Walking With a Venous Leg Ulcer: Does Exercise Actually Help It Heal?

Quick answer: a venous leg ulcer exists because blood is not being cleared out of the leg properly, and the calf muscle is the pump that does that clearing. Compression remains the core treatment, but walking and ankle exercises are how the pump gets used. A multicentre trial in Madrid primary care (NCT04039789) tested a structured nurse-led exercise and walking programme added on top of usual compression care.

Why does the calf muscle matter so much?

Veins in the leg carry blood back up against gravity, helped by one way valves and by the calf muscle squeezing the deep veins every time you take a step. When those valves fail, blood pools in the lower leg, pressure in the small vessels rises, fluid and inflammatory cells leak into the tissue, and the skin around the ankle becomes discoloured, hardened and fragile. Eventually it breaks down, often after a minor knock, and heals badly because the underlying pressure problem is still there.

This is why these ulcers are so persistent, and why dressings alone rarely close them. Two things reduce that pressure: external compression, and the calf pump. A person who barely walks, or who walks with a stiff ankle and a shuffling gait, is running the pump at a fraction of its capacity even while wearing perfect bandaging.

What was the Madrid trial testing?

The Active Legs trial (NCT04039789), sponsored by the Gerencia de Atencion Primaria in Madrid, was a randomised, multicentre, pragmatic trial run in primary care health centres. Both groups received the usual treatment: assessment, cleaning, debridement, moist wound healing and multilayer compression therapy according to regional guidelines.

The intervention group additionally received a structured educational programme delivered by nurses in the clinic: four lower limb exercises of progressive difficulty to be done at home twice a day, five days a week, plus a graded walking plan building up towards 150 minutes a week. The primary outcomes were complete healing and the time taken to heal. Secondary outcomes tracked degree of healing on the Resvech 2.0 scale, ulcer area, quality of life, pain, and how well people actually stuck to the programme, measured in part by step count.

Honest status: the trial ran from May 2021 and is listed as completed at the end of December 2023, but no results have been posted to the ClinicalTrials.gov record. It is also worth being straightforward about scale: the protocol planned for 224 participants and the registry records 44 actually enrolled, so even when results appear, this study on its own will not settle the question. Treat it as an indication of what clinicians are testing, not as proof that exercise heals ulcers faster.

What is usually recommended alongside compression?

• Ankle pumps. Sitting or lying, point the toes away and then pull them back towards you, slowly and through the fullest range you can manage. This is the single most direct way to work the calf pump.
• Ankle circles and heel raises. Keeping the ankle mobile matters. A stiff ankle is one of the strongest predictors of a poorly functioning calf pump.
• Regular walking, built up gradually. Short frequent walks are usually easier to sustain than one long one, and they are gentler on a painful leg.
• Elevation when resting. Legs raised above heart level for a spell during the day helps drainage, and complements the exercise rather than replacing it.
• Avoid long motionless standing or sitting. Standing still is harder on the venous system than walking. If work requires it, move the ankles regularly.

Any exercise programme should be agreed with the nurse or doctor managing the ulcer. Pain, arterial disease, unsteadiness on the feet and heart or joint conditions all change what is sensible, and some people need their circulation assessed before compression or exercise is increased.

Does exercise replace compression?

No, and this is the important point. In the Madrid trial, both arms received multilayer compression. Nobody was asked to swap bandaging for walking. Compression is the treatment with the strongest evidence behind it for venous leg ulcers, and exercise is being studied as something added on top of it. If compression has been prescribed, it needs to be worn as directed even on the days when walking feels like enough.

When should you get help?

Contact your doctor or wound care nurse if the ulcer is growing, the surrounding skin becomes hot, red or increasingly painful, the discharge increases or starts to smell, or you develop a fever. Seek prompt review too if pain increases when you elevate the leg or if the foot becomes cold, pale or bluish, as that can point to an arterial problem where compression may not be appropriate. Any leg ulcer that has not shown clear progress after around four weeks of proper treatment deserves reassessment rather than more of the same.

This article is general information, not medical advice. Please consult your doctor, wound care nurse or other qualified professional about your own situation.

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