Compression therapy for leg ulcers: Time to move beyond dogmas. Real-world pressure measurements reveal very strong compression at application and an antigraduated pressure profile

Introduction Compression therapy is a cornerstone of venous leg ulcer management, yet many recommendations on optimal compression pressure and the need for graduated pressure profiles are based on limited clinical evidence or theoretical assumptions, as only a few objective data are available. The lack of routine pressure assessment has contributed to persistent assumptions and controversies. This study aimed to evaluate the compression pressures and pressure distribution profiles applied by experienced clinicians in their routine clinical practice. Methods A multicenter observational study was conducted during Phlebology and Wound Care meetings. One hundred clinicians experienced in compression bandaging applied their usual inelastic compression systems to fellow volunteer clinicians. Compression pressure was recorded using a device with sensors at three points on the lower leg: B (ankle region), B1 (lower calf), and C (mid-to high-calf). Pressure at point B1 was used as the reference compression pressure, and pressure profiles were analyzed. Results The median compression pressures were 52 mmHg (IQR 44–64) at point B, 60 mmHg (IQR 45–71) at point B1, and 55 mmHg (IQR 43–69) at point C. Only 15% of clinicians applied pressures ≤40 mmHg, whereas 66% applied pressures >50 mmHg. A traditionally graduated pressure profile was observed in only 13% of applications. In contrast, 87% of clinicians produced non-graduated profiles, including inverse-graduated or progressive profiles (23%), pressure peaking at point B1 (40%), or other atypical patterns (24%). In all non-graduated profiles, calf pressure exceeded ankle pressure. Conclusions In routine practice, experienced clinicians commonly apply strong compression pressures well above 40 mmHg and rarely achieve a graduated pressure profile. These findings challenge prevailing assumptions about the application of compression and underscore the importance of objective pressure measurements to guide future research, guidelines, and clinical practice.