the day.¹ Even when all of these criteria do not apply, many individuals with these symptoms still self-identify as having restless legs, which we recognize as “restless leg symptoms” to avoid confusion with the formal diagnosis.

In the absence of other identifiable conditions, ‘true’ restless leg syndrome is caused by abnormalities in dopamine and iron levels in the central nervous system.² However, it’s important for patients and medical practitioners to recognize that restless leg symptoms share characteristics with the symptoms of other common conditions, such as lower spine/lumbar damage, osteoarthritis, and - of most interest to us vein specialists at Dallas Vein Institute - venous reflux disease.³⁻⁴

 

Connection Between Restless Legs and Venous Reflux Disease

Venous reflux disease refers to the condition in which blood in a vein or a group of veins flows backwards (away from the heart), causing blood to accumulate in the veins. Venous reflux disease is often recognized by visible signs on the surface of the leg, such as varicose veins, skin changes, and in extreme cases ulcers. Why venous reflux disease contributes to restless leg symptoms isn’t well understood. One theory has proposed that an excessive accumulation of blood in veins at the base of the spine - caused by venous reflux disease - could cause leg pain, tingling, and other abnormal sensations in the legs;⁵ but little work has been done to prove that this is the case.

In any case, a significant proportion of individuals who experience restless leg symptoms are actually dealing with a vein problem. One population study of 16,543 primary care patients found that ~45% suffered from ‘unpleasant sensations in the legs’ (restless leg symptoms), ~10% were formally diagnosed with RLS, and ~20% of individuals who reported restless leg symptoms were found to have venous reflux disease.³

Another study looked at 174 consecutive subjects presenting to a phlebology practice for vein treatment and compared them to 174 matched control subjects. The researchers found that ~35% of their phlebology subjects had evidence of restless leg symptoms, and all but one of these restless leg subjects was confirmed to have venous reflux disease. In contrast, ~20% of the control group had evidence of restless leg symptoms, but of those that did, a staggering ~90% were found to have venous reflux disease as well.⁶

While these studies have some notable limitations, they do highlight the important interplay between restless leg symptoms and vein disease that we observe in our daily practice.

 

Vein Treatment May Help Alleviate Restless Leg Symptoms

Restless legs are one of the many subtle symptoms of vein disease. In our experience, individuals that present with restless leg symptoms and venous reflux disease can see substantial improvement in their symptoms when steps are taken to manage their vein disease.⁷⁻⁹ The patient that we described at the beginning of this article followed up with us on her results recently (about 6 weeks after her vein treatment), and provided us with a few quotes:

"I'm sleeping the best I've slept in years....My restless legs issues are gone...I don't have that urge to move my legs around at night and I fall asleep much faster...I'm very happy with the results! I would do it again."

 

Evidence For Vein Treatment In Restless Legs

High quality clinical evidence on this subject is limited, but there are two areas of study that validate our patient’s testimonial:

(1) The Journal of Dermatologic Surgery published a study in 1995 that treated 113 individuals with restless legs and ultrasound-confirmed vein disease with sclerotherapy. All but two of these individuals (98%) reported immediate relief from their restless legs. 8% of those that found relief with vein treatment reported that their restless leg symptoms returned 1 year after their initial treatment, and 28% reported that their symptoms returned 2 years after their initial treatment.¹⁰ The authors did not reveal whether or not the recurrence of symptoms they observed was related to recurrent vein disease.

(2) The Journal of Venous Disease published findings from a study of 35 individuals with notably severe restless leg symptoms and concurrent vein disease. These individuals were treated with minimally invasive ablation treatment and ultrasound-guided sclerotherapy. On average, patients in this study reported an 80% improvement in their symptoms on the international restless leg syndrome rating scale questionnaire, and 30% of patients reported that their restless leg symptoms were completely eliminated by vein treatment.¹¹

If you’re losing sleep or dealing with frequent discomfort because of restless legs, a simple ultrasound test may reveal that your veins are the culprit, especially if you can see visible signs of vein disease. Vein problems are very common, but they're also very treatable.

 

About the Author

Dr. Dev Batra, M.D. is a vein specialist and founding partner of Dallas Vein Institute. Holding board certifications in radiology and vascular & interventional radiology, he is well-versed in vein issues and has been voted one of D-Magazine’s best doctors in Dallas for three years running.

This blog post was written with research and editorial assistance from OnChart™.

 

References

[1] Allen, R. P., Picchietti, D., Hening, W. A., Trenkwalder, C., Walters, A. S., Montplaisi, J., … Zucconi, M. (2003). Restless legs syndrome: Diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Medicine, 4(2), 101–119.

[2] Allen, R.P. and Earley, C.J. The role of iron in restless legs syndrome. Mov Disord. 2007; 22: S440–S448

[3] Hening, Wayne & S Walters, Arthur & Allen, Richard & Montplaisir, Jacques & Myers, Andrew & Ferini-Strambi, Luigi. (2004). Impact, diagnosis and treatment of restless legs syndrome (RLS) in a primary care population: The REST (RLS Epidemiology, Symptoms, and Treatment) primary care study. Sleep medicine. 5. 237-46. 10.1016/j.sleep.2004.03.006.

[4] Möller, C., Wetter, T. C., Köster, J., & Stiasny-Kolster, K. (2010). Differential diagnosis of unpleasant sensations in the legs: Prevalence of restless legs syndrome in a primary care population. Sleep Medicine, 11(2), 161–166.

[5] Walters, A. S., & Rye, D. B. (2010). Evidence continues to mount on the relationship of restless legs syndrome/ periodic limb movements in sleep to hypertension, cardiovascular disease, and stroke. Sleep, 33(3), 287.

[6] Guo S, Huang J, Jiang H, et al. Restless Legs Syndrome: From Pathophysiology to Clinical Diagnosis and Management. Frontiers in Aging Neuroscience. 2017;9:171. doi:10.3389/fnagi.2017.00171.

[7] Kanter, A. H. (1995). The Effect of Sclerotherapy on Restless Legs Syndrome. Dermatologic Surgery, 21(4), 328–332.

[8] Hayes, C. A., Kingsley, J. R., Hamby, K. R., & Carlow, J. (2008). The effect of endovenous laser ablation on restless legs syndrome. Phlebology: The Journal of Venous Disease, 23(3), 112–117.

[9] Allen, R. P., Picchietti, D., Hening, W. A., Trenkwalder, C., Walters, A. S., Montplaisi, J., … Zucconi, M. (2003). Restless legs syndrome: Diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Medicine, 4(2), 101–119.

[10] Kanter, A. H. (1995). The Effect of Sclerotherapy on Restless Legs Syndrome. Dermatologic Surgery, 21(4), 328–332.

[11] Hayes, C. A., Kingsley, J. R., Hamby, K. R., & Carlow, J. (2008). The effect of endovenous laser ablation on restless legs syndrome. Phlebology: The Journal of Venous Disease, 23(3), 112–117.

 

Medical Disclaimer

The Materials available in the Dallas Vein Institute blog are for informational and educational purposes only and are not a substitute for the professional judgment of a health care professional in diagnosing and treating patients.

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