Knowledge · Clinical Examination

Varicose Vein Examination for MRCS Part B: Distribution, Skin Changes and Special Tests

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Examine varicose veins with the patient standing: map the long and short saphenous distributions, look for skin changes of chronic venous hypertension, palpate for a saphena varix, then perform the tap, tourniquet and Trendelenburg tests.

Examine varicose veins with the patient standing, because the veins fill under gravity. Map the distribution against the long and short saphenous systems, look for the skin changes of chronic venous hypertension, palpate for a saphena varix, then use the special tests and say that duplex ultrasound is what confirms the diagnosis.

Key takeaways

The long saphenous vein runs anterior to the medial malleolus and up the medial calf and thigh; the short saphenous vein runs posterior to the lateral malleolus to the popliteal fossa.
The saphenofemoral junction lies inferolateral to the pubic tubercle, a mean 2.4 cm lateral and 1 cm inferior to it on ultrasound.
Haemosiderin staining, lipodermatosclerosis, atrophie blanche and venous ulceration over the medial gaiter area are the marks of chronic venous hypertension.
NICE CG168 recommendation 1.3.1 uses duplex ultrasound to confirm the diagnosis and the extent of truncal reflux.
CG168 1.2.1 says to refer people with bleeding varicose veins to a vascular service immediately.

How is this station marked in MRCS Part B?

A physical examination station is marked out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication, and professionalism carry 4 marks each. The examiner also gives the station a separate global rating of pass, borderline or fail.

Two things follow from that split. More than half the marks sit outside your knowledge of the condition, so a silent, technically correct examination scores poorly. And you are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

How do I start the varicose vein examination?

Gel your hands, introduce yourself, explain and gain consent, then expose both legs from the groin down and stand the patient up on a step or the floor with something to hold.

Walk around the patient and look at the front, the medial side and the back of each leg before you touch them.

How do I map the distribution of the varicosities?

Decide which system the veins belong to, because that is what determines the treatment.

Long saphenous distribution: anterior to the medial malleolus, up the medial calf, a hand's breadth medial to the knee, then up the medial thigh to the saphenofemoral junction.
Short saphenous distribution: posterior to the lateral malleolus, over the posterolateral calf, to the popliteal fossa.
Look also for superficial thrombophlebitis, which presents as hard, tender, inflamed veins.
Comment on the distribution out loud rather than simply saying the patient has varicose veins.

What skin changes of venous disease should I look for?

Haemosiderin staining, the brown pigmentation of the medial gaiter area from extravasated red cells.
Venous eczema and oedema.
**Lipodermatosclerosis** is fibrosis and induration of the subcutaneous fat from chronic venous hypertension.
The inverted champagne bottle leg, where the proximal calf swells and the distal calf is constricted by lipodermatosclerosis.
Atrophie blanche, the pale scarred areas that follow healed ulceration.
Venous ulceration, characteristically over the medial malleolus, with a sloping edge, a granulating base and a warm limb with palpable pulses.

Also look for the pale, hairless, cool limb of coexisting arterial disease, because that changes whether compression can be used.

What do I palpate?

Palpate along the varicosities to confirm the distribution you inspected.
Feel for a **saphena varix**, a dilatation of the long saphenous vein at the saphenofemoral junction, which is compressible, disappears on lying down and has a cough thrill.
Palpate the pedal pulses, or offer to, because arterial disease coexists.
Offer to palpate the abdomen for a mass compressing the iliac veins or inferior vena cava, and to examine the pelvis where indicated.

What are the special tests and what do they show?

All three tests localise the level of incompetence, and all three are bedside approximations of what duplex now measures directly.

The tap test

Place one hand over the saphenofemoral junction and tap a varicosity lower down the leg. A palpable thrill transmitted upwards indicates a continuous column of blood and therefore incompetent valves between the two points.

The Trendelenburg test

Lie the patient down, raise the leg to empty the veins, and press over the saphenofemoral junction. Stand the patient up with the pressure maintained. If the veins stay empty, the incompetence is at the saphenofemoral junction alone, and releasing the pressure fills them.

The tourniquet test

The same manoeuvre with a tourniquet instead of a finger, repeated at successively lower levels. Empty the leg, apply the tourniquet high on the thigh, and stand the patient up.

Veins stay empty: the incompetence is above the tourniquet.
Veins fill: the incompetence is below it, so move the tourniquet down and repeat.
Repeat above the knee for a mid-thigh perforator, below the knee for the saphenopopliteal junction, and mid-calf for calf perforators.

Say that in practice NICE CG168 recommendation 1.3.1 uses duplex ultrasound to confirm the diagnosis of varicose veins and the extent of truncal reflux, and to plan treatment. The bedside tests demonstrate understanding; duplex makes the decision.

What does NICE say about referral and treatment?

CG168 recommendation 1.2.1 refers bleeding varicose veins to a vascular service immediately. Recommendation 1.2.2 refers symptomatic primary or recurrent varicose veins, skin changes thought to be caused by chronic venous insufficiency, superficial vein thrombosis with suspected venous incompetence, and an active or healed venous leg ulcer.

For confirmed truncal reflux, CG168 1.3.2 offers endothermal ablation first, then ultrasound-guided foam sclerotherapy if that is unsuitable, then surgery. Compression hosiery is not offered as a treatment unless interventional treatment is unsuitable.

What are the most common mistakes at this station?

Examining the patient lying down, so the veins are empty and nothing can be mapped.
Looking at the front of the leg only and missing short saphenous varicosities.
Placing the saphenofemoral junction below the mid-inguinal point instead of inferolateral to the pubic tubercle.
Performing the tourniquet test once and stopping, rather than moving down the leg.
Never mentioning duplex ultrasound.
Forgetting the pedal pulses before recommending compression.

MRCS Part B Questions has a varicose vein examination station with a marked checklist at /Sample-Questions. Reviewed and updated 15 September 2026.

Key evidence

Varicose veins: diagnosis and management (CG168), recommendations — NICE (2013)
Redefining the surface anatomy of the saphenofemoral junction in vivo — Clinical Anatomy (2014)

FAQ

Why is the examination of varicose veins done standing?

Because superficial veins empty when the leg is raised and refill under gravity when it is dependent. Standing the patient distends the varicosities so you can map their distribution, feel a saphena varix and see the full extent of the disease. The special tests then begin with the leg raised and emptied.

Where exactly is the saphenofemoral junction?

It lies inferolateral to the pubic tubercle. An ultrasound study of 100 healthy adults put the centre of the junction at a mean 2.4 cm lateral and 1 cm inferior to the pubic tubercle, and inferior to it in 90 per cent of limbs. Older descriptions placing it a fixed distance below the mid-inguinal point are less accurate.

Are the tourniquet and Trendelenburg tests still used?

They are still examined and still worth knowing, because they demonstrate that you understand where reflux occurs. In clinical practice they have been replaced by duplex ultrasound, which NICE CG168 recommends to confirm the diagnosis and the extent of truncal reflux and to plan treatment.

What is a saphena varix and how do I recognise it?

It is a saccular dilatation of the long saphenous vein at the saphenofemoral junction, and it is the classic mimic of a femoral hernia. It is soft and compressible, disappears completely when the patient lies down, has a bluish tinge and transmits a thrill when a distal varicosity is tapped or the patient coughs.

When must a patient with varicose veins be referred urgently?

NICE CG168 says to refer people with bleeding varicose veins to a vascular service immediately. Symptomatic veins, skin changes from chronic venous insufficiency, superficial vein thrombosis with suspected incompetence, and an active or healed venous leg ulcer all warrant referral, but not on the same timescale.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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