Venous disease of the lower limbs and its effects on driving

Superficial phlebitis

Superficial phlebitis is a benign process characterized by erythema, pain and oedema all along the affected vein.

Treatment consists of resting the leg, keeping it elevated, and taking anti-inflammatory agents.

Advice

• The patient must not drive until the symptoms have remitted.
• Deep vein thrombosis (DVT) initially causes superficial venous distension, cyanosis and increased volume of the affected limb with pain and functional impotence.
• It is a more serious condition, which carries a risk of pulmonary embolism, and requires long-term treatment with an anti-coagulating medication.

Advice

• Driving is contraindicated from the onset of symptoms until their complete remission.
• While there is an existing risk of pulmonary embolism, the patient may not drive.
• Patients who are on anticoagulation must be advised of the increased risk they run of suffering haemorrhages if they have even small collisions, so they need to be extremely prudent when driving.
• Massive deep vein thrombosis evolves into phlegmasia cerulea dolens with serious oedema, associated arterial spasm and distal bed thrombosis, which leads to necrosis in half of all cases.
• These episodes require heparin therapy, fibrinolytics and in certain cases intervention by thrombectomy and fasciotomy to try and vascularise the limb.

Advice

• Driving is contraindicated from the onset of symptoms until their complete remission.
• If the patient undergoes surgical treatment, the expert will let the patient know when the limb has completely recovered and he can once again drive without limitations.
• If postphlebitic or post-surgical sequelae occur, the doctor will warn that the patient has reduced driving capacity and possible adaptations or restrictions in each case.
• Patients who are on anticoagulation must be advised of the increased risk they run of suffering haemorrhages if they have even small collisions, so they need to be extremely prudent when driving.
• Lymphoedema of the lower limbs is chronic and painless, of primary origin or secondary to injuries, surgery or lymphatic obstruction.
• Essential lymphoedema is white, firm and vespertine like the venous variety, but does not hurt or cause cyanosis, and gets a little better at night. It is more common at the front of the foot, first in the toes and then the dorsal face.
• At the outset the oedema is intense but soft, and causes some tiredness, then it evolves into a chronic hard rigid oedema, which does not change with postural changes and makes movement difficult.
• There are some very serious cases that mean driving is impossible because the feet cannot be moved, and at the same time, the position of driving makes them worse.
• The most important complications of lymphoedema are cellulitis and repetitive lymphangitis, which present with redness, pain and increased swelling of the affected limb, with general effects and fever.
• Meticulous foot hygiene is necessary to avoid infections, and the lower limbs should be elevated, elastic stockings worn and lymphatic drainage performed.
• When infections occur rest and antibiotic treatment are obligatory.
• Surgery may be performed in selected cases of massive oedema.

Advice

• In advanced cases, lymphoedema can limit movement of the legs and feet, interfering with driving as the driver cannot operate the pedals or does must do it slowly has poor control.
• At the same time, the driving position makes lymphoedema much worse, and this is why patients are warned not to drive for long periods in any case.
• Frequent rest stops are recommended during journeys, during which the patient must walk, and if possible elevate the legs.
• It is not a good idea to point the vehicle’s heating at the sufferer’s legs.
• Patients with extensive surgical or radiological lymphadenectomies can present lymphoedema in the upper and lower limbs, which can be made clumsy or disabled in some cases.
• Improvements in the patient’s condition, with reduction of lymphoedema, will allow the doctor to recommend when the patient may once again drive, in accordance with the appropriate recommendations.
• Deep vein failure is characterised by heaviness, tension in the calf, clumsy movements and tiredness throughout the day.
• In prolonged bipedestation or sedestation, tingling is frequent, as are paresthesia and oedema. In the end pain and cramps appear, with paresthesia and itching of the foot at night.
• Walking immediately relieves the pain, which also improves when the limbs are elevated to a horizontal position, from which it can be inferred that the driving position makes the situation worse.
• Dermatitis is frequent due to dryness and itching, because of the infection of irritations and scratching, and frequently due to allergies to topical medications.
• Treatment is limited to an ever-decreasing application of compression, avoiding a sedentary lifestyle and an orthostatic position.
• Losing weight and exercise are recommended, with advisable postures such as elevated legs or constant movement, always far from heat.
• Venotonic medications such as diosmin, troxerutin and hydrosmin are very well tolerated, except for some mild digestive effects.

Advice

• The inside of the vehicle should be kept cool. Try not to direct the heating at the legs in winter.
• Stop often during long journeys to stretch the legs and elevate them.
• Try to drive in the morning, when the legs are not tired from daily activity.
• If the heaviness and swelling of the legs is pronounced, this will make it difficult to move and the patient must not drive.
• Visible varicose veins in the saphen, both internal and external, can also appear along the longitudinal arch of the foot.
• They might not cause discomfort, but they could cause symptoms such as phlebitis, haematoma, pain in the area, haemorrhaging from being knocked or ulcers.
• Treatment begins by using support stockings less and less frequently, postural measures an sclerotic therapy. In certain cases, phleboextractory surgery is indicated.

Advice

• If the varicose veins are not causing discomfort, the patient may drive.
• Patients with varicose veins complicated by haemorrhage, phlebitis, pain from knocking, etc, should rest and they should not drive until the limb is free of symptoms and there are no limitations against driving.
• Drivers with varicose veins should be more careful inside the vehicle not to knock themselves on the controls or pedals.
• The inside of the vehicle should be kept cool. Try not to direct the heating at the legs in winter.
• Stop often during long journeys to stretch the legs and elevate them.
• A patient who undergoes saphen phleboextraction must not drive until the limb has recovered its mobility, sensitivity and adequate muscle strength, which usually takes between two and four weeks.
• The varicose ulcer presents on the sole of the foot or underneath the tibial maleolo, and is more frequent on flat feet, and can become chronic, painful, or get infected.
• If it gets complicated, it turns into lymphangitis, where in addition to strained, sensitive red areas, painful lymphoedemapathy usually develops. The foot gets inflamed and shivering, fever and the patient feels ill.
• Treatment begins with local treatment of the ulcer to avoid local infection. These treatments can last for weeks, and if the ulcer does not heal or is resistant to treatment, it will need to be removed surgically and skin grafts may be required.
• If infection occurs, antibiotic treatment and antithrombotic prophylaxis are obligatory.

Advice

• You cannot drive if bandages are immobilising your leg or foot.
• Apposites that allow adequate movement of the limb do not preclude the patient from driving.
• Ulcers, that because of their location or symptoms, interfere with the vehicle’s pedals mean that the patient must not drive.
• Drivers with infected ulcers, located in places where the body rests or for which rest with the foot elevated have been recommended, mean the patient must not drive until they are healed or the doctor has expressly permitted driving.
• Acute lymphangitis requires a recovery and close follow up period during treatment, which means the patient may not drive until the limb has recovered and medical authorization has been obtained.