Safe Socks: What Your Mother Never Told You
November 2016 Issue
Ignored, neglected, and often abused, our feet help us soldier through an inhospitable world of obstacles and challenges, dependent largely on our socks as a first line of defense for health, healing, and protection. From therapeutic compression to blister prevention to comfort, the right sock, chosen with consideration of the user's climate, activity, and health condition, can make a world of difference to you and your patients.
We asked experts to share their insights, observations, and tips-and collected some thoughtful advice about socks and their role in protecting foot health that your mother probably never told you.
Fred Lanier, sales manager, Comfort Products, Croydon, Pennsylvania, says socks deserve to be called what they are-an interface. "Because we've worn socks all our lives, we think we can just buy any old sock at the store, then the orthotist will fit a nice pair of shoes and everything will be fine. If there's a breakdown, it's never the sock that's blamed-it's always the shoe or the orthotist," he says, suggesting that orthotists and pedorthists educate patients about the need for wearing appropriate socks.
"Because the brace or shoe is made to correct an issue, there could be problems if they don't have full contact, or the fit is not right. If you get a proper insert, you ought to get the proper interface, because it definitely will make a difference," he emphasizes.
Revolutionary is not too strong an adjective to describe the GlideWear® Shear Protection Socks made by Tamarack Habilitation Technologies, Blaine, Minnesota, which uses the company's patented material, says Dennis Janisse, CPed, president and CEO, National Pedorthic Services, headquartered in Milwaukee. "It's a unique material; the dual-layer, breathable fabric lies smoothly against itself and virtually decreases friction and shear in all directions. It doesn't hold the moisture in, thereby helping to control temperature, as well," he notes.
GlideWear's properties are similar to Tamarack's ShearBan® low-friction interface material used in orthotic shoe inserts for treatment of diabetes-related foot ulcers. GlideWear was first used on wheelchair seating and underwear for patients who are bedbound to prevent the development of ulcers. Later, it was applied to the heel and ankle of socks for patients who are bedbound, and was recently added to the toe caps of Knit-Rite's diabetic socks.
"This is a...sock that will protect the forefoot, where most of the diabetic foot ulcers occur," Janisse explains. "It protects the metatarsals and also will decrease shear in the hammertoe area.
"A really exciting development is the partial foot sock [Tamarack] introduced. If someone has had a transmetatarsal amputation and lost part of their foot, it's very hard to put a sock on there. The skin at that distal end of an amputation is very susceptible to breakdown, but these short socks really fit the foot, while the front of the sock, with its GlideWear cap, will decrease shear and friction on the end of the foot."
Joe Hofmeister, Tamarack's CEO, reports receiving positive responses from pedorthists, orthotists, and podiatrists about the GlideWear diabetic sock. "They are recognizing that it protects the diabetic foot from friction and shear. The first result is pain relief, and the more important result is that friction transfer has proven to speed the healing of a diabetic injury.
"What we believe-but what we have to clinically prove-is that if you heal the ulcer, and then you wear the sock...you can reduce the recurrence rate. Thereby, we would be able to go to the FDA [U.S. Food and Drug Administration] one day and use the word 'prevention,'" he says.
Janisse is currently involved in the study to prove the clinical benefits of diabetic socks. "We're looking at the GlideWear sock decreasing the callusing. Pictures show amazing improvement in one case, where in three months a patient's calluses just totally disappeared by using that sock," he says.
Shear and friction continue to be a source of concern to Janisse, as others pursue the development of socks that offer that protection.
"What makes it [shear and friction] so difficult is that we can't measure it," Janisse says. "If you know what you're looking for, you can identify it, but it's not easy. There are machines that can register the resistance between two surfaces, but we just don't have a way yet to measure it inside the shoe, where it would be so much easier for everyone to recognize and understand. It will come," he says.
There are other developments in the diabetic sock arena that Elliott Crooks, Ruby Leather & Orthopedic, Commerce City, Colorado, points to. "The traditional advice for diabetics [who are] unable to feel blisters or small wounds because of [lack of] foot sensitivity has been to get a white or light-colored sock so that any bleeding will show up. This is the same reason that diabetic shoe inserts are typically covered in a light pink low-friction foam, as opposed to the identical foam in black. Now there's also a sock with the foot body in white to show any wounds, but starting below the ankle. The sock is black above, so it looks like a normal dress sock and doesn't scream either 'diabetic sock' or 'dork.'
"Socks have proliferated," he says, noting that one of his favorite outdoor companies now lists 411 sock selections on its website. "They're dealing with more than 30 vendors in more than a dozen best-use categories, including skiing and snowboarding-plus running socks of the no-show, low-cut, just over the ankle, or crew varieties. And that's just an outdoor store which doesn't carry diabetic-type socks."
What he finds most positive is the preponderance of natural fibers in this census. "Out of those 411 sock options, more than 300 are either wool or wool blends, with about 44 polyester or polyester blends, with single entrants like silk or silk blends making up the balance."
SPORT-SPECIFIC SOCK OPTIONS
While some sock types and styles rely on clever marketing rather than substance and value, many sport-specific socks are worthwhile investments, according to Megan Leahy, DPM, Illinois Bone and Joint Institute, Chicago, and spokesperson for the American Podiatric Medical Association.
"Running a marathon in everyday socks, I would expect to experience more blisters," she says. "Soccer socks are longer and help protect the legs from the shin guards; running socks tend to have more cushioning in the ball of the foot and the heel, and they usually have a bit of elastic in the arch, which helps provide arch support. There's a lot of variability within running socks. You could even make a distinction between shorter and longer runs. As a runner myself, I choose a thicker, cushier sock when I'm doing a longer run, while I'm not afraid to go with something a little bit thinner with a shorter run.
"There are even socks that are double-layered, which decrease some of that friction and shearing and help prevent blisters. They're good for all-around use, but some tend to be more expensive, and I would reserve those for the longer runs, where you're more inclined to develop blisters," Leahy adds.
Crooks notes that fit is especially important in a sport-specific sock. "If you choose a sock for running or for tennis, you might want it a little snugger than for general casual walking, so there's less likelihood of blistering. It comes down to personal preference, however. I prefer a slightly looser, more comfortable fit, myself, because my feet are pre-diabetic."
He speculates that the SmartWool® Adrenaline sock and its high-tech combination of seven different weaves-with strategically placed mesh and varied ribbing-may have initiated today's avalanche of innovative approaches to sport socks.
Outdoor socks are not new; designs for hiking, backpacking, and mountaineering have all used the same basic sock design, but in different thicknesses and weights, recognizing the need for moisture and shock absorption. While makers offer sock styles for every sport from cycling to soccer to snowboarding, skiing, and yoga, Crooks observes that they don't have to be all that different from each other.
"What you get is minor to moderate comfort and performance improvements," he says. "A good ski sock, given that downhill skiing involves pressing forward on the front of your foot, comes with extra padding up the shin, as well as padding on the underside of the foot. They tend to be midweight socks as opposed to really heavy ones because the heavier socks make for a tighter fit, and that means poor circulation and cold toes."
Leahy says she prefers a wool sock like SmartWool, but advises those looking for a sporting-type sock to visit a sporting goods store and ask for guidance. "It's a difficult area to navigate. I think you're better off actually handling the sock, versus choosing one based on how it looks online. Most employees at such stores are educated about the products by the representatives from those companies; they've also tried the products, and are an excellent resource," Leahy says.
Janisse agrees. "I think some of the best shoe fitters and people with knowledge that aren't certified pedorthists are the folks in those athletic shoe stores."
ARE COMPRESSION SOCKS FOR EVERYONE?
"There are whole line[s] of socks that offer compression," Leahy says. "You'll see athletes wear them during the sport and even after a rigorous workout or rigorous activity. The intent is to keep those lymphatics and the venous flow going back toward the heart, and flushing out all those toxins, and evidently it's supposed to help with recovery."
Lanier agrees that long-distance runners, especially, have found that wearing light compression socks helps send the blood back toward the heart and rejuvenates the runner. "Compression pushes your veins together to push the blood back to the heart; that's also great for [people with diabetes], because the legs are the farthest things from the heart."
"There are now lines of socks that are really comparable to compression stockings we used to think of more for medical reasons," Leahy explains. "Returning that venous flow is really great for people who stand or are seated all day. And basically, all of the sporting goods stores or running specialty stores also carry not the medical version, but an athletic version of compression stockings, which I think would be completely appropriate to use if there are no health contraindications."
They may cost more than pharmacy versions, because customers pay for the increased selection that athletic styles offer, she notes. "I've been pretty impressed, and some of my patients who don't want to wear a nudecolored compression stocking will go to a sporting goods store for one that looks more athletic."
Sockwell, Chattanooga, Tennessee, offers socks with three zones of graduated compression that come in stripes and argyle designs; Leahy also mentions bright neon colors and designs "with a lot of flash."
Even concealing a nude compression stocking under something more attractive can work, as long as the outer layer is not more compressive than the inner layer, says Leahy. While she says that option can be a bit hotter, it might help with friction, and some patients find that wearing something on top of the compression stocking protects their legs from rubbing caused by AFOs or other orthoses.
Europe is a bit ahead of us where compression is concerned, she says. "Their airports have what they call 'flight socks'-compression socks to help prevent deep venous thrombosis and the swelling that a lot of us experience when we're flying. I certainly think it's a great idea for anyone flying who has been cleared to use compression."
Janisse agrees that while on a plane for long periods, wearing compression socks is a good idea, but he warns of sizing risks for those who wear nonprescription compression hosiery-especially those wearing graduated compression styles.
Compression hose come in varying lengths, even to the hip, he points out. "If someone has a medical issue and they don't wear the right height, that can be counterproductive, because you're doing compression in one part of the leg and there's none in other parts of the leg."
With so many unknown aspects-even unsuspected health conditions-it is best, he says, to get guidance from a physical therapist or a knowledgeable representative in the athletic department where the hosiery is sold.
"There are different gradients of compression," says Janisse. "Sometimes people just like to wear them because it feels better. When you get above a certain compression, however, you should not be dispensing it without a prescription; when you get to those high compressions, that can be dangerous."
Leahy concurs, urging anyone with health problems to consult with a podiatrist or primary care physician to ensure that wearing compression socks is a safe option.
Because anyone could have an undiagnosed condition, though, Lanier also advises those seeking a sport compression sock to find a pedorthist or orthotist to fit them properly-even if it's an athlete who appears to be in good health.
The good news, however, for orthotists and pedorthists who prescribe good-quality diabetic socks or compression hosiery, is that patients who may have felt that the price was too high are discovering that sport and specialty socks from mainstream retailers cost at least as much.
"It's starting to change the perception of patients, and active people are already seeing the benefits of well-designed, quality socks," Lanier says. "We're finding that people understand that they're going to be responsible for their healthcare and will have to spend some money to get good, proper healthcare.
"Our biggest problem is that it's difficult for pedorthists to get paid for socks. Medicare doesn't cover [them]. A pedorthist may charge $10 for a pair of socks, while Walmart has socks three for $5. Although the $10 socks will probably fit better, feel more comfortable, and wear five times longer, we're such a price-driven industry right now that everybody wants to know what's going to be the best deal today.
"And when things go wrong with their cheap cotton sock," Lanier stresses, "it's not the interface that bears the blame, but the shoe or the fitter-that's what [patients] believe." Even the long-running battle Janisse has been waging to find a good, affordable, cost-effective diabetic sock that patients on fixed incomes can afford may become winnable if third-party payers start providing coverage. "It will take a long time," Lanier admits.
Choosing the right diabetic sock can be problematic, not only due to the lack of reimbursement, but also because there is no rule about what defines a diabetic sock. "A diabetic sock should be seamless, nonbinding at the top, and fit comfortably," Lanier says. "But anyone can put a label on any sock and call it a diabetic sock; there are no controls or penalties. It's a case of buyer beware, so it's always best for those with diabetes to trust the expert who fits their footwear."
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.