Patients often present with a constellation of lower extremity symptoms that are vague, overlapping, and frequently misattributed to other conditions. This is especially true in cases of burning, itching, and nocturnal leg cramps, which are commonly assumed to be neurological in origin. However, for some patients, the root cause lies not in the nerves—but in the veins.

In this blog, we explore the case of a 40-year-old white female who presented with persistent lower extremity symptoms. Despite a questionable diagnosis of peripheral neuropathy, her ultimate relief came from a different diagnosis altogether: chronic venous insufficiency.

Initial Presentation: A Classic, Yet Overlooked, Symptom Cluster

The patient came to our clinic complaining of nocturnal leg cramps, burning sensations in her feet, intermittent itching, and persistent fatigue in her legs. These symptoms had progressively worsened over the previous year. By the time of presentation, she was experiencing disrupted sleep and had difficulty walking more than a few blocks without discomfort and numbness. The impact on her quality of life was significant—she could no longer enjoy long walks with her dogs, something she once loved.

She had previously been seen by a neurologist and was given a working diagnosis of peripheral neuropathy, though diagnostic studies were inconclusive. She was prescribed medications for neuropathic pain, but they provided little to no relief.

Reframing the Differential: Could This Be Venous?

Given the chronicity and nature of her symptoms, we expanded the differential to include venous pathology. It's not uncommon for patients with chronic venous insufficiency (CVI) to report burning, itching, cramping, and even numbness in the lower extremities—particularly when the venous reflux is longstanding and untreated.

A venous duplex ultrasound was ordered to evaluate for superficial venous reflux, which often goes undiagnosed in patients labeled with idiopathic neuropathy or restless leg syndrome.

Diagnostic Findings: Bilateral Great Saphenous Vein (GSV) Reflux

Ultrasound imaging revealed bilateral great saphenous vein (GSV) reflux extending from the saphenofemoral junction down to the ankle. Additionally, several random refluxing tributaries—both saphenous and non-saphenous—were identified, along with extensive reticular veins and spider veins on both legs.

These findings were consistent with CVI and superficial venous reflux disease, both of which are known contributors to the kinds of symptoms this patient was experiencing.

Treatment Plan: A Multi-Modality, Phased Approach

Over the course of six weeks, the patient underwent a staged, minimally invasive treatment plan designed to address the underlying reflux and improve her microvascular circulation.

1. Endovenous Laser Treatment (EVLT)

The first step was EVLT, targeting the refluxing segments of the GSV bilaterally. Using a 1470 nm laser, the affected veins were closed under ultrasound guidance, halting the backward flow of blood and reducing venous hypertension.

2. Ultrasound-Guided Foam Sclerotherapy (UGFS)

Following EVLT, we addressed several refluxing tributaries using ultrasound-guided foam sclerotherapy. This technique allowed precise targeting of incompetent branches that could not be effectively treated with EVLT alone.

3. Visually Guided Sclerotherapy (VGS)

Finally, to treat the reticular and spider veins, the patient underwent visually guided sclerotherapy. This not only improved cosmetic appearance but also supported symptomatic relief by reducing local inflammation and microvascular congestion.

Healing and Recovery: A Dramatic Improvement

The patient tolerated all procedures well, with minimal discomfort and no complications. Compression therapy was used post-procedurally as per standard protocol.

Within two weeks of the initial EVLT, she began reporting improvements in sleep quality and reduction in nighttime leg cramps. By the end of the treatment cycle, she noted complete resolution of burning and numbness in her feet. For the first time in over a year, she was able to walk her dogs without stopping due to pain or discomfort.

A Changed Life: Patient-Reported Outcomes

At her six-week follow-up, the patient was overjoyed. She described being able to:

• Sleep through the night without cramps or burning sensations
• Walk 2–3 miles daily without numbness or fatigue
• Discontinue previously prescribed neuropathic medications
• Regain confidence in her mobility and physical activity

While venous treatment is often associated with cosmetic benefits, this case underscores the functional and quality-of-life improvements that can be achieved with appropriate vascular evaluation and intervention.

Clinical Takeaways

1. Venous Insufficiency Can Mimic Neuropathy

Patients with burning feet, numbness, and leg fatigue are often referred to neurology. However, these symptoms can stem from superficial venous reflux, particularly when no clear neurological diagnosis is made. Venous ultrasound should be part of the workup in patients with unexplained lower extremity symptoms.

2. Minimally Invasive Vein Treatments Offer Durable Relief

Techniques like EVLT, ultrasound-guided foam sclerotherapy, and visual sclerotherapy offer a highly effective, outpatient solution with little downtime. In appropriately selected patients, they can resolve symptoms and restore normal activity levels.

3. Comprehensive Evaluation Matters

This patient’s dramatic improvement stemmed from a thorough, root-cause-oriented workup. Rather than chasing symptoms, we assessed the venous system as a possible contributor—an approach that proved curative in her case.

Keywords for Clinicians and Search Engines

For providers and readers seeking more information, here are some key search terms related to this case:

• nocturnal leg cramps and venous reflux
• burning in feet not neuropathy
• superficial venous insufficiency symptoms
• EVLT for leg pain
• ultrasound guided foam sclerotherapy for venous disease
• spider veins and reticular veins treatment
• chronic venous insufficiency vs neuropathy
• saphenous vein reflux symptoms
• treatment for aching, itching legs
• misdiagnosed neuropathy due to venous issues

Final Thoughts

This case is a powerful reminder that not all leg pain is neurological, and not all burning or numbness is neuropathy. As clinicians, it's our responsibility to maintain a broad differential and consider chronic venous insufficiency as a potentially reversible cause of distressing lower extremity symptoms.

If you or your patients are experiencing similar symptoms—nocturnal cramps, burning in the feet, or unexplained leg fatigue—a venous ultrasound evaluation may be an important next step.

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