AVLS: Testing for Venous Insufficiency of Lower Extremities Should be Done in the Standing Position

The American Vein and Lymphatic Society (AVLS) believes that all testing for venous insufficiency of the lower extremities should be done in the standing position, unless constrained by physical limitations of the patient. This scanning method produces better studies and promotes an ergonomically welcoming workplace.

Research supports the standing position versus supine or reverse Trendelenburg positions during duplex scanning for the detection of venous reflux.  Studies have shown that supine or reverse Trendelenburg positions may result is false positive as well as false negative readings. 

The standing position provides accurate, detailed information about the pathophysiology of reflux in the lower extremity veins by allowing the entire circumference of the lower extremity to be investigated. Conversely, the supine or reverse Trendelenburg positions limit visualization of the lateral and posterior lower extremity. 

While the standing examination is the most reliable and accurate way to perform this examination, it can be challenging for the sonographer and bring about ergonomic strain. The proper equipment, along with sound protocols, protects you and your staff from unnecessary work-related injuries.

According to The Society of Diagnostic Medical Sonography white paper (2018), an estimated 90% of clinical sonographers experience symptoms of work-related musculoskeletal injuries. Employers may pay up to $20 billion a year in direct costs for worker’s compensation and medical expenses, and up to five times that amount in indirect costs from lost revenue, absenteeism, and the hiring and training of new employees.

The following equipment is recommended by the AVLS to provide accurate venous insufficiency examinations while preventing workplace injuries.

  • Rapid Cuff Inflator – A hands-free pneumatic cuff inflation device provides reproducible distal augmentation and reduces sonographer twisting and bending during the examination. 
  • Height Adjustable Stool – It is important for the sonographer to be able to sit at a comfortable level during the examination. The height should be adjusted to the level of the lower extremity being evaluated. 
  • Height Adjustable Ultrasound Equipment – The ultrasound machine, keyboard and monitor should all be adjustable. The sonographer’s head should be balanced over his or her shoulders, facing straight ahead with the keyboard positioned closely to avoid reaching.
  • Standing Platform – A platform (or steps) allows the patient to stand above the level of the sonographer, avoiding unnecessary bending.

With these tools your sonographers will be able to set up a comfortable examination room, helping them to avoid workplace injuries and their associated costs. This will also allow your sonographers to obtain accurate, reproducible venous reflux examinations that deliver better treatment plan options. 

Thank you so much for you time and consideration of your patients and sonographers.


The American Vein and Lymphatic Society Ultrasound Section

References for Patient Positioning During Venous Reflux Testing

Labropoulos N, Tiongson J, Pryor L et al. (2003). Definition of venous reflux in lower-extremity veins. Journal of Vascular Surgery 38(4):793-798.

Van Bemmelen P, Beach K, Bedford G et al. (1990). The mechanism of venous valve closure: its relationship to the velocity of reverse flow. Arch Surg 125(5):617-9.

Markel A, Meissner M, Manzo R et al. (1994). A Comparison of the Cuff Deflation Method with Valsalva's Maneuver and Limb Compression in Detecting Venous Valvular Reflux. Arch Surg 129(7):701-5.

Lurie F, Comerota A, Eklof B et al. (2012) Multicenter assessment of venous reflux by duplex ultrasound. Journal of Vascular Surgery. 55(2):437-45.

Demuth P, Caylor K, Walton T et al. (2012) Clinical Significance of standing versus reverse Trendelenburg position for the diagnosis of lower extremity venous reflux in the great saphenous vein. The journal for vascular ultrasound. 36(1):19-22.

Carty G, Steele J, Clemens J et al. (2013) Standing versus supine evaluation for superficial venous reflux. The journal for vascular ultrasound. 37(30):119-124.

Masuda E, (2019). American Venous forum appropriate use project.

Shammas N, Knowles M, Shammas W et al. (2016). Detecting Venous Refluxing using a sixty-degree reverse Trendelenburg position in symptomatic patients with chronic venous disease. Journal of Invasive cardiology. 28(9):370-2.

Labropoulos N, Zygmunt J. (2012). Clinical Significance of standing versus reversed Trendelenburg position for the diagnosis of lower extremity venous reflux in the great saphenous vein. Journal for vascular ultrasound. 36(2):159-160.

Work Place Injury Reference

Murphey, S. (2018) Work related musculoskeletal disorders in sonography. Society of Diagnostic Medical Sonography. Plano, Texas, 1-10.

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