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C&P Exam Prep: Post-Phlebitic Syndrome (Chronic Venous Insufficiency)

DC 7121 cardiovascular 38 CFR 4.104

DBQ Overview

Interview + Physical
Form Name
Artery_and_Vein
Form Code
Artery_and_Vein
Page Count
10
Examiner Type
Vascular Surgeon, Cardiologist, or Internal Medicine
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of Post-Phlebitic Syndrome (also known as Chronic Venous Insufficiency or post-thrombotic syndrome) for VA disability rating purposes under Diagnostic Code 7121. The examiner will assess symptoms resulting from prior deep vein thrombosis (DVT) or other venous damage, including edema, skin changes, pain, and ulceration in the affected extremity(ies).

What the examiner evaluates:

  • Presence and severity of edema (swelling) in the affected extremity and whether it is relieved by elevation
  • Presence of stasis pigmentation (brownish skin discoloration) - beginning vs. persistent
  • Presence of eczema/stasis dermatitis - beginning vs. persistent
  • Presence and character of ulceration - intermittent vs. persistent
  • Presence of subcutaneous induration (hardening of tissue beneath the skin)
  • Severity of pain - aching or fatigue with prolonged standing or walking vs. constant pain at rest
  • Whether symptoms are relieved by compression hosiery or elevation of the extremity
  • Varicose vein characteristics - asymptomatic visible/palpable vs. symptomatic
  • Which extremities are affected (right lower, left lower, right upper, left upper)
  • Functional impact on daily activities and occupational functioning
  • Assistive devices used (compression stockings, cane, walker, wheelchair, braces)
  • Treatment history including surgery, compression therapy, wound care, medications
  • Presence of trophic changes, persistent coldness, diminished pulses (to rule out arterial involvement)
  • Vascular lab values if available (ankle-brachial index, toe pressures, transcutaneous oxygen tension)

The physical exam will focus on inspection and palpation of the affected lower extremity(ies). Wear clothing that allows easy access to your legs - shorts or pants that can be rolled up are ideal. Remove compression stockings before the exam if possible (or bring them to show the examiner), but note how long you had them off before the exam, as swelling may appear reduced. Ideally, arrive after being on your feet for a period of time to demonstrate the condition at its worst, consistent with M21-1 guidance on reporting the full severity of your condition.

Typical duration: 30-45 minutes

Ankle-Brachial Index (ABI)

Ratio of ankle blood pressure to brachial (arm) blood pressure; used primarily to assess arterial circulation and rule out peripheral arterial disease as a confounding or comorbid diagnosis

What to expect:

A blood pressure cuff will be placed on your ankle and arm; a Doppler ultrasound probe will be used to detect pulse sounds. Normal ABI is 1.0-1.3. For venous insufficiency, ABI is typically normal (-0.8), which helps confirm the condition is venous rather than arterial in origin.

Key thresholds:

  • -0.8 — Consistent with venous etiology; supports post-phlebitic syndrome diagnosis
  • 0.5-0.79 — Suggests moderate arterial disease; may complicate wound healing and rating
  • <0.5 — Suggests severe arterial disease; may indicate combined venous/arterial pathology

Tips:

  • This test rules out arterial disease - a normal ABI actually supports your venous diagnosis
  • Inform the examiner if you have diabetes, as calcified vessels may artificially elevate ABI
  • Results are typically recorded bilaterally for comparison

Pain considerations: Inform the examiner if cuff inflation causes significant pain or discomfort in the affected extremity, as this may indicate sensitivity consistent with your venous insufficiency symptoms.

Limb Circumference / Edema Assessment

The degree and distribution of swelling in the affected extremity, assessed by visual inspection, palpation (pitting edema test), and sometimes tape measurement at standardized anatomical landmarks

What to expect:

The examiner will press on the skin of your ankle, lower leg, or foot to check for pitting edema (an indentation that remains after pressure is released). They may compare both legs. They will also visually inspect for skin color changes, texture changes, and visible varicose veins.

Key thresholds:

  • Intermittent edema — Supports lower rating levels (0-10%)
  • Persistent edema relieved by elevation — Supports 10-20% rating range
  • Persistent edema NOT completely relieved by elevation — Supports higher rating (30%+)
  • Massive, board-like edema — Supports highest rating levels (100%)

Tips:

  • Do NOT wear compression stockings the morning of your exam - arrive with your legs in their natural, uncompressed state to allow the examiner to see the true extent of swelling
  • If you can, stand for 30-60 minutes before the exam to maximize visible edema
  • Tell the examiner how your swelling typically looks at its worst - end of the day, after prolonged standing - even if it appears reduced at the time of exam
  • Note whether swelling is worse in hot weather, after long periods of sitting or standing, or at certain times of day

Pain considerations: Describe any tenderness, tightness, or heaviness associated with the swelling, as these qualify as symptoms beyond mere appearance and affect the rating.

Skin/Dermatological Assessment

Presence and severity of stasis pigmentation, stasis dermatitis (eczema), subcutaneous induration (fibrosis), and ulceration - all of which are specifically named in the DC 7121 rating criteria

What to expect:

Visual inspection of the skin from the ankle to the lower leg; the examiner will note the presence, location, and extent of any skin discoloration, scaling, weeping, thickening, or open/healed ulcers. They will document whether these findings are beginning/early-stage or persistent/established.

Key thresholds:

  • Beginning stasis pigmentation or eczema — Supports 10% rating criterion
  • Persistent stasis pigmentation or eczema — Supports 20-30% rating criterion
  • Persistent subcutaneous induration — Supports 20-30% rating criterion
  • Intermittent ulceration — Supports 20% rating criterion
  • Persistent ulceration — Supports 30-100% rating criterion depending on extent

Tips:

  • Bring photographs of your leg on bad days, especially if you have had ulcers that are currently healed - document that they were present
  • Point out ALL areas of discoloration, scaling, or thickening to the examiner - do not assume they will notice every area
  • If you have active or recently healed ulcers, describe how long they typically last and how often they recur
  • Subcutaneous induration feels like hardened, rope-like tissue; make sure the examiner palpates affected areas if you know you have this

Pain considerations: Stasis dermatitis and ulcers are often painful, itchy, or burning - describe these sensations specifically so the examiner documents the full symptom burden.

Transcutaneous Oxygen Tension (TcPO2)

Oxygen levels in the skin, used to assess tissue perfusion and wound healing potential; more commonly used when ulceration is present or arterial disease is suspected

What to expect:

A small electrode is placed on the skin of the foot; it heats slightly to dilate capillaries and measures oxygen diffusing through the skin. Values >40 mmHg suggest adequate healing potential.

Key thresholds:

  • >40 mmHg — Adequate perfusion; wound healing expected
  • 20-40 mmHg — Impaired perfusion; wound healing compromised
  • <20 mmHg — Severely impaired perfusion; high amputation risk

Tips:

  • This test may not be routinely performed but may be ordered if ulceration is present
  • Inform the examiner of all current wound care treatments
  • Low values strengthen the case for a higher disability rating

Pain considerations: The test is generally painless, but inform the examiner of any hypersensitivity in the area being tested.

Estimate

Rating Criteria Breakdown

100% Massive, board-like edema with constant severe pain and exte ...

Massive, board-like edema with constant severe pain and extensive trophic skin changes; condition is effectively disabling with inability to ambulate or work; may include recurrent non-healing ulcers or severe complications.

Key Symptoms

  • Massive, board-like (brawny) edema of the entire extremity
  • Constant pain at rest
  • Extensive and severe trophic skin changes throughout the limb
  • Persistent non-healing ulceration
  • Inability to ambulate without assistive devices
  • Dependency on wheelchair or severe restriction of daily activities

CFR: Veteran cannot ambulate without wheelchair or walker due to massive bilateral lower extremity edema that is rock-hard (brawny edema/elephantiasis), has constant burning pain rated 8-10/10 even at rest, and has multiple simultaneous chronic venous ulcers that have been present for months without healing.

30% Persistent edema that is NOT completely relieved by elevatio ...

Persistent edema that is NOT completely relieved by elevation; stasis dermatitis with disfigurement; persistent ulceration; or a combination of severe findings across multiple categories.

Key Symptoms

  • Persistent edema that is only incompletely relieved by elevation
  • Stasis dermatitis with significant disfigurement of the leg
  • Persistent ulceration (open ulcer present for extended periods)
  • Constant pain or marked functional impairment
  • Requirement for ongoing intensive wound care or multiple compression garments

CFR: Veteran has marked chronic edema that remains significantly swollen even after 6+ hours of leg elevation overnight, has a non-healing venous ulcer on the medial malleolus present for 3 months requiring weekly wound care, and has extensive lipodermatosclerosis (subcutaneous induration) throughout the lower leg.

20% Persistent edema that is relieved by elevation; persistent s ...

Persistent edema that is relieved by elevation; persistent stasis pigmentation; persistent eczema; persistent subcutaneous induration; intermittent ulceration.

Key Symptoms

  • Persistent edema (present most or all days) relieved by elevation
  • Persistent stasis pigmentation (established, chronic brownish discoloration)
  • Persistent eczema / stasis dermatitis (chronic, not just beginning)
  • Persistent subcutaneous induration (palpable hardening beneath skin)
  • Intermittent ulceration (ulcers that open and heal periodically)

CFR: Veteran has chronic brownish-purple discoloration of the bilateral lower legs from ankle to mid-calf, persistent daily swelling that requires leg elevation for 2+ hours to partially resolve, and reports two episodes of venous ulceration in the past year that healed with wound care.

10% Symptomatic varicose veins with one or more of the following ...

Symptomatic varicose veins with one or more of the following: aching or fatigue in the leg after prolonged standing or walking; symptoms relieved by elevation or compression hosiery; beginning stasis pigmentation; beginning eczema; intermittent edema.

Key Symptoms

  • Aching in leg after prolonged standing
  • Aching in leg after prolonged walking
  • Fatigue in leg after prolonged standing or walking
  • Symptoms relieved by elevation of extremity
  • Symptoms relieved by compression hosiery
  • Beginning stasis pigmentation (early brownish discoloration)
  • Beginning eczema (early stasis dermatitis)
  • Intermittent edema (comes and goes, not constant)

CFR: Veteran reports leg aching and heaviness after standing at work for more than 30 minutes, relieved by sitting with leg elevated; early brownish discoloration around medial ankle noted on exam; mild pitting edema present at end of day but resolved in the morning.

0% Asymptomatic post-phlebitic syndrome with only visible or pa ...

Asymptomatic post-phlebitic syndrome with only visible or palpable varicose veins present; no pain, no edema, no skin changes, no functional impairment.

Key Symptoms

  • Asymptomatic visible varicose veins
  • Asymptomatic palpable varicose veins
  • No edema
  • No stasis pigmentation or eczema
  • No pain or functional limitation

CFR: Veteran has dilated superficial veins visible on the lower extremity but reports no symptoms and has no objective findings beyond the visible/palpable veins.

How to Describe Your Symptoms

Edema (Swelling)

How to describe:

Be specific about timing, location, severity, and what relieves it. Specify whether swelling is present every day (persistent) or only some days (intermittent). Describe how much elevation is needed and whether it fully resolves the swelling. Quantify: 'My ankle is the size of a grapefruit by 3 PM every day. I elevate my leg above heart level for 3 hours before bed and wake up with it still somewhat swollen - it never completely goes away.'

Worst-day example:

“On my worst days, my entire left lower leg swells from my ankle to my knee. The skin feels tight and shiny. I cannot fit into regular shoes by midday and must wear specially fitted footwear. Even after elevating my leg all evening, I still wake up with visible swelling. The leg feels heavy and aching all day.”

What the examiner listens for:

Whether edema is intermittent or persistent; whether elevation completely or only partially relieves it; bilateral vs. unilateral involvement; impact on footwear and mobility

Understatements to avoid:

Saying 'my legs swell sometimes' without specifying frequency, severity, or that elevation does not fully resolve it. Do not say 'it goes away when I put my feet up' if in reality the swelling persists even after elevation.

Pain and Discomfort

How to describe:

Distinguish between aching/heaviness with activity (lower rating), constant pain at rest (higher rating), and burning or throbbing. Use a 0-10 scale for both typical and worst-day pain. Describe what triggers and worsens pain - standing, walking, heat. Describe what provides relief - elevation, compression, rest.

Worst-day example:

“On my worst days, my left leg throbs and burns constantly even when I am lying down with it elevated. I rate the pain 7 out of 10 at rest and 9 out of 10 after standing for more than 10 minutes. The pain keeps me awake at night. I cannot stand in line at a grocery store without needing to find something to lean on within 5 minutes.”

What the examiner listens for:

Whether pain occurs only with activity or also at rest; severity using a numeric scale; impact on sleep and daily activities; whether it limits the distance the veteran can walk or time they can stand

Understatements to avoid:

Saying only 'my leg aches sometimes.' Do not minimize rest pain. Do not fail to mention that pain disrupts sleep if it does. Do not say pain is only a 2/10 if on bad days it is significantly higher - report your typical worst-day experience.

Skin Changes (Stasis Pigmentation, Eczema, Induration)

How to describe:

Describe the location, extent, and duration of skin changes. Note whether changes are permanent (persistent) or only occur during flares (beginning). Describe any itching, scaling, weeping, or cracking. Indicate how long skin changes have been present.

Worst-day example:

“The entire lower third of my right leg, from ankle to mid-calf, has permanent dark brownish-purple discoloration that has been there for over two years and does not go away. The skin is thickened, leathery, and hard - like wood - especially around my ankle. During flares, the skin becomes red, extremely itchy, weeping, and painful. I scratch it in my sleep.”

What the examiner listens for:

Duration (beginning vs. long-standing); whether changes are permanent or intermittent; location and body surface area affected; presence of itching, weeping, scaling; presence of palpable induration

Understatements to avoid:

Not pointing out all affected areas during physical exam. Calling established, chronic, permanent skin changes 'sometimes I get a rash' - use the correct medical language: stasis pigmentation, stasis dermatitis. Do not forget to mention induration (hardening) if it is present.

Ulceration

How to describe:

Describe the history of all ulcers: how many episodes, how long each lasted, where on the leg, how they were treated, and whether any are currently open. Bring photographs and wound care records. Specify whether ulcers recur (intermittent) or have been continuously present (persistent).

Worst-day example:

“I have had four venous ulcers on my left inner ankle over the past three years. The most recent one was open for four months and required weekly wound care visits. Right now I have a 2 cm ulcer on my right medial malleolus that has been open for six weeks. It drains fluid daily and is painful to the touch and when I walk.”

What the examiner listens for:

Number and frequency of ulcer episodes; duration (intermittent vs. persistent/non-healing); location and size; type of treatment required; current status (open vs. healed); impact on mobility

Understatements to avoid:

Mentioning only current ulcers without documenting the history of prior ulcers. Saying an ulcer 'healed fine' without noting how long it took or how many times it has recurred. Not bringing wound care records or photographs.

Functional Limitation and Daily Activities

How to describe:

Describe specific activities you can no longer do or must modify because of your venous insufficiency. Quantify limitations: how far you can walk, how long you can stand, what you can no longer do at work. Describe how the condition affects sleep, self-care, employment, and social activities.

Worst-day example:

“On a bad day, I cannot stand for more than 5 minutes without severe leg pain and swelling. I can no longer do my job in retail, which requires standing for 8 hours. I had to move to a desk job and keep a footstool under my desk. I cannot go grocery shopping without using the motorized cart. I sleep with two pillows under my legs but still wake up with pain at 3 AM.”

What the examiner listens for:

Specific functional limitations that map to the DBQ section on functional impairment; impact on occupational functioning; need for assistive devices; sleep disruption; restriction of recreational and social activities

Understatements to avoid:

Saying 'I can get around OK' when in reality you have significantly modified your lifestyle to accommodate the condition. Not mentioning job modifications, use of compression garments, leg elevation requirements during the workday, or restrictions on travel and standing.

Treatment and Compression Therapy

How to describe:

List all treatments you use: compression stockings (class/pressure, how many hours per day), leg elevation (how often, how long), wound care, medications (diuretics, pentoxifylline, topical agents), vascular procedures. Emphasize that these treatments are ongoing and managing, not curing, the condition.

Worst-day example:

“I wear 30-40 mmHg medical-grade compression stockings every day, all day. Without them, my leg swells to the point I cannot put on shoes within two hours. Even with stockings I still swell by afternoon. I have to elevate my leg for at least 90 minutes per session multiple times per day. I take a water pill (furosemide) daily. Despite all this treatment, my symptoms are still significantly limiting my life.”

What the examiner listens for:

Compliance with conservative treatment; effectiveness of treatment (partial vs. complete relief); extent of ongoing daily management required; need for medical-grade compression vs. over-the-counter; history of interventions (ablation, vein stripping, sclerotherapy)

Understatements to avoid:

Do not arrive wearing compression stockings without telling the examiner how long you had them on, as they will artificially reduce visible edema. Do not say 'compression stockings help a lot' without specifying that they only partially control symptoms and that the condition persists despite their use.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to request a copy of the completed Disability Benefits Questionnaire (DBQ) through your VA eFolder after the exam.
  • You have the right to record your C&P examination in states that permit one-party consent recording. Check your state's laws before the exam and inform the examiner at the start if you choose to record.
  • You have the right to submit lay evidence, including personal statements (VA Form 21-4138), buddy statements, and photographs, to supplement the DBQ and describe your symptoms in your own words.
  • You have the right to challenge an inadequate C&P examination. If the examiner did not perform an in-person physical examination, failed to review your records, or the DBQ is missing key findings, you may request a new examination or supplemental opinion.
  • You have the right to a VA-provided examiner free of charge. You do not have to pay for your C&P examination.
  • You have the right to submit private medical opinions from your own treating physicians or independent medical experts to support your claim, and the VA must consider them.
  • You have the right to know the reason for any adverse rating decision. If your claim is denied or rated lower than you believe is accurate, you have the right to request a decision review through the Supplemental Claim, Higher-Level Review, or Board of Veterans' Appeals lanes.
  • You have the right to have a Veterans Service Organization (VSO) representative, accredited attorney, or claims agent assist you before, during, and after the claims process at no cost (for VSOs).
  • You have the right to have the VA apply the benefit of the doubt in your favor when the evidence is in approximate balance - the standard is not 'beyond a reasonable doubt' but rather 'at least as likely as not' (38 CFR 3.102).
  • You have the right to request that the VA develop your claim by obtaining relevant records, including VA medical records, military records, and Social Security records, at no cost to you.
  • You have the right to present oral testimony before the Board of Veterans' Appeals if your claim reaches that level.
  • You have the right to have your condition rated based on the criteria for the diagnostic code most favorable to you if your condition reasonably fits under multiple codes (38 CFR 4.7, benefit of the doubt).

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.