Background: Venous leg ulcers (VLUs) affect 1-3% of the population and impose substantial pain-related morbidity, yet vascular pain remains underrecognized in clinical practice and research. Objectives: This narrative review synthesizes current evidence on the pathophysiology, clinical manifestations, and management strategies for VLU-associated pain. Methods: A comprehensive literature search was conducted across PubMed/MEDLINE, Scopus, Embase, and Web of Science (January 2015-July 2025) following SANRA guidelines. Search terms included "vascular pain", "venous leg ulcer", "chronic venous disease" and related terminology. Studies addressing pathophysiology, clinical characteristics, diagnostic approaches, and therapeutic interventions were included. Results: VLU pain demonstrates complex pathophysiology encompassing nociceptive, neuropathic, and nociplastic components driven by venous hypertension, chronic inflammation, and central sensitization. Pain prevalence ranges from 50-87% in VLU patients, significantly impacting quality of life and functional status. Evidence supports a five-strategy management framework: (1) treating underlying venous pathology through early ablation, (2) optimized compression therapy achieving ~40 mmHg ankle interface pressure, (3) procedure-specific local anesthesia using topical agents, (4) multimodal systemic analgesia targeting neuropathic features, and (5) adjunctive venoactive drugs. Patient-reported outcome measures reveal substantial psychosocial burden beyond wound-related symptoms. Conclusion: VLU pain represents a distinct clinical entity requiring mechanism-based, multidisciplinary approaches. Early venous intervention, evidence-based compression protocols, and targeted analgesic strategies show promise for improving outcomes. Critical research gaps include dedicated pain-focused clinical trials, standardized outcome measures, and personalized treatment algorithms. Enhanced recognition and systematic management of vascular pain could substantially improve patient-centered outcomes in chronic venous disease.
