Heavy legs, varicose veins and venous problems: causes, walking and new treatments

health medicine

Introduction

Heavy legs, swollen ankles, aching at the end of the day and varicose veins are often put down to "poor circulation". The phrase is understandable but vague. In many cases, the problem mainly concerns venous return: blood struggles to travel back up from the legs to the heart, which raises the pressure in the veins.

One important cause is indeed the malfunction of venous valves, small structures that normally stop blood from flowing back down under gravity. When they no longer close properly, venous reflux sets in. The vein gradually widens and varicose veins can appear.

Valves are not the only factor, however. How well the calf muscle pump works, the vein wall itself, after-effects of a past thrombosis, obesity, pregnancy, heredity and immobility can all play a part. Chronic venous disease is therefore a mechanical, anatomical and biological problem, whose exact cause varies from person to person (source 1).

One question stands out: if valves could be repaired, would patients' health improve? Probably yes in some severe forms, especially when the valves of the deep veins are badly damaged. But for ordinary superficial varicose veins, the strategy is often not to repair the valve but to close or remove the vein that no longer works.

Walking, for its part, can genuinely help. It activates the calf muscle pump, reduces pooling of blood and can relieve symptoms. It does not, however, repair a damaged valve or make an established varicose vein disappear.

Key terms

• Venous return: the flow of blood from the legs back to the heart.
• Venous valve: a small flap inside a vein that limits the backflow of blood.
• Venous reflux: abnormal backflow of blood towards the feet, usually due to valves not closing fully.
• Chronic venous insufficiency: long-term inadequate functioning of the venous system.
• Chronic venous disease: a broader term covering symptoms, varicose veins, oedema and vein-related complications.
• Calf muscle pump: the mechanism by which contractions of the calf muscles squeeze the veins and push blood upwards.
• Venous duplex ultrasound: an ultrasound scan that shows the veins and measures, among other things, the direction and speed of blood flow.
• Endovenous ablation: closing a diseased vein from the inside, for example with a laser or a radiofrequency probe.
• Venous ulcer: a chronic leg wound caused by persistently high venous pressure.

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Ariel Toledano is a well-known vascular physician and phlebologist in Paris, and one of the pioneers of advanced laser treatments in phlebology. A recognised specialist in venous insufficiency, he explains in detail the mechanisms behind heavy legs, varicose veins and spider veins.

1. How does blood get back up from the legs to the heart?

A system fighting gravity

Venous blood from the legs has to travel up to the heart, while standing naturally makes it pool in the feet. Several mechanisms work together:

1. Venous valves direct blood upwards and limit its descent.
2. Contractions of the calf muscles squeeze the deep veins.
3. Movements of the ankle and foot help the veins fill and empty.
4. Breathing creates pressure changes that help blood return to the chest.
5. The vein wall contracts and relaxes to adjust the vein's diameter.

The calf is sometimes called the leg's "second heart". The phrase is figurative, but it reflects a physiological reality: when walking, muscle contraction propels some of the blood upwards.

The role of the valves

Valves work like flaps. When blood is pushed towards the heart, they open. When the pressure reverses, they close to stop blood from flowing back down.

If a valve becomes incompetent, it no longer closes completely. Blood then flows backwards. This increases the amount of blood in the vein and the pressure on its wall. The vein can widen, which makes the valve close even less well.

A vicious circle can set in:

1. the valve closes poorly;
2. blood flows back;
3. pressure rises;
4. the vein widens;
5. the valve closes even less well;
6. the surrounding tissues gradually suffer the consequences of this venous hypertension.

Is the problem always a faulty valve?

No. A blocked vein, for example after deep vein thrombosis, can also disrupt the return of blood. Some people have both obstruction and reflux. In other cases, the muscle pump is weakened by a sedentary lifestyle, limited ankle mobility, a neuromuscular disease or joint pain.

Varicose veins can therefore involve several combined mechanisms. That is why a clinical examination supplemented by a duplex ultrasound is often needed before choosing a treatment.

2. Why do heavy legs and varicose veins appear?

The most common symptoms

Chronic venous disease can cause:

• a feeling of heaviness or tiredness in the legs;
• dull aches, pulling sensations or cramps;
• itching;
• a feeling of warmth;
• swollen ankles or legs;
• symptoms that are worse at the end of the day;
• improvement when the legs are raised or after walking.

Heat, prolonged standing and immobility can make symptoms worse. Walking and ankle movements, by contrast, often relieve them.

Risk factors

Several factors can increase the risk or make things worse:

• heredity;
• age;
• pregnancies;
• overweight or obesity;
• prolonged standing or sitting;
• lack of physical activity;
• a history of venous thrombosis;
• jobs that involve staying still for long periods;
• hormonal changes;
• reduced ankle mobility.

Heredity does not mean a person will necessarily develop varicose veins, but it can make the vein wall more vulnerable. Hormones and pregnancy can also encourage veins to widen.

Possible complications

A varicose vein is not always dangerous. Many are mostly a cosmetic issue or cause moderate discomfort. But more advanced venous disease can lead to:

• painful inflammation of a superficial vein;
• bleeding from a varicose vein;
• changes in skin colour;
• eczema or irritation around the ankle;
• hardening of the tissues;
• a chronic wound, called a venous ulcer.

Severity cannot therefore be judged only by the size or number of varicose veins. Some small varicose veins cause many symptoms, while large ones may remain fairly untroublesome for a long time.

3. What does a duplex ultrasound show?

Venous duplex ultrasound is the reference examination for assessing the leg veins. It can:

• check whether the veins are open;
• detect an obstruction or a thrombosis;
• look for reflux;
• identify the vein responsible;
• distinguish the superficial from the deep system;
• prepare for possible treatment.

NICE guidelines recommend duplex ultrasound to confirm varicose veins, determine the extent of reflux and plan management (source 2).

The scan is especially useful when symptoms are significant, when varicose veins recur, with persistent oedema or when skin changes appear.

It answers concrete questions:

• Is the great saphenous vein incompetent?
• Does the reflux come from a superficial or a deep vein?
• Are the deep valves working?
• Are there after-effects of a thrombosis?
• Is an intervention technically feasible?

It is important not to conclude that there is venous insufficiency on the basis of heavy legs alone. Other causes are possible: arterial, lymphatic, joint, muscular, drug-related or general problems.

4. Can walking really help?

A physiologically sound effect

Yes, walking can genuinely help. Every step works the muscles of the foot and calf. Their contraction squeezes the deep veins and pushes blood towards the heart.

Even when the valves are imperfect, walking can temporarily improve venous emptying. It also avoids long periods during which blood sits still in the legs.

Exercise is therefore generally considered a useful measure to reduce the symptoms of chronic venous disease. European guidelines state that exercise should be considered for patients with symptomatic chronic venous disease (source 1).

What to expect

Walking can help to:

• reduce the feeling of heavy legs;
• limit swelling caused by immobility;
• maintain calf strength;
• improve ankle mobility;
• improve overall fitness;
• help with weight control;
• cut down the time spent sitting or standing still.

It cannot, however:

• restore a destroyed valve;
• make an existing varicose vein disappear;
• clear a venous obstruction;
• replace prescribed compression;
• replace an intervention when significant reflux is causing symptoms or complications.

What do studies say?

Physiological logic and the level of clinical evidence need to be distinguished.

The logic is solid: the calf muscles do contribute to venous return. Studies also show that exercise can improve muscle strength, ankle range of motion and some calf pump parameters.

However, a Cochrane review published in 2023 concluded that the available evidence was still insufficient to determine with certainty the full benefits and risks of exercise in people with non-ulcerated chronic venous insufficiency (source 3). The studies were few, small and used different exercise programmes.

This does not mean walking is useless. It means research cannot yet say exactly:

• what walking duration is optimal;
• what intensity is most effective;
• whether a structured programme beats regular informal activity;
• which patients respond best;
• to what extent exercise prevents long-term complications.

How to walk in practice

Unless there is a medical contraindication, it is best to start gradually:

1. walk for 10 to 15 minutes at a comfortable pace;
2. repeat regularly, ideally every day or nearly;
3. gradually increase the duration;
4. avoid sitting for several hours without getting up;
5. do a few ankle movements during still periods;
6. adapt the activity to your age, joints and fitness.

Three ten-minute sessions can be a good alternative to a single thirty-minute walk. Cycling, swimming and ankle flexion-extension exercises are also worthwhile.

Unusual pain, breathlessness, sudden swelling of one leg only or a rapid worsening should prompt medical advice rather than carrying on without assessment.

5. Treatments currently available

Everyday measures

Management depends on the stage of the disease. It can include:

• regular physical activity;
• fewer periods of immobility;
• raising the legs when it brings relief;
• weight loss where needed;
• avoiding excessive heat if it makes symptoms worse;
• treating wounds and skin problems;
• appropriate compression.

Walking should not be seen as a stand-alone treatment, but as part of an overall strategy.

Compression

Compression stockings, socks or bandages apply pressure to the leg, usually strongest at the ankle and gradually decreasing upwards. This pressure reduces vein widening and helps blood return.

European guidelines state that elastic stockings exerting at least 15 mmHg at the ankle can reduce venous symptoms; with oedema, levels of 20 to 40 mmHg may be used depending on the situation (source 1).

Compression must be chosen correctly. Stronger is not automatically better. A medical assessment is particularly important in case of:

• arterial disease of the legs;
• complicated diabetes;
• pain when walking;
• cold feet or colour changes;
• neurological disorders;
• decompensated heart failure;
• difficulty putting on and taking off the garment.

Treatments for superficial veins

When duplex ultrasound shows reflux in a superficial vein, several options exist:

• endovenous thermal ablation, by laser or radiofrequency;
• sclerotherapy, which injects a product to close the vein;
• phlebectomy, which removes small varicose branches through tiny incisions;
• surgery, now reserved for certain situations when other methods are unsuitable.

NICE guidelines generally recommend thermal ablation first where possible, then ultrasound-guided foam sclerotherapy and, if needed, surgery (source 2). The North American SCAI guidelines published in 2025 also cover these options (source 4).

Closing a diseased superficial vein may seem paradoxical. In reality, this vein no longer does its job: it has become a reflux pathway. Blood can generally use the deep veins and the other functioning superficial veins.

Venoactive drugs

Some medicines or supplements are offered to reduce heaviness or oedema. They can sometimes bring symptomatic relief, but they do not repair valves or remove a varicose vein.

Data on phlebotonics vary by product. A Cochrane review reported possible benefits on some oedema or symptoms, but with limited quality of evidence and considerable heterogeneity between the treatments studied (source 5).

Be wary of promises to "cleanse the veins", repair valves naturally or cure the problem for good with a food supplement. Such marketing claims do not necessarily match the scientific data.

6. Repairing valves: why would it be worthwhile?

The theoretical benefit

If a deep valve became competent again, it could stop blood flowing back and reduce venous pressure. This could improve:

• oedema;
• pain;
• the feeling of heaviness;
• skin damage;
• ulcer healing;
• quality of life.

The benefit would be particularly great for patients with severe deep venous insufficiency, especially after venous thrombosis. In these cases, closing a superficial vein is not always enough, because the main problem lies in the deep veins.

Why aren't all faulty valves repaired?

Several difficulties explain this:

1. Deep veins are hard to reach. They lie deep in the leg and their anatomy varies from patient to patient.
2. The venous system runs at low pressure. An implanted valve must work in an environment very different from that of heart valves.
3. Venous blood flows more slowly. This can encourage clots to form around a device.
4. The valve must open in the right direction and stay closed in the other.
5. It must withstand movement and changes in vein diameter.
6. A device can block, migrate or cause thrombosis.
7. Venous disease can affect several segments at once.

A single valve does not necessarily solve the whole problem. Obstruction also has to be looked for, the other valves assessed and the muscle pump checked.

Repair or replacement?

Researchers are exploring several approaches:

• direct repair of an existing valve;
• surgical reconstruction of the wall;
• transplanting a vein segment containing a working valve;
• a biological valve implanted in a vein;
• a valve delivered by catheter;
• synthetic or hybrid devices.

Direct repair is technically delicate and only suits certain anatomies. Replacement with a biological valve could be easier to standardise, but its long-term safety and effectiveness still have to be shown.

7. Which new treatments are actually in development?

Implantable venous valves

The approach most directly linked to the valve question is implantable valves for severe deep venous insufficiency.

The VenoValve device has been studied in patients with advanced venous disease resistant to usual treatments. The SAVVE study was a prospective, multicentre, single-arm study of patients with, in particular, severe skin damage, ulcers or advanced complications (source 6).

Published results with three-year follow-up reported a lasting improvement in some clinical scores and restored venous competence in selected patients (source 7). These results are encouraging, but they should be interpreted with caution:

• the study did not involve people with merely heavy legs;
• the patients had severe disease;
• the trial was not randomised against standard treatment;
• the number of participants was limited;
• a manufacturer's results need to be confirmed by independent teams;
• the risks of thrombosis, reintervention and long-term failure must continue to be monitored.

In April 2026, the US FDA granted an IDE (Investigational Device Exemption) for the TAVVE pivotal study, designed to evaluate a venous valve implanted by catheter. The protocol plans an initial safety cohort of around ten patients, followed by a larger study comparing the device with standard care (source 8). Approval to start a trial does not mean the device is already a routine or authorised treatment for all patients.

Potential advantages of catheter-based implantation

A valve placed by an endovascular route could, if it works, avoid major open surgery. It could be of interest for frail patients or those for whom surgical reconstruction would be too demanding.

The hoped-for advantages are:

• a less invasive procedure;
• faster recovery;
• the possibility of treating some deep insufficiency;
• a more direct restoration of valve function.

But there are many hurdles:

• positioning the valve precisely;
• preventing it from migrating;
• preventing clots;
• keeping it open;
• ensuring a good fit with the vein's diameter;
• showing a benefit greater than, or complementary to, compression and existing treatments.

Non-thermal techniques and mechanochemical systems

Other innovations mainly concern the treatment of superficial veins. They aim to close the diseased vein while limiting heat or incisions.

These include:

• mechanochemical methods;
• medical glues;
• more precise catheters;
• devices using focused ultrasound;
• combined ultrasound-guided treatments.

These methods may reduce some of the drawbacks of laser or radiofrequency, but they do not repair valves. They mainly treat the anatomical consequence: the superficial vein that has become a reflux pathway.

Their place depends on comparative results, side effects, cost, availability and the experience of the teams. A technical innovation should not be confused with definitive proof of superiority.

Treating venous obstruction

In some patients, the main problem is not reflux but an obstruction of the pelvic or iliac veins, sometimes after a thrombosis. Endovascular treatments, including venous stenting in selected situations, may be considered.

In that case, replacing a valve would not be enough: a proper passage for blood would first have to be restored. Anatomical diagnosis by imaging is therefore essential.

8. What innovations could change

New treatments are unlikely to replace walking, compression and medical assessment. They are more likely to add to the existing toolkit.

In future, care could become more personalised:

The scientific challenge is not only to create a new valve. Its implantation must be shown to:

• genuinely improve quality of life;
• reduce ulcers and recurrences;
• reduce hospital admissions;
• remain effective for several years;
• have an acceptable benefit-risk balance;
• offer more than well-managed compression;
• work across different patient profiles.

Health authorities and medical societies will also consider cost and access. An effective but very complex technology will not be available in every country straight away.

9. Practical advice for people with heavy legs

What can be done day to day

While waiting for an assessment, several measures are generally reasonable:

• walk regularly;
• avoid sitting or standing still for hours;
• move your ankles on long journeys;
• raise your legs if it brings relief;
• keep a weight compatible with good mobility;
• avoid heat if it makes symptoms worse;
• ask for advice before wearing strong compression;
• see a doctor if symptoms persist or worsen.

Walking can be built into the day: get off one stop early, take the stairs when possible, move around for a few minutes every hour and do ankle flexes while seated.

When to see a doctor

A medical consultation is particularly advisable in case of:

• painful or worsening varicose veins;
• daily swelling;
• itching or changes in skin colour;
• eczema around the ankle;
• a wound that does not heal;
• a bleeding varicose vein;
• symptoms that persist despite walking and simple measures;
• a history of thrombosis.

NICE guidelines provide for referral to a vascular service for symptomatic varicose veins, skin changes, suspected superficial vein thrombosis or an ulcer (source 2). In France, the warning signs listed by the national health insurance (Assurance Maladie) largely overlap with these (source 9).

Emergencies

Seek prompt medical advice for sudden swelling of one leg, significant calf pain, or unusual redness or warmth. Sudden breathlessness, chest pain or fainting is an emergency.

These symptoms should not automatically be put down to varicose veins, as they may indicate deep vein thrombosis or pulmonary embolism.

Health disclaimer: this article is for information only and does not replace a consultation. The choice of compression, medication or interventional treatment must take into account the clinical examination, the duplex ultrasound, medical history and current treatments.

Conclusion

Faulty valves play a central role in many forms of varicose veins and venous insufficiency, but they are not the only cause. Venous return also depends on the calf muscle pump, the vein wall and the absence of obstruction.

Repairing or replacing a valve could indeed improve the health of some patients, particularly those with severe deep venous insufficiency, significant oedema, skin damage or ulcers resistant to usual treatments. Early results with biological valves are encouraging, and trials of catheter-implanted devices are an important step.

It is still too early, however, to speak of a routine treatment. Research has yet to confirm long-term effectiveness, possible complications and the exact place of these devices relative to compression, endovenous treatments and surgery.

For people with heavy legs or common varicose veins, walking remains a useful and accessible measure. It activates the calf muscle pump, reduces immobility and can improve symptoms. It does not repair a valve, but it helps the venous system work as well as it can despite its limits.

The most rational approach is therefore twofold: move regularly to support venous return, and see a doctor when symptoms warrant an assessment, including a duplex ultrasound. Future treatment will probably be less uniform than today: it will seek to repair the valve where possible, close the vein when it has become useless, clear the system when there is a blockage and preserve the patient's mobility in every case.

Sources

1. De Maeseneer M. et al., "European Society for Vascular Surgery 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs", 2022, European Society for Vascular Surgery.

2. National Institute for Health and Care Excellence, "Varicose veins: diagnosis and management" (CG168), July 2013; last surveillance review: February 2016, NICE.

3. Araujo D.N. et al., "Physical exercise for the treatment of non-ulcerated chronic venous insufficiency", Cochrane Database of Systematic Reviews, 2023, PubMed.

4. Attaran R.R., Edwards M.L., Arena F.J. et al. (SCAI Guideline Panel), "2025 SCAI Clinical Practice Guidelines for the Management of Chronic Venous Disease", Journal of the Society for Cardiovascular Angiography & Interventions, 2025, PubMed Central.

5. Martinez-Zapata M.J. et al., "Phlebotonics for venous insufficiency", Cochrane Database of Systematic Reviews, 2020, Cochrane Library.

6. Ochoa Chaar C.I., Hager E.S., Griffin C.L., Smeds M.R.; SAVVE Trial Investigators, "SAVVE US pivotal study of patients with severe chronic insufficiency due to deep valvular venous reflux: One-year results after VenoValve implantation", Journal of Vascular Surgery: Venous and Lymphatic Disorders, 2026, PubMed Central.

7. Cifuentes S., Figueroa A.V., Glickman M., Ulloa J.H., "Three-Year Outcomes of Surgical Implantation of a Novel Bioprosthetic Valve for the Treatment of Deep Venous Reflux", Annals of Vascular Surgery, 2025;118:138-147, PubMed.

8. enVVeno Medical Corporation, "FDA IDE Approval for TAVVE Pivotal Study of the enVVe Transcatheter Venous Valve", 29 April 2026, U.S. Securities and Exchange Commission.

9. Assurance Maladie, "Varices des jambes : que faire pour se sentir mieux ?" (in French), 18 March 2026, ameli.fr.