MEASURING FOR A PERFECT FIT

Below Knee:
With a tape measure, measure the narrowest circumference at the ankle just above the malleoli. Do not measure circumference at the malleoli. Take swollen ankles into account. If necessary see whether the opposite ankle wouldn’t provide a more accurate assessment. If you have to measure with swollen ankles, try measuring early morning or first use a compression bandage to reduce oedema. Measure the widest circumference at the calf. Measure the length from the heel (ground when standing) to the bend of knee. Bend of knee means literally bending knee, finding the crease behind the knee with your finger and straightening the leg with finger in place. Beware of the patient with feet in plantar flexion when in bed. You could easily measure too short. Be sure to keep the ankle at 90°.

Thigh Length:
Measure ankle and calf as above.Measure thigh circumference one inch (2,5cm) below gluteal crease. This usually is as high as one can get on the inner leg.Measure length from heel (ground when standing) to gluteal crease. Again, be sure to keep foot at 90° when measuring.

HOW TO FIT COMPRESSION HOSIERY

Insert hand into stocking, grab heel of stocking, turn it inside out holding on to the heel of the sock. (Like Grandma used to do)

Insert the foot with thumbs on inside of stocking up to the heel. This could be made easier by bending the knee and placing the foot on the opposite knee. This way you are closer to the action! Arthritic and overweight patients might find this difficult. Try a chair in front of you for support! At this stage the stocking might slip back especially if you try to pull heel (stocking) over heel (foot). Don’t worry, this is fine.

Now slide stocking on itself over heel in single layer, taking care not to bundle the stocking and thus causing a thick elastic band which only makes it more difficult. The stocking will slide easily at first and then get stuck as it struggles to go over the heel. As soon as you experience resistance, insert your thumbs to “work” it up even further. At this stage the folded stocking will have reached the midway point between heel and toes.

Now insert you fingers under this fold formed at the foot arch and gently flip it over the heel which is easy because of the leverage effect and little compression at the fold.

Gradually work stocking upward until in place. Make sure the heel (stocking) is exactly over heel (foot) and the topband (cuff) is 2.5cm below bend of knee. This is probably the most important aspe

ct of a correct fit. Bend the patients knee when fitted, to check that no tourniquet forms when bent and adjust if necessary. Explain at this stage to the patient the importance of no folds at this point as it will cause a tourniquet and discomfort.

Remove remaining creases by “playing” the stocking. This is done by rubbing the stocking length-wise until the crease disappears. Do not pull at the top!

Never fold back any stocking onto itself just because it seems too long or operative tools are in the way. Check the size of the stocking again and make sure it was not pulled up too high. Remember that any stocking can be pulled higher then the intended height.

Should you encounter any pain or discomfort having fitted a stocking, immediately remove stocking and elevate the leg. Pain or discomfort is almost always caused by improper use of stocking. Compression hosiery never causes pain, it relieves pain. Should you encounter pain and discomfort, contact your supplier or call the Medis Helpline for advice.

MORE ABOUT STOCKINGS

Handwash in luke warm water with mild soap. Do not tumble dry. Do not wash with fabric softener.

Air dry but not in direct sunlight or with direct heater/fire exposure.

Purchase some powder free latex (nice and sticky) gloves at your local supermarket and use them to fit stockings easier. Ask your supplier how to use them correctly. It makes a huge difference.

Often patients in need of stockings are arthritic or overweight. Always insist on special training by your supplier, otherwise you will never wear them. A little training goes a long way.

The majority of patients need only below knee stockings. This include patients with varicose veins in the upper leg. The reason is simple: Varicose veins do not cause side-effects in the upper leg, only in the lower leg. On the other hand compliance with below knee stockings is 100% better than with thigh length stockings for obvious reasons.

REPLACING STOCKINGS

How often do I replace my stockings? Most companies would say every six months. A better way to look at it is to say:” When it stops doing the job” . If you had oedema and the stocking is still effective, good for you. If you had pain and the pain is still under control, good for you.

Replacement is very much in the hands of the user though and some users get away with 12-24 months. Others only two months.

KNEE OR THIGH LENGTH IN DVT PREVENTION

Anti-Embolism Stockings is effective because it increases the venous velocity in the deep vein system.

The increase in venous velocity is mostly brought about by graduated compression on the plantar plexus in the foot as well as the calf and its superficial venous plexus.

Compression on the thigh with its bulk of muscle and subcutaneous fat is 8-10mmHg and has a negligible effect on venous velocity.

If increased venous velocity is effected by below knee stockings, it has to equally increase venous velocity in the venous system of the upper leg. Where else could the increased flow go?

Anatomy of the majority of patients is such that thigh length stockings will always tend to roll down or crease in the fat folds causing a tourniquet effect. This has been proved to cause reverse gradient and increase in DVT incidence.

It is well documented that the majority of DVTs in the lower limb that dislodge and cause Pulmonary Embolism, originate from the popliteal and inguinal areas. This has understandably left practitioners with the perception that this area should be compressed. Not so; upper stocking has negligible effect on increased venous velocity.

A patient in thigh length stockings could increase the compression at the knee, to as high as 50mmHg, by bending the knee to 90°. This once again will cause a reverse gradient. Remember, the compression at the ankle is only 18mmHg. And what do we do on day one; we sit the patient in a chair, sometimes for two hours, knees bent to 90°!

Two situations may still warrant thigh length stockings: 1) Knee replacements where surgeons want to get rid of the oedema to mobilize quicker – At Groote Schuur this is not seen as good enough reason to go above knee. 2) Patient with oedematous thigh due to acute DVT.

In the acute DVT the latest is to mobilize from day one having been treated with LM Heparin. The patient is placed on 30-40mmHg thigh length compression stockings! This has been proven to have no increased incidence in PE.

References:

  1. Effectiveness of Elastic Stocking Decompression. E.F. Bryars et al. Arch Surg, 1977.
  2. Graduated Compression Stockings – Knee Length or Thigh Length. T. Benkö et al. Clinical Orthopaedics and related research. 2001
  3. Graded compression stockings in elective orthopaedic surgery. A.J. Best et al. J Bone and Joint Surg. 2000.
  4. Graduated compression stockings in the prevention of post-operative deep vein thrombosis. P. C. Jeffreys and A.N. Nicolaides. BR. J Surg, 1990.
  5. Graduated, static,external compression of the lower limb: A Physiological Assessment:D Lawrence and V.V. Kakkar. Br. J. Surg. 1980.
  6. Type of compression for reducing venous stasis. B. Sigel et al. Arch Surg. 1975.
  7. Effect of ‘anti-embolism’ compression hosiery on leg blood volume. R.A. Sparrow et al. Br. J. Surg. 1995.
  8. Thigh length versus knee length stockings in the prevention of deep vein thrombosis. M.J. LeF. Porteous et al. Br. J. Surg.1989
  9. Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin. H. Partsch. J. of Vasc. Surg. ,Nov 2000.

10. In Vivo pressure profiles of thigh-length graduated compression stockings. C.J. Wildin et al. Br. J. Surg., 1998.

COMPRESSION IN SPORT

Very little research has been published on this very new subject. Much of the evidence is anecdotal and need to be proved with quality research. Compression for years has been the stepchild of the R>I>C>E family. It now finely arrived!

Sports compression has now been successfully introduced in many different sports in South Africa :

  • Cricket – At national and provincial level
  • Rugby – Provincial and Super Twelve
  • Hockey – National and Provincial
  • Marathon and other Long Distance Running (Comrades)
  • Cycling
  • Golf
  • Hiking

Super Twelve Rugby teams use compression socks to prevent DVT during long distance flights. They are particularly prone to DVT’s due to muscle trauma with oedema or heamatoma after a heavy match.

An Australian study group showed that a high percentage of Olympic athletes treated for minor muscle injuries, in fact had asymptomatic DVT’s and were treated incorrectly! This could be partly due to the long flights and dehydration.

The incident of Economy Class Syndrome in the normal population is now thought by some to be lower than previously expected. Be careful though to extrapolate to sportsmen with a very specific make-up, especially rugby players.

Our research shows that:

CSOCK SPORT decrease muscle and ligamentous injuries. Muscles and tendons come under tremendous stress during exercise. Compression socks have a caging effect on muscle and tendon. This means muscle and tendon is held in close proximity of the tibia and fibula and restricts lateral movement. The sock though allows longitudinal motion.

CSOCK SPORT prevents DOMS (Delayed onset muscle soreness) which is stiffness on day two, following heavy exercise.DOMS is currently thought to be due to muscle damage at spindle level. Due to the “caging” effect explained above, muscle damage at this level is reduced to the minimum, which reduces DOMS. Athletes get back to training much faster!

CSOCK SPORT prevents oedema caused by centrifugal and gravitational forces typically seen in cricket, long distance running and cycling. Oedema causes unnecessary heaviness of the feet restricting leg mobility. The removal of oedema weight has the advantage of lighter feet for 42km in a marathon!

Cricketers fielding all day complain of heaviness and oedema of the feet. By wearing compression socks they are more nimble in the field. (As experienced by our national side)

CSOCK SPORT shortens recuperation following any inflammatory condition of the lower leg, including ligamentous injuries of the ankle, torn calf muscles and heamatoma of the calf. Oedema causes reduction in arterial (and oxygen) supply due to hydrostatic force of interstitial oedema.Torn ligamentous ends are separated by oedema. Compression forces them closer to each other with better healing.

CSOCK SPORT will improve aerobic and anaerobic efficiency of the athlete.Superficial plantar plexus and venous plexus of lower leg normally are filled with oxygen-depleted red blood cells.Compression forces these oxygen-depleted cells to the deep venous system where they are circulated and oxygenated. Spanish research shows a 6% increase in aerobic efficiency and 11% increase in anaerobic efficiency. Lateral movement of muscle constitutes a waste of energy. Energy is preserved by the caging effect of hosiery already explained.

CSOCK SPORT helps with removal of waist materials such as lactic acid from the interstitial tissue. Venous blood and lymph are the mediums in which cellular waste material is removed . Removal of oedema facilitates the removal of waste.

CSOCK SPORT has been shown to be highly efficient in controlling shin splint discomfort/pain (As experienced by Gogga Adams, cricketer). Shin splints or medial tibial periostitis is a common problem of athletes who changed shoes, surface or technique. Also common with training on hard surfaces especially with repeated explosive take-offs. The caging effect and removal of swelling/oedema explains it success in preventing and treating shin splints.

LEG FATIGUE

Research has shown that standing on your legs for long periods, causes muscle fatigue. Creatine Kinase (CK) levels which is released when muscle is damaged, is raised when measured over 24hr period. Research has shown these levels to improve to “normal” when the same routine is repeated 14 days later but wearing Class 1 compression hosiery. For this reason many doctors, theatre sisters, pharmacists, sales people etc. wear compression hosiery during working hours to reduce leg fatigue/pain.

COMPRESSION HOSIERY AND ALLERGY

Compression hosiery is mostly made of inert fabrics and rarely causes allergy. Fabrics used to manufacture compression hosiery are:

  • Elastomide- In various forms including Microfibre, Coolmax etc.
  • Elasthane – Also known as Spandex, which provides most of the elastic compression.
  • Cotton – Often included for comfort and sweat absorbtion
  • Rayon – Also known as wood fibre or “wood silk”
  • Wool – Seldomly used
  • Mohair – Used for its special qualities in diabetic socks.

Of all the fabrics, Elasthane and Spandex theoretically should cause the most problems but rarely makes up more than 10% of the fabric. It is also “buried” in the weaving process which allows for very little skin contact, if any.

Allergy however does occur in a very small percentage of patients. Always be aware that the allergy could be caused by soap left on the stocking or leg during washing. This is exacerbated by sweating which occurs under hosiery.

Be aware of skin rash cause by shaving of legs. This could irritate the hair follicle and cause an impetigo and mimick an allergy.


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