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182 ATYPICAL CAUSES OF LEG ULCERATION
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CHAPTER
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4
Musculoskeletal Factors
inLeg Ulcers
Assessment andManagement
RONA FRANCES CAMPBELL
here is a growing recognition that sub- optimal movement,
T
reduced mobility and impaired biomechanical function have an
impact on the development and longevity of lower limb complications that relate to chronic venous disease (CVD), venous leg ulcers
(VLUs) and lymphoedema (Araujo et al. 2016; Farrelly 2018;
Meulendijks etal.2020a,2020b).
Enhancing patient movement and addressing musculoskeletal
(MSK) and biomechanical concerns is key in optimising compression
therapy during an episode of ulceration. Optimal movement and
mobility also helps to mitigate complications like peripheral oedema
and impaired joint mobility (Wounds2016).
Optimal physical function reects adequate motor control, physical tness and the ability to mobilise freely on a regular basis (Langhammer et al.2018). Inactivity or immobility, whether because of
pain, injury, systemic disease, neuropathy, nondisease or the ageing process, can lead to sub- optimal movement and
changes in physical and biomechanical function that can increase
venous hypertension (Langhammer etal.2018).
neurological MSK
Lower Limb and Leg Ulcer Assessment and Management, First Edition.
Edited by Aby Mitchell, Georgina Ritchie, and Alison Hopkins.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
188
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Musculoskeletal Factors in Leg Ulcers 189
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People with CVD and VLUs are known to present with biomechanical issues, for example impairment in ankle joint movement or
gait dysfunction (Figure 4.1) (Back et al. 1995; Clarke-
Moloney
etal. 2007; Araujo et al.2016). These issues can result in adverse
changes in important physiological processes that ensure lower limb
health and venous return, namely the veno- muscular pumps (VMPs)
(Uhl and Gillot2015; NICE2021). The VMPs are important anatomical pumps in the lower limb, and they help mediate haemodynamic
homeostasis within the circulatory system and aid venous return
when activated through regular MSK movement (Uhl and Gillot2015). An important VMP in the lower limb is the calf muscle
pump (CMP). Failure and dysfunction of this pump through a reduction in ankle joint range of motion (ROM) and adverse changes in
gait are major contributory factors in the development and chronicity
of CVD and VLUs (Lattimer etal.2017).
This chapter will examine the factors that inuence mobility,
lower limb biomechanical function and the inuence of sub- optimal
gait, with a focus on the lower limb VMPs and ankle joint ROM.
Ambulatory
Venous Hypertension
Abnormal Muscle
Pump Function
Neuropathy
Decreased Mobility,
Range of Motion
FIGURE 4.1 Biomechanical factors that inuence venous leg ulceration.
Source: Shiman etal.2009/John Wiley & Sons. Reproduced with
permission.
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Gait
Abnormalities
Pain
Venous Leg
Ulceration
190 MUSCULOSKELETAL FACTORS IN LEG ULCERS
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Understanding how these biomechanical factors aect the management of patients with CVD and VLUs is vital. These factors relating
to mobility impairment are known to have a negative inuence on
the onset and progress of CVD, VLUs and wound healing (Padberg
etal.2004). Moreover, a loss in mobility is known to have an impact
on quality of life (QoL) (Meulendijks etal.2020b).
RISK FACTORS
There are known non- modiable established risk factors in patients
who have CVD and VLUs, such as age, sex and family history
(NICE2021). However, there is a sub- section of modiable risk factors that relate to mobility and the biomechanical function (refer to
risk factors in Chapter5) for those who have CVD and VLUs which
are poorly understood, and these relate to sub- optimal mobility and
biomechanical and gait dysfunction.
During holistic lower limb assessment, screening for risk factors
that relate to an individual’s mobility and biomechanical function in
conjunction with those relating to VLUs is important for optimal
clinical outcomes, as poor mobility can have an impact on many
areas within wound care management (O’Brien et al.2014; Smith
etal.2018). However, screening for mobility risk factors for patients
who have VLUs may be perceived as challenging for a nurse when
evidence suggests that delivering essential care can in some cases be
dicult in a busy clinical setting (Guest etal. 2018). Moreover,
biomechanical and mobility factors are not always recognised as
important risk factors for the development and chronicity of VLUs
within wound care management (Farrelly2018).
A poorly recognised mobility risk factor for the development and
chronicity of VLUs is CMP dysfunction. The CMP is in the lower,
posterior leg and is one of the important VMPs in the lower limb and
foot. The VMPs are responsible for 90% of the venous return from
the lower limb to the trunk (Williams et al. 2014). The CMP is
responsible for approximately 65% of the net venous blood return
within the lower limb, which is enabled through adequate movement at the ankle (Williams etal.2014).
CMP dysfunction is not only a risk factor for VLUs, but also for
deep vein thrombosis (DVT), and is an independent predictor of
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Musculoskeletal Factors in Leg Ulcers 191
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all- cause mortality (Araki etal.1994; Back etal.1995; Milic etal.2009;
Halkar et al. 2020). Therefore, recognition of CMP dysfunction is
important not only within the context of VLU management, but in
relation to the overall health of the patient.
A major biomechanical risk factor inuencing CMP dysfunction
is the loss of ankle joint ROM (Back etal.1995; de Souza etal.2022).
Research suggests that when ankle joint ROM is reduced there is
an increased risk of developing an ulceration (Table 4.1) (Araki
etal.1994). Once an ulcer has developed, the episode of wound healing can be prolonged compared to people with adequate ROM when
using compression bandaging (Barwell etal.2000). When movement
at the ankle is impaired, there is a reduction in the functional
TABLE 4.1
avenous leg ulcer.
Risk factor Explanation
Immobility Increased risk of venous hypertension
Limited ankle range of
motion (ROM)
Sedentary lifestyle Obesity
History of leg frac-
ture or trauma
Lower limb dysfunction/
structural deformities
Underlying
musculoskeletal disease
Biomechanical risk factors that may contribute todeveloping
and oedema
Reduction in joint ROM
Sarcopenia
Obesity
Calf muscle pump (CMP) dysfunction
Impact on gait
Fixed joint position
Gait impairment
Impact on CMP function
Impaired gait
Damage to the venous and lymphatic anatomy
Impaired joint ROM
Leg length discrepancy
Pelvic obliquity
Genu valgum/recuvartum
Highly pronated or supinated foot postures
Diseases that cause issues with balance and
proprioception
Diseases that result in structural deformities
Diseases that result in gait dysfunction
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