Ankle ulcer for 6 years

86 year old male had a recurring ankle ulcer that was being managed with local wound care only. Eventually, an MR angiogram was obtained showing severe tibial artery disease. Skin perfusion pressures showed decrease perfusion but with values suggesting wound healing was obtainable. Further evaluation with venous ultrasound showed incompetence in the great saphenous and small saphenous veins with an incompetent distal calf perforater. The lack of visible varicose veins should not preclude evaluation for venous disease. This is a common misperception -> the lack of typical findings of venous disease means there is no venous disease. All ulcers around the ankle are venous until proven otherwise. The patients incompetent veins were treated, pain resolved and the patient's ulcer at 3 weeks was rapidly improving.