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Original Investigation |

Neuropathy and Ankle Mobility Abnormalities in Patients With Chronic Venous Disease

Elizabeth Yim, MPH1; Alejandra Vivas, MD1; Andrea Maderal, MD1; Robert S. Kirsner, MD, PhD1
[+] Author Affiliations
1Department of Dermatology and Cutaneous Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
JAMA Dermatol. 2014;150(4):385-389. doi:10.1001/jamadermatol.2013.6723.
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Importance  How complications associated with chronic venous insufficiency (CVI) develop is not clear. The central source of the complications is likely a dysfunction of the calf muscle pump, which includes veins and their valves, the gastrocnemius and other lower leg and foot muscles as well as the nerves supplying the muscles, and ankle mobility limitations. The least well-studied source of complications is the relationship between range of ankle movement (ROAM), neuropathy, and the clinical severity of the disease.

Objective  To study sensory neuropathic changes and ankle mobility in patients with CVI to help elucidate the pathophysiologic development of venous ulcers.

Design, Setting, and Participants  A cross-sectional study took place from August 2011 to August 2012 at the outpatient wound clinic and the wound healing research clinic at the University of Miami Hospital. Sixty-four limbs from 42 individuals were evaluated and individually classified according to the clinical aspect of the clinical-etiology-anatomy-pathophysiology classification for CVI.

Main Outcomes and Measures  Range of ankle movement was measured using goniometry, measuring active ankle combined plantarflexion and dorsiflexion and combined inversion and eversion. Peripheral neuropathy was measured subjectively through the Neuropathy Symptom Score and objectively through the Neuropathy Disability Score scales.

Results  More patients with severe CVI had reduced plantarflexion-dorsiflexion ROAM compared with patients with mild CVI (25 [89%] vs 11 [31%]; P < .001) and reduced inversion-eversion ROAM (22 [79%] vs 4 [11%]; P < .001). Patients with worse CVI had significantly worse neuropathy with higher Neuropathy Symptom Score and Neuropathy Disability Score values compared with patients with less severe CVI.

Conclusions and Relevance  We found a relationship between reduced ROAM and worse neuropathy with increased severity of CVI. Management in patients with CVI should include testing for neuropathy and improving ankle mobility.

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Figure 1.
Chronic Venous Insufficiency: Range of Ankle Movement (ROAM) (Plantarflexion-Dorsiflexion) in the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) Classification Groups

Mean ROAM decreased as the clinical severity of CEAP classification increased. Boxes indicate range; bars, mean; limit lines, SE; circles, outliers.

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Figure 2.
Chronic Venous Insufficiency: Range of Ankle Movement (ROAM) (Inversion-Eversion) in the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) Classification Groups

Mean ROAM decreased as the clinical severity of CEAP classification increased. Boxes indicate range; bars, mean; limit lines, SE; circles, outliers.aExtreme outlier (>3 times the height of the box).

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