How do you tell a venous ulcer from an arterial ulcer?

A venous ulcer sits in the gaiter area above the medial malleolus, has a sloping edge, aches less when the leg is elevated, and has palpable pulses with surrounding pigmentation. An arterial ulcer is punched out, sits at the toes, heel or pressure points, hurts more on elevation and better when the leg hangs down, and has reduced or absent pulses.

Why must the arterial supply be checked before compression bandaging?

Compression is the treatment for venous ulceration but reduces perfusion further in an ischaemic limb, where it can cause tissue loss. The arterial supply is assessed clinically and with an ankle-brachial pressure index before compression is applied.

Leg ulcers — venous, arterial or neuropathic?

Written and clinically reviewed by Dr. Mohammed Maree, consultant minimally invasive and bariatric surgeon, Al-Makassed Hospital, Jerusalem, and Assistant Professor of Surgery, Al-Quds University. Last updated 6 October 2026.

Venous, arterial and neuropathic ulcers are managed in opposite directions — one is compressed, one must never be compressed until the arteries are checked, and one is offloaded. Getting the category right is therefore the whole decision, and the history gets you most of the way there before you look at the leg.

The three patterns

	Venous	Arterial	Neuropathic
Usual site	Gaiter area, above the medial malleolus	Toes, heel, lateral malleolus, pressure points	Sole, under the metatarsal heads, heel
Pain	Aching, better with the leg elevated	Severe, worse on elevation, better hanging the leg out of bed	Painless — and that is the point
Edge	Sloping, irregular	Punched out, well defined	Punched out, callus around it
Surrounding skin	Pigmentation, eczema, lipodermatosclerosis, varicose veins	Cold, hairless, shiny, pale on elevation	Warm foot, thick callus, deformity
Pulses	Present	Reduced or absent	Often present

The questions that sort them

Does the pain get better when you put the leg up, or when you hang it down? Up is venous; down is arterial. One question, two different diseases.
How far can you walk before your calf hurts, and does it stop when you stand still? Intermittent claudication, and its distance, measures the arterial supply.
Do you get pain in the foot at night that wakes you? Rest pain is critical limb ischaemia and is urgent.
Can you feel your feet normally? Numbness, burning or a sensation of walking on cotton wool points to neuropathy.
Have you had a DVT, a fracture, or veins stripped? Previous deep venous damage explains a venous ulcer years later.

Before any compression bandage

Compression is the treatment for a venous ulcer and is dangerous in an ischaemic limb. The arterial supply is therefore checked first, clinically and with an ankle–brachial pressure index, before compression is applied by anyone. In a patient with diabetes the index can be falsely raised by calcified, incompressible vessels, which is one reason a diabetic foot is assessed by someone experienced rather than by the number alone.

Surgical pearl

A painless ulcer in a patient with diabetes is not a reassuring ulcer. It is painless because the protective sensation has already been lost, which is exactly why it was allowed to form.