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Effects of isokinetic calf muscle exercise Reprints and permissions:
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program on muscle strength and venous DOI: 10.1177/0268355517695401
journals.sagepub.com/home/phl
function in patients with chronic venous
insufficiency

Sabriye Ercan1, Cem Çetin2, Turhan Yavuz3, Hilmi M Demir4

Abstract
Objective: The aim of this study was to observe the change of the ankle joint range of motion, the muscle strength
values measured with an isokinetic dynamometer, pain scores, quality of life scale, and venous return time in chronic
venous insufficiency diagnosed patients by prospective follow-up after 12-week exercise program including isokinetic
exercises.
Methods: The patient group of this study comprised 27 patients (23 female, 4 male) who were diagnosed with chronic
venous insufficiency. An exercise program including isokinetic exercise for the calf muscle was given to patients three
days per week for 12 weeks. At the end of 12 weeks, five of the patients left the study due to inadequate compliance with
the exercise program. As a result, control data of 22 patients were included. Ankle joint range of active motion,
isokinetic muscle strength, pain, quality of life, and photoplethysmography measurements were assessed before starting
and after the exercise program.
Results: Evaluating changes of the starting and control data depending on time showed that all isokinetic muscle strength
measurement parameters, range of motion, and overall quality of life values of patients improved. Venous return time
values have also increased significantly (p < 0.05).
Conclusion: In conclusion, increase in muscle strength has been provided with exercise therapy in patients with chronic
venous insufficiency. It has been determined that the increase in muscle strength affected the venous pump and this
ensured improvement in venous function and range of motion of the ankle. In addition, it has been detected that pain
reduced and quality of life improved after the exercise program.

Keywords
Chronic venous insufficiency, isokinetic, muscle strength, exercise

Introduction
Functional disability of muscle pump due to impaired
1
muscle strength plays an important role in the patho- Department of Sports Medicine, Dr. Ersin Arslan Education and
physiology of chronic venous insufficiency (CVI). Research Hospital, Gaziantep, Turkey
2
Department of Sports Medicine, Faculty of Medicine, Süleyman Demirel
Exercise therapy is recommended to eliminate the prob-
University, Isparta, Turkey
lem of muscle pump dysfunction.1,2 3
Department of Cardiovascular Surgery, Faculty of Medicine, Süleyman
In the study of De Moura et al.,3 it has been reported Demirel University, Isparta, Turkey
4
that walking speed, range of motion (ROM), strength, Department of Sports Medicine, Van Education and Research Hospital,
and functional capacities of patients with CVI were Van, Turkey
worse than those of normal individuals. Yang et al.4,5
Corresponding author:
have found that calf muscle strength and endurance of Sabriye Ercan, Department of Sports Medicine, Dr. Ersin Arslan
patients with CVI were insufficient compared to the Education and Research Hospital, Gaziantep, Turkey.
control group of healthy individuals. Email: [email protected]
2 Phlebology 0(0)

Cetin et al.1 have reported that calf muscle function as Table 1. Summary of exercise program.
well as thigh muscle function are significantly impaired,
ROM and stretching exercise, 10 rep  3 sets
and exercise programs to improve the lower extremity
Thera-band exercise, flexion-extension-internal and external
strength will be useful in the treatment of CVI. rotation, 10 rep  3 sets
Other researchers have also reported that decline in Isokinetic exercise (60 /s, 90 /s, 120 /s), 10 rep  3 sets
venous compliance can be improved by ROM, strength, Stability exercise on balance board, 10 min
and endurance exercises and by compression therapy.2,6,7 Walking on treadmill (60% HR max), 20 min
ROM exercises and isometric and isotonic Intermittent pneumatic compression (JOBST), 20 min
strengthening exercises for the ankle muscles are the ROM: range of motion; rep: repetition; s: second; HR: heart rate; max:
exercises that can be recommended.8 In the literature, maximum; min: minute.
ROM exercises and isometric strengthening exercises
have been applied to patients, and significant results
were obtained. However, there is no study investigating
the effectiveness of isokinetic muscle strength exercises. Patients’ ankle joint ROM, isokinetic muscle strength,
We made the design of our study on this deficiency pain, quality of life, and PPG measurements were
in the literature. ROM exercises, resistance training assessed before starting and after the exercise program.
with Theraband, isokinetic exercises at angular speeds The presence of painful venous ulceration, active
of 60/s, 90/s, 120/s, stability exercises, walking exer- local infections, the patient incompatibility during the
cises, and intermittent pneumatic compression pump test, non-compensatory heart and lung failure, periph-
was applied to patients with CVI three days a week eral arterial disease, diabetes, vasodilator treatment,
for 12 weeks under physician supervision. orthopedic disorders of the ankle, and any systemic
The aim of this study was to observe the change of disease which would prevent the working on the isokin-
the ankle joint ROM, the muscle strength values of etic dynamometer was defined as exclusion criteria.
plantar flexion (PF) and dorsiflexion (DF) measured PPG device (ELCAT Vasoquant VQ1000 D-PPGÕ ,
with an isokinetic dynamometer, Visual Analog Scale Germany) was used for VRT measurement and CVI
(VAS) scores, EQ-5D quality of life scale, and venous grading, while isokinetic dynamometer (HUMACÕ
return time (VRT) in CVI-diagnosed patients by pro- NORMTM Testing & Rehabilitation System, USA)
spective follow-up after giving calf muscle strength was used for isokinetic muscle strength measurements
enhancing (exercise) workout programs. and exercises.
PPG measurements of the patients whose history
and physical examination findings were compatible
Methods with stage C3–C4 CVI were carried out by the cardio-
The patient group of this study comprised 27 patients vascular surgeon. According to results of PPG, patients
(23 female, 4 male) who were diagnosed with stage C3– who have VRT values below 25 s and who do not have
C4 CVI by the CEAP (Clinical signs (C), etiology (E), the exclusion criteria were included in the study. The
anatomical features (A), underlying pathophysiological grade of CVI was recorded as mild insufficiency if
cause (P)) classification according to patients’ history, the VRT was 20–24 s, moderate if VRT was 10–19 s,
the findings of the physical examination, doppler ultra- and severe if VRT was <10 s. Patients were directed
sonography and photoplethysmography (PPG) tests at to the sports medicine physician after diagnosis and
the Cardiac and Vascular Surgery Clinic of Süleyman staging.
Demirel University Medical Faculty. VAS scoring was used to define the severity of the
Risk factors for CVI among the study group were complaints of the CVI patients, and EQ-5D quality of
determined as prolonged standing in 13 patients, preg- life scale was used in order to determine the effect of
nancy in 9 patients, obesity in 4 patients, and history of CVI on the overall quality of life.
thrombophlebitis in 1 patient. In addition, eight The ankle joint range of active motion was measured
patients got the history of CVI in family members dis- by the metal goniometer (Baseline Stainless, USA) before
playing genetic tendency to CVI. Informed consent was isokinetic muscle strength measurements of patients.
obtained from all the patients in the study group in Submaximal warming exercise was performed on the
accordance with the Helsinki Declaration, and the cycle ergometer for 10 min before muscle strength test,
approval for the study was granted by the Local and stretching exercises were performed for 5 min
Ethics Committee of Süleyman Demirel University before and after muscle strength test. Peak torque
with Decision No. 90 at meeting on 27 March 2013. (PT) and total work values of ankle PF and DF have
An exercise program including isokinetic exercise for been detected with isokinetic tests.
the calf muscle was given to patients three days per The ankle PF and DF muscle strength tests were
week for 12 weeks (Table 1). applied at speeds of 60–120/s in concentric/concentric
Ercan et al. 3

mode. The tests were applied in prone position at a Table 2. Clinical analyses values.
ROM of 15 DF and 40 PF.
Starting data Control data p
After the tests, patients were included in the exercise
program. Exercises continued three days a week for PPG VRT(s) 14.6  5.5 20.4  9.6 0.001a
12 weeks (60 min per session and 20 min JOBST for VAS 63 1.7  1.9 0.001a
recovery). Patients did not use varsity socks and did EQ-5D index value 0.5  0.2 0.7  0.2 0.001a
not receive any medical treatment during this period. EQ-5D VAS value 64.3  21.8 80.5  15.7 0.001a
The data of patients with treatment compliance over PF ROM ( ) 38.2  10.2 44.1  7.4 0.004a
90% were included in the study and were analyzed.
DF ROM ( ) 25.4  6.8 29.5  8.8 0.018a
PF PT (Nm) @ 60 /s 23.8  18.9 36.6  18.9 0.001a
Statistical Analyses DF PT (Nm) @ 60 /s 15.8  8 21.7  7.2 0.001a
Statistical analysis was performed with SPSS version Ratio PT (%) 84.6  37.3 68.1  25.9 0.017a
22 software. The frequency distribution of data was PF PT/BW (%) 31.1  20.9 49.6  22 0.001a
investigated. Descriptive statistical data were given as DF PT/BW (%) 21.4  8.9 29.9  9 0.001a
mean  standard deviation. Accordance of the group PF IPT (Nm) @ 120 /s 16.8  12 22.8  14.4 0.001a
with normal distribution was determined with DF IPT (Nm) @ 120 /s 12.4  5.6 15.4  6.2 0.001a
Kolmogorov–Smirnov test. Changes of the starting and PF TW (Nm) 94  95.4 161  115.9 0.001a
control data depending on time were evaluated with DF TW (Nm) 80.1  52.7 121.6  57.5 0.001a
Dependent samples t test. The evaluation of the test stat-
istics was made at a significance level of alpha ¼ 0.05. Note: Data are given as mean  standard variation. PPG: photoplethys-
mography; VRT: venous return time; s: second; VAS: Visual Analog Scale;
PF: plantar flexion; DF: dorsiflexion; ROM: range of motion; Nm: Newton
Results meter; PT: peak torque; BW: body weight; IPT: initial peak torque (mean
of first three repetition); TW: total work.
a
Initially 27 patients were included in the study. At the Statistically significant difference.
end of 12 weeks, five of the patients left the study due to
inadequate compliance with the exercise program. As a life values of patients improved. VRT values have also
result, control data of 22 patients were included. increased. These data showed that calf muscle exercise
Twenty patients were female and two were male program for 12 weeks improved the ankle joint ROM,
(mean age: 48  9 years, mean height: 159  7 cm, and muscle strength, overall quality of life, and the VRT
mean body weight: 72  13 kg). and reduced pain in CVI patients.
According to lower extremity PPG measurements, Failure in the calf muscle pump function with
CVI was observed in a total of 39 lower extremities, venous reflux is the basis of pathophysiology in CVI.
consisting of 17 right side and 22 left side. Thirty- In previous studies, severity of venous ulceration which
three of them were determined as stage C3 CVI while is the final stage of CVI has been found as being asso-
six were stage C4 CVI. ciated with pump function failure.9 Therefore, it is
Of the 17 right lower extremities, CVI was deter- important to determine the degree of muscle pump
mined as mild in 4, moderate in 9, and severe in 4, and venous function insufficiency.
while of 22 left extremities, CVI was determined as It was emphasized that when the effect of exercise on
mild in 3, moderate in 17, and severe in 2. muscle strength is released, decline in disease or improved
According to the Dependent samples t test results, venous function will be detected. In our case series, time-
evaluating changes of the starting and control data dependent VRT increase with increase in muscle strength
depending on time, it was determined that VRT was detected after exercise application. These findings
increased significantly (p < 0.05). VAS score decreased, also support the positive effects of exercise in the treat-
and EQ-5D quality of life scale improved (p < 0.05). ment of patients with venous insufficiency.
The ankle ROM values increased significantly There are several different methods for the evalu-
(p < 0.05). Increase in PT, PT/body weight, total work ation of venous function in many other studies. In the
done values in the direction of PF and DF and decrease study of O’Brien et al.,10 calf muscle pump function
in agonist/antagonist ratio were observed by isokinetic measurements were made with the use of air plethys-
measurement (p < 0.05) (Table 2). mography after a 12-week home-based progressive
resistance exercise program, and the authors have
reported that the ejection fraction has increased and
Discussion
the residual volume fraction has reduced. Padberg
At the end of our study, all isokinetic muscle strength et al.2 have investigated the hemodynamic effects of
measurement parameters, ROM, and overall quality of exercise by duplex ultrasound scanning and air
4 Phlebology 0(0)

plethysmography and reported that after six months of both morphologically and pathophysiologically.
exercise, the calf muscle pump parameters returned to Investigations performed on muscle biopsies of CVI
normal, but there was no change in the degree of reflux patients have shown type 2 myofibrillary atrophy in
and the stage of the disease. In addition, Yang et al.4,5 the gastrocnemius muscle, muscle necrosis, regener-
have not detected any change in the venous reflux ation, denervation, ischemic muscle cells denaturation,
although there was an increase in ejection fraction and inflammatory cell proliferation, and interfascicular vein
decrease in residual fraction in the air plethysmography dilatation damage.18,20
measurements after six-week intensive exercise program. Muscle performance is traditionally evaluated by
These studies show an improvement in the calf muscle manual muscle testing. However, manual muscle test-
pump function as in our study, but it is not obvious ing determines just the force which occurs at a certain
whether there is a significant change in the VRT. point of the width of movement; therefore, it does not
Several theories regarding the pathophysiology of provide accurate and reliable results. Furthermore, par-
pain in CVI patients have been presented. One of these ameters such as work, force, and endurance can not be
theories points at the change in the sensory innervation obtained by manual muscle testing, and it has been
of venous wall, the other points at the increase in endo- reported that the rate of 23%–31% deficit was deter-
neurial venous pressure and microangiopathic venous mined in isokinetic knee test applied to patients who
ischemia.11 displayed normal results by manual muscle testing.
Pain levels in patients with CVI show correlation with Isokinetic test provides a quantitative measure-
the stage of the disease.11 VAS is a commonly used ment of the musculoskeletal system performance.
method in the determination of the level of pain or in Acquired objective parameters provide possibility to
the comparison of pre and post treatment pain levels of save the patient’s follow-up data and to evaluate the
CVI patients.1,11,12 In this study, we also used VAS for disease improvement. Isokinetic testing allows the kine-
the definition of pain levels in the CVI patients. VAS matic analysis of the movement by the comparison of
scores of our case series were decreased in the 12th the two sides in the extremity segments, by determining
week of control. the rate of agonist/antagonist muscle strength rates and
Calf pain caused by insufficiency of calf pump is fre- by the measurement of the work capacity and endur-
quently seen in the 60- to 65-year-old people. Subhedar ance of muscles movement. Feedback may be given to
et al.13 have observed that VAS scores of the patients the patient during the test and exercise by showing
reduced by the strength exercises for quadriceps and calf his own performance graphics or numerical results on
muscles. a monitor.21 Ankle isokinetic muscle strength evalu-
Pain is not the most important symptom in all cases. ations are used safely in researches with all these posi-
Feeling of heaviness, itching, cramps, and other symp- tive aspects.22,23 In this study, isokinetic dynamometer
toms can also be detected which can make the diagnosis has been used in the ankle muscle strength measure-
difficult. The degree of clinical symptoms and progres- ments and treatment programs of CVI patients.
sion of the disease is correlated with the overall quality ROM in which the measurement will be made is of
of life of patients.11 great importance in terms of standardization of the iso-
‘‘EQ-5D quality of life scale’’ used in our study is a kinetic muscle strength measurement tests. Koutsioras
general health scale. Turkish validity and reliability stu- et al.24 have carried out the isokinetic muscle strength
dies of the scale are made.14 Statistically significant measurements on the ankle muscles of the running long
increase was detected between our patients start and jump athletes in the prone position at 15 DF, 40 PF,
control EQ-5D scale values. and 55 ROM.24 Considering the earlier studies done,
Regular contraction of the calf muscles is an essen- we performed isokinetic muscle strength measurements
tial factor for lower extremity venous return.15 The calf and isokinetic exercises at a ROM of 15 DF and 40 PF
muscle pump is called as ‘‘peripheral heart’’ owing to its in our study.
role in venous return from the lower extremities.16 According to the evaluation of patients beginning
A long-term weakness in the calf muscles leads to the and control values, increase in all isokinetic strength
slowing down of lower extremity blood flow and measurement parameters and decrease in agonist/
increased risk of deep venous thrombosis.15 It has antagonist strength ratio were observed (in the aspect
been indicated that exercises to rehabilitate the muscle of PF and DF). Positive changes from baseline occured
pump function, in addition to medical or surgical treat- in our study.
ment, may be useful as supportive therapy in patients O’Brien et al.10 have investigated the efficacy of
with severe CVI.1,2,4,17,18 walking and calf muscle exercise in their study and at
As it is shown in various researches, calf muscle the end of 12 weeks, they found an increase in ROM
strength and endurance are lower in patients with and improvement in walking, balance, and quality
CVI.6,19 Changes in muscle structure can be shown of life.
Ercan et al. 5

In another study, 49 CVI patients with healed function has been demonstrated once more in this
venous ulcers were compared with control group, and study, the effect of isokinetic exercise has been studied
difference between groups was found in terms of the for the first time in the literature.
ankle PT/BW in the direction of PF and the total Evaluation of the data obtained in this study led to
work parameters.25 the following conclusions:
Kan et al.17 have applied supervised isotonic calf
muscle exercises to 10 patients with venous ulcers for 1. Increase in muscle strength is being provided with
seven consecutive days and detected a significant improve- exercise therapy in patients with CVI.
ment in venous volume ejection fraction at the end of the 2. In addition to the increase in muscle strength, the
exercise period. In this study, it has been shown that calf increase in muscle strength affects the venous pump
muscle exercises will provide improved venous function and this ensures improvement in venous function.
even in such a short period of one week. 3. Improvement in the ROM of the ankle is provided.
Kahn et al.26 have showed that six-month training pro- 4. Pain reduces and quality of life improves after the
gram provided an improvement in 95 patients with post- exercise program.
thrombotic syndrome. The applicability of exercise therapy
in patients with post-thrombotic syndrome can be evalu-
Acknowledgements
ated in multicentered clinical trials. Thus, it has also been
reported that exercise therapy is important in the lower The authors would like to thank all the participants for gra-
ciously donating their time and also like to thank Mustafa
extremity venous system diseases other than CVI.
Onur Serbest, Aykut Recep Aktas, Yonca Sonmez, and Emel
Agonist/antagonist ratio, obtained by isokinetic
Sesli Cetin for their assistance in this research. The authors
muscle force measurements, gives the rate of muscles also thank Scientific Research Projects Coordination
which provide opposite movements of the joint. DF/PF Department of Suleyman Demirel University.
muscle ratio must be 33% for the functional capability
and stability of the ankle joint.27 This rate has been Author contributions
found to increase due to the weakness in the calf
The study design was created by CÇ, SE and TY. SE and TY
muscle in patients with CVI. Cetin et al.1 have reported diagnosed the cases. SE, HMD, and YBA treated the
the rate of 51  14% for DF/PF in CVI patients in their patients. All data were collected by SE, HMD, and YBA.
case series.1 SE and CÇ analyzed the data and wrote the manuscript.
At the beginning of our research, agonist/antagonist All authors reviewed and edited the manuscript and approved
ratio of the ankle of patients was higher than healthy the final version of the manuscript.
individuals. Patients start and control agonist/antagon-
ist ratio values showed a significant decrease. Declaration of Conflicting Interests
The slightest change in the ROM of the ankle may The author(s) declared no potential conflicts of interest with
cause greater hemodynamic changes. A change of respect to the research, authorship, and/or publication of this
1.5 cm in ankle rotation axis leads to 8.3% increase in article.
extension PT.28 Dix et al.29 have showed that restriction
in the ankle ROM was correlated with the stage of Ethical Approval
venous disease.29 The ankle exercises are suggested to The approval for the study was granted by the Local Ethics
be beneficial as they help the calf muscle contraction Committee of Suleyman Demirel University with Decision
and protect the ROM of the ankle.30 No. 90 at meeting on March 27, 2013.
Back et al.31 have demonstrated that in patients with
CVI, the ROM is lower than in normal individuals and Funding
the reflux increases, ROM decreases in correlation with The author(s) disclosed receipt of the following financial sup-
the degree of the disease. In accordance with Back port for the research, authorship, and/or publication of this
et al., Shiman et al.32 have also reported that there is article: This research was funded by Scientific Research
a reduction of ROM of patients with venous ulcers, and Projects Coordination Department of Suleyman Demirel
venous hypertension will decrease with calf strength University Research Grant 3618-TUI-13.
and ROM exercises.
In our study, we plan to create meaningful change in Guarantor
the ROM values with hemodynamic alterations by adding SE and CÇ.
ROM exercises and stretching workouts to the exercise
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