Heart failure, kidney failure, excess salt intake and obesity are typically at the top the list of causes of swollen and achy legs. However, when one looks across the spectrum of patient ages, the most common cause and most treatable cause of lower extremity swelling and achy legs is venous insufficiency, or venous reflux disease. For many years venous insufficiency was typically referred to as “varicose veins” and if no varicose veins were present the possibility of venous insufficiency was not further considered. Unfortunately for many patients this is often still the case today. The diagnosis of venous insufficiency as the potential cause for patients’ swollen and achy legs should not be dismissed based solely on the absence of visible varicose veins. Many patients with venous insufficiency may not have any evidence of varicose veins and may just have swelling as their main complaint.