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•Venous reflux and duplex ultrasound are important diagnostic tools when determining venous insufficiency•The time to diagnosis is highly variable depending on a patient’s presentation with evolution of the ulcer(s) and tolerance for treatment protocols.•Because of its ease of use, ultrasound testing the most employed imaging technique to assess venous pathology.•Insufficiency is chronic in nature and recurrent lower extremity ulcers wax and wane.