Lower limb
A leg ulcer is defined by the National Wound Care Strategy as ‘an ulcer that originates on or above the malleolus but below the knee that takes more than 2 weeks to heal’. There are several reasons why people get leg ulcers, the most common one (approx. 60 – 80%) being due to venous insufficiency arising from faulty valves in the veins and/ or poor calf muscle pump action. A smaller percentage of ulcers (10 – 20%) are caused by poor circulation in the arteries or as a result of other diseases such as diabetes or rheumatoid arthritis.
It is estimated that approximately 1.5% of the adult population in the UK is affected by active leg and foot ulceration, which equates to 730,000 patients (Guest 2019). Without correct treatment, ulcers can remain unhealed for many months or sometimes years, resulting in episodes of infection, pain and immobility. The biggest proportion of leg ulceration is due to venous insufficiency. However, many ulcers do have a mixed aetiology with elements of arterial disease or chronic oedema which may be further complicated by heart failure.
The Oxford Health Tissue Viability team has recently revised our previous pathways (Lower Limb Wound pathway, Chronic Oedema Pathway, and The Heart Failure and Compression Therapy pathway) to make one pathway for all lower limb care; this revised guidance brings the previous pathways together into one simplified document, which we hope clinicians will find more accessible. This pathway encompasses all aspects of lower limb care, in line with the NWCSP-Leg-Ulcer-Recommendations-v2-1.8.2023 and the Wounds UK Best Practice Statement – The Use of Compression Therapy for peripheral oedema: Considerations in people with Heart Failure (2023)
All clinicians delivering leg ulcer care are expected to use this pathway.
Chronic Oedema
Chronic oedema is an umbrella term for swelling that does not respond to elevation or diuretics and which has been present for three months or more. It can occur in the limbs and/or the trunk, head and neck or genitalia. There are a number of possible causes including;
- Dependency’ oedema: associated with immobility
- Venous oedema: e.g. resulting from venous disease such
as post-thrombotic syndrome or severe varicose veins
- Oedema associated with obesity
- Lymphoedema: primary and secondary
- Oedema related to advanced cancer
- Oedema due to heart failure
Left untreated chronic oedema of the lower limbs can progress and cause skin changes such as discolouration, eczema, dry skin plaques and hardening of the tissues. The risk of developing leg ulcers increases as the tissues become more vulnerable to injury and wounds fail to heal properly. The tissues become prone to infection and can require hospital admission. In the advanced stages the limbs change shape developing skin folds with hard cobblestone skin. They can begin to leak fluid profusely as the skin is unable to contain the fluid.
Chronic oedema can have a significant impact on a person’s quality of life. It is also costly to the health service in terms of time, resources and staffing. The key to managing chronic oedema is early intervention to prevent disease progression. The main interventions include compression therapy, skin care, exercise and elevation. Managing chronic oedema complicated with ulceration, lymphorrhoea (leaky legs) or infection can prove a challenge. However, with appropriate management strategies, these factors can be reduced.
Compression therapy
Correctly applied compression therapy is recognised as the mainstay of treatment for both the preventative and therapeutic care of venous disease, with high compression bandaging now established as the treatment of choice for venous leg ulceration. Compression therapy is mainly delivered through the application of bandaging or compression hosiery.
Compression therapy aims to reverse the effects of venous hypertension by:
- Decreasing the capacity of and pressure within the superficial veins
- Assisting venous return by increasing the blood flow velocity in the deep veins
- Reducing oedema and subsequent wound exudate levels
- Minimising or reversing skin changes that impact on wound healing.
Reduced compression therapy can be applied in the absence of any red flags for compression (please refer to the Lower Limb Care pathway) as part of immediate and necessary care. High compression therapy should not be applied before the arterial status of the limb has been established (by completing a holistic vascular assessment including ABPI) and should be applied in line with local policy and guidelines.
Please refer to the following Hosiery Booklet and Hosiery Formulary for guidance on the selection and application of compression hosiery in Oxfordshire:
The Lower Limb Care pathway 2024
Page last reviewed: 11 February, 2025