Foot Orthotics

There are basically two types of orthotics that a podiatrist will prescribe, functional and accommodative.

The Accommodative Orthotic:

The purpose is to cushion and relieve pressure. Often prescribed for the diabetic foot. The diabetic foot is prone to ulcerations from pressure points and calluses. They are also used to relieve foot pain coming from a multitude of causes, heel pain, plantar fasciitis, metatarsal pain in the ball of the foot, etc. Since they are made from a mold of your foot they can be made to control foot functions also. Take for example: a person walks on the inside of their foot (pronates), the orthotic can be made to adjust the heel strike allowing for a better weight distribution. The accommodative orthotic is also designed to absorb shock. This helps with pain reduction in the foot, ankles, knees and back. These custom orthotics tend to be softer and thicker since they are made to absorb shock. They are often made of foams and rubber materials. Since they tend to be thicker, roomy shoes must be worn, such as sneakers. Many times a Therapeutic Shoe is advised because they are wider and deeper just for this purpose. The last thing you need is a diabetic rubbing his/her toe against the shoe, forming a blister. The accommodative insert is usually full length and is meant to replace the original shoe insert.

 

The Functional Foot Orthotic:

This custom orthotic is used to alter the gate of an individual by adjusting the way the foot hits and rolls across the ground. In doing this a person’s walking gait is altered. The functional orthotic is made to apply arch support for flat footed and high arched feet. They are made to correct over pronation and over supination. They are made to relieve pain in areas such as the heel, the arch, the front foot pad, toes, ankles, knees back etc. and specific problems, hammer toe, curly toe, Morton’s toe, plantar fasciitis, etc. Functional Orthotics tend to be made of more rigid materials (thermoplastics, polypropylene, composite fiber) and are typically thinner. They can be rigid, semi rigid depending on their purpose, such as walking or running. The functional orthotic will likely take more time to feel comfortable and usually require a break in period. Take for example a person has been flat footed their whole life and now arch support is applied, it will most likely hurt at first.

A store bought insert can be purchased for as little as $20.00 where as a custom insert can cost upwards of $300.00. Typically a manufactured charges $85.00 to the doctor and they mark it up to the patient. Most doctors say they have great success rates with patients. How are they made? They are made from a mold of your feet, newer methods include laser imaging of the mold, with a C&C machine carving out the shoe insert to an exact copy of your foot. This is all overseen by a Licensed Pedorthist, a person who is trained at making Orthotics. The Pedorthist will make sure that the insert lies in a way that will change the walking gait.

Why are inserts becoming so popular?

If you talk to someone over 50 they probably played in a sport and did not have any foot padding less than a shoe insert. I recently talked to someone who is 57 and he played basketball through college. When asked about shoe inserts he reported, “When I played in the 60’s and 70’s we had two choices, “Converse white or black, high top or low top.” I have always had foot pain, I wish they had some kind of insert to help.” So you have a twofold buying spree, baby boomers who want to remain active are feeling the pain and parents who see there are ways to correct their children’s feet at an early age. Many people are also taking their health into their own hands because of the rising cost health insurance. One person stated, “I went to the doctor and received a $350.00 shoe insert which my health insurance didn’t cover. I loved the way they worked but was reluctant to buy another pair because of the cost. Then I found out I could order them online and save $200.00. The only knowledge I needed was to explain the purpose of what I wanted. Inserts for walking with flat feet, which they already knew from the imprint of my foot mold.”

VENOUS/LEG ULCERS

Approximately 80% of leg ulcers are venous ulcers. Venous are usually located above the ankle and below the knee. The appearance is dark red with granular composition and dead tissue is common. Venous Ulcers can be big or small, wet or dry, painful or not painful, odorous or not odorous. Leg veins includes many valves that prevent blood from flowing backwards towards the foot as it is being pumped upward towards the heart. This is called “Venous Reflux” When a person is standing the pressure of the blood in the legs (Venous Pressure) equals the weight of the blood column between the foot and the right atrium. This pressure should be in the 80-100 mmHG range. When a person is walking the foot and calf muscles increase the flow of blood upwards. When the valves in the veins are damaged the blood is oscillating/slushing around instead of being pumped upwards. Picture some of the blood falling downward towards the foot, when all should be going upward towards the heart. The added pressure from the blood falling backwards eventually elongates the veins. The blood is not oxygenated as it should be. The skin will eventually break down allowing bacteria to infect areas below the skin. When an ulcer appears many will apply creams and ointments hoping to heal the area but the real cause comes from underneath, lacking blood supply.

 

Other Factors that can contribute or cause “Leg Ulcers”

  • Diabetes
  • Smoking
  • Kidney Failure
  • Poor circulation, often caused by arteriosclerosis
  • Specific Medications
  • Pressure caused lying in one position – Wheelchair or bedridden
  • Prone because of Genetics
  • Sickle Cell Anemia
  • High Cholesterol
  • Heart Disease
  • High Blood Pressure
  • Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
  • Inflammatory diseases including vasculitis, lupus, scleroderma or other rheumatological conditions

Treatment: Healing rates of up to 70% at 12 weeks can be obtained and when combined with a program to prevent ulcer recurrence can dramatically improve patient outcome. Effective symptom control either with dressings or analgesia can improve quality of life and patient tolerance of compression therapy. The higher the level of compression the patient can tolerate the lower the recurrence rate. Compression Stockings are the mainstay of venous ulcer management. Gradual compression, with greatest pressure (about 40 mm Hg) at the ankle, tapering off to lower pressure (about 18 mm Hg) below the knee. Various compression bandage systems and stockings can be used. If numbness, pain, tingling occur seek medical advice.

Runners are Prone to Plantar Fasciitis and Blood Clots

As we get older we are prone to aches pain and injuries. Older for runners could be as early as 40 years old or sooner depending on how hard you run. Below we have good information on how to prevent and/or treat blood clots and plantar fasciitis. Two major factors that can affect a runner at any age.

Article Cause and Effect of Plantar Fasciitis

There are over two million cases of plantar fasciitis treated in America every year. It is one of the most commonly treated symptoms addressed by a podiatrist and is slightly more prevalent in women than men. Most cases are reported from people between the age of 40 and 70. The planta fascia runs from the heel bone to the toes. This is a long ligament and is very strong as it supports the arch and springs the energy created by walking/running from the heel to the toes. Just like a carbon fishing rod it is very strong and will flex from up and down but stretch it length wise and the fibers will tear. When this happens pain and inflammation are felt, usually around the heel and arch area at the bottom of the foot.

 

Symptoms of Plantar Fasciitis:

  • Pain in the morning on the bottom of the foot, near the heel, that will subside after a brief period of walking.
  • Typically the pain develops gradually, but after several weeks, the pain escalates and doesn’t diminish. Most often described as a sharp pain in the heel or arch although some people describe it as a dull pain.
  • Tenderness is felt when pressure is applied to the heel pad or the arch. Most often there is no swelling or bruising.
  • The pain is greater after exercising than during the exercise.

Read the rest of the article here:  https://www.mondaymedical.com/blog/cause-and-effect-of-plantar-fasciitis/

Plantar fasciitis In Runners By Patricia Pande, MClScPT, CSCS, CPed

The literature cites a number of causes of plantar fasciitis in runners, including long plantar arch alterations, rearfoot pronation, and magnitude of plantar loads. Plantar fasciitis in runners can also be associated with fasciosis.

Muscle atrophy. Several studies suggest an association between plantar fasciitis and muscle atrophy, particularly of the intrinsic foot muscles. Chang et al found that forefoot muscle volume, assessed using magnetic resonance imaging (MRI), was significantly lower in the affected limbs of patients with unilateral plantar fasciitis than in the healthy limbs.16 In another MRI study, Cheung et al found that rearfoot intrinsic muscle volume was lower in experienced runners with chronic plantar fasciitis than in healthy runners, while forefoot muscle volume was similar between groups. Kibler et al also found that runners with plantar fasciitis had significantly worse ankle plantar flexion strength than healthy runners; this weakness could be related to muscle atrophy or to reflex inhibition with increased load on the plantar fascia.

Although these studies do not confirm muscle atrophy as the cause of plantar fasciitis or that strengthening exercises will relieve symptoms, research does suggest that intrinsic muscle activation from forefoot contact to toe off may reinforce ligamentous structures. Further studies are needed to evaluate the effectiveness of exercises to improve muscle activity and orthotic interventions to support the foot for generation of muscle power.

Plantar loads. Recently, Ribeiro et al found lower loading rates in runners with acute plantar fasciitis (pain for more than four months) than in chronic cases (diagnosed a mean of 1.5 years earlier, presenting with fascial abnormalities but no acute inflammation or pain). However, loading rates in all runners with plantar fasciitis were higher than in healthy runners. The authors hypothesized that the lower loading rates in the symptomatic runners than in the chronic group were due to a pain-avoidance response, and that higher loading rates in the chronic plantar fasciitis group were due to the loss of a protective mechanism against pain in the degenerated tissue, as well as a reduced ability to attenuate shock.

Similarly, Pohl et al found that maximum instantaneous load rate was significantly higher in female runners with a history of plantar fasciitis than in control runners. Changes in tissue stiffness and fat pad atrophy may contribute to higher loads and may further complicate treatment by reducing lubrication and shock absorption Furthermore, loads related to the running surface may also contribute to plantar fasciitis.

Running pace and volume. There is conflicting information about the impact of running pace and volume on the risk of injuries, including plantar fasciitis. A study by Knobloch et al found that marathon runners have a lower risk of plantar fasciitis than runners of shorter distances, which suggests faster pace may be a risk factor and higher volume may be protective. However, other prospective studies have linked lower extremity injuries, including plantar fasciitis, to higher running volume. Whether due to pace or volume, the resulting stress may overload tissue.

Structural variables. Thickening of the plantar fascia has been associated with plantar fasciitis, and may arise from a combination of bending, compression, and shearing forces from muscle weakness or from degenerative thickening. Wearing et al found that thicker fascial structures were associated with a lower arch in patients with plantar fasciitis but not in healthy controls; it is still not clear whether this finding suggests that having a low arch causes the disability or results from gait adaptation.

Root’s theory that foot type contributes to plantar fasciitis remains controversial. The fact that the spectrum of foot types does not form a bell-shaped curve complicates the argument, as does the prevalence of subject-specific kinematic variations. Additionally, the connection between foot structure and plantar fasciitis is unclear.  Some researchers found a lower arch index with increased range of dorsiflexion in female runners with plantar fasciitis than in their healthy counterparts, but others suggest this relationship is not easily defined due to the foot’s adaptability to prevent injury. Nielsen et al found no increased risk of running-related injury in novice runners with moderately pronated feet. Additional well-controlled randomized prospective studies of homogenous running groups are critical to furthering our understanding of these factors.

Biomechanics. Kinematics and kinetics during walking in individuals with plantar fasciitis differ from healthy volunteers, and clinicians should consider the possibility that these or related differences may extend to running. The coupling mechanisms between the hindfoot, tibia, and arch during running are well-documented, but the relationship between segments of the foot is not clearly understood. Still, it is important for clinicians to be aware that treatments or interventions focused on a single aspect of the foot can also affect other aspects of the kinetic chain.

Clinical applications

The American Physical Therapy Association’s clinical practice guidelines for treatment of plantar fasciitis combine stretching, activity limitation, iontophoresis, night splints, and prefabricated or custom inserts. The American College of Foot and Ankle Surgeons recommends initial treatment with ice, stretching, ergonomics, off-the-shelf arch supports, nonsteroidal anti-inflammatory drugs, and corticosteroid injections, with progression to custom foot orthoses and physical therapy if little or no improvement after six months.

Inserts must be able to absorb ground reaction forces, particularly in runners. Prefabricated and customized EVA (ethylene vinyl acetate) orthotic devices were associated with similar levels of pain relief in patients with noncomplicated plantar fasciitis after eight weeks. Interestingly, another study found reduction of plantar pressures at the heel associated with two types of EVA sham orthoses (flat and contoured) were similar to those associated with custom foot orthoses—a finding the authors attributed to the attenuating and pressure-redistributing properties of EVA. The findings of Pfefffer et al also support the use of less rigid orthotic devices in this patient population; felt and silicone or rubber were more likely to be associated with symptom relief than more rigid devices.

The use of orthoses to control or supplement motions has been the traditional mainstay of treating runners and nonrunners with plantar fasciitis. Research has demonstrated that orthotic devices are associated with kinetic and kinematic effects in healthy runners. One study showed a decrease in forefoot to rearfoot coupling angles with the use of foot orthoses, and another showed a change in rearfoot eversion angle and eversion velocity in female distance runners.Mündermann et al found that molded foot orthoses and molded and posted foot orthoses both reduced vertical loading rates and ankle inversion moments in healthy runners. However, researchers have not yet determined whether similar biomechanical effects can be expected in runners with plantar fasciitis, or to what extent those changes might affect patient symptoms.

Recent studies in which workload or strain causes pain in connective and muscular tissue support interventions to reduce kinetic effects on such tissue. Nigg’s Preferred Movement Pathway theory stresses force reduction and advocates self-selection based on comfort; however, this and other similar theories need vigorous scientific inquiry.

Conclusions and recommendations

Clinicians should advocate for the cost-effective, judicious use of foot orthoses for runners with plantar fasciitis, in accordance with the present body of knowledge, which suggests such devices should:

  • be comfortable
  • provide shock absorption
  • not increase torque at other lower extremity joints
  • fit well in the shoe without hindering use of the toe flexors and intrinsic muscles
  • be semicustomizable for patient comfort; and
  • address any compensatory adaptations.

Future studies should continue to assess the kinematic causes and effects of plantar fasciitis in the running population, along with factors that predict positive response to treatment.

Patricia Pande, MClScPT, CSCS, CPed, is a physical therapist, pedorthist, strength and conditioning specialist, and founder of FootCentric.  Read the whole article here: http://lermagazine.com/article/plantar-fasciitis-clinical-considerations-in-runners

Let’s Talk about Blood Clots

Below you will read how runners, especially those who are traveling to an event are prone to blood clots.

By Amanda Zaleski, MSc; and Beth Taylor, PhD                                                          There are several published case studies of athletes who have experienced deep vein thrombosis (DVT), pulmonary embolism (PE), or both following athletic competition or physical activity. Tao and Davenport, for example, reported on a female triathlete who was diagnosed with DVT and PE after competing in a half Ironman triathlon. After competing in the triathlon she traveled five hours by car the following morning. She subsequently experienced symptoms of left lower extremity swelling and pain, accompanied thereafter by dyspnea and lightheadedness on exertion. There are also several published cases of DVT and PE occurring after marathon running. Mackie and Webster described two male marathon runners who developed DVT and PE approximately one week after running a marathon; in both cases, DVT was misdiagnosed initially (either as a muscle strain or Baker cyst).

The myriad benefits obtained from regular sustained exercise are undeniable. However, such case reports indicate that, in at least a small fraction of otherwise healthy avid exercisers, there may be an augmented risk of DVT following endurance exercise.

Car, bus, train, or air travel by an athlete who has recently engaged in endurance exercise may shift the hemostatic balance, increasing the risk of venous complication.

Research has established that strenuous endurance exercise, such as marathon running, activates the coagulatory system (clot formation) by immediately increasing markers of coagulation such as thrombin-antithrombin complex (TAT), prothrombin fragment 1 and 2, and D-dimer. In response, the fibrinolytic (clot breakdown) system (eg, tissue plasminogen activator [t-PA] antigen and activity) activate in coordination with the coagulatory system following exercise, such that changes in coagulation are paralleled by an activation of fibrinolysis to preserve hemostatic balance. In other words, in healthy athletes, postexercise clot formation is approximately equal to clot breakdown. This phenomenon, by which both markers of coagulation and fibrinolysis are increased in the bloodstream, is termed “hemostatic activation.”

While exercise-induced hemostatic activation is not detrimental for most individuals, factors incident to marathon running may disproportionately activate the coagulatory system, increasing the risk for venous thromboembolism (VTE) and contributing to reports of DVT, PE, or both—all of which have been reported after prolonged strenuous endurance events in otherwise healthy athletes. Given that marathon participation has increased 40% over the past decade, with 550,637 finishers in 2014, this has implications for the increasing numbers of athletes who compete in endurance events.

Risk factors for VTE

Benefits of regular sustained aerobic exercise are indisputable. Paradoxically, endurance training and competition expose athletes to factors that may increase their risk for VTE. Virchow’s triad is composed of three factors—venous stasis, endothelial cell injury, and hypercoagulability—that augment blood clot risk. Endurance athletes are exposed to a combination of these factors; they experience repetitive microtrauma, endothelial damage, and dehydration during competition, followed by periods of inactivity, immobility, and stasis while traveling to and from athletic events or recovering from the event.

The superimposition of car, bus, train, or air travel on an athlete who has recently engaged in endurance exercise, for example, may shift the hemostatic balance in athletes postcompetition, thereby increasing the risk of VTE in certain individuals. The MEGA trial reported that any travel by car, bus, train, or plane longer than four hours increases risk of DVT twofold, and, indeed, there are several published case reports and substantial anecdotal evidence on the Internet detailing athletic individuals who have experienced VTE after the combination of competition and travel. To the best of our knowledge, however, we are the first group to examine the effect of prolonged exercise and air travel on thrombotic risk factors.

We examined 41 time-qualified runners participating in the 2010 Boston Marathon who either flew more than four hours (travel group) or drove less than two hours (control group) to the race. We obtained blood samples to assess coagulation (TAT, D-dimer, P-selectin, and microparticles) and fibrinolysis (t-PA) the day before the marathon, immediately after the event, and the day after the marathon following the flight home.

Baseline TAT, t-PA, D-dimer, P-selectin, and microparticle levels were not different between travelers and controls. Immediately following the marathon, all markers of coagulation and fibrinolysis were significantly higher than baseline, indicating that hemostatic activation had occurred. However, among individuals who flew more than four hours, the increase in coagulation factor TAT from baseline to after the race in the travel group was nearly double the increase seen in the controls (5 ± 4 to 12.9 ± 15.6 mg/L vs 4 ± 1.2 to 6.1 ± 1.2 mg/L; p = .02).

Similarly, exercise-induced increases in D-dimer, a clinical biomarker of DVT, were also significantly greater immediately after the marathon in the travel group of athletes than in controls (142 ± 83 to 387 ± 196 ng/mL vs 85 ± 26 to 233 ± 95 ng/mL; p = .02). In fact, six of the runners in the travel group (vs no local controls) had D-dimer values that exceeded the clinical threshold for preliminary diagnosis of DVT (> 500 ng/mL).

Most notable, however, was that marathon-induced increases in the fibrinolytic factor t-PA did not differ between control and travelers, indicating a hemostatic shift toward a more procoagulatory state in athletes who flew to Boston and ran the marathon. Moreover, the increase in the TAT response was greatest in the oldest runners (p < .01), and older subjects also had greater P-selectin values (a marker of inflammation) than younger subjects, indicating that age appears to moderate the coagulatory response to endurance exercise in combination with cross-country air travel.

These data provided the first evidence that the combination of marathon running and air travel disrupts the hemostatic balance and favors a coagulatory response, which appears to be exacerbated with increasing age. Other factors specific to endurance athletes that could additionally exacerbate VTE risk include oral contraceptive use, presence/family history of a clotting disorder, sex, injury, bradycardia, atrial fibrillation, or previous history of VTE.

Compression socks during a marathon

Researchers obtained venous blood samples from marathon runners the day before the event, immediately after the event, and 24 hours later.

The Evidence-Based Clinical Practice Guidelines from the American College of Chest Physicians suggests the use of properly fitted compression socks to mitigate blood clot risk in high-risk populations. The use of compression socks, or mechanical prophylaxis, to maintain hemostatic balance has been studied with participants at rest and has been shown to be effective in reducing VTE in some clinical populations (eg, patients with a previous history of DVT or recent surgery),26 but contraindicated in others (eg, patients with arterial insufficiency).27

Awareness of VTE in endurance athletes has grown significantly in the past few years, and, consequently, running associations and events are increasingly urging athletes to wear compression socks during flight and competition to diminish DVT risk.2 Although these informal (albeit common-sense) recommendations are grounded in evidence derived from clinical populations, the efficacy of compression socks to attenuate marathon-induced hemostatic activation has been tested only recently.

Our group recently examined the safety and efficacy of compression socks worn during a marathon on hemostatic activation immediately following the 2013 Hartford Marathon in Connecticut. We randomly assigned runners (n = 20) to a compression sock group or a control group at the initial screening. The runners reported to the marathon exposition the day before the event. We obtained venous blood to measure coagulatory factors (TAT, D-dimer), a fibrinolytic factor (t-PA), and hematocrit (Figure 1). We also obtained blood immediately after completion of the marathon in the main medical tent approximately 100 m from the finish line and within 24 hours of the race finish.

Runners in the sock group (n = 10) were compression sock naïve; they received their socks (19-25 mm Hg at the ankle) at the marathon expo and were instructed to wear them to the race start and throughout the duration of the marathon . Runners in the control group (n = 10) were instructed to wear their typical athletic socks, but refrain from compression sock use during training, the marathon, and on the day after the marathon.

Plasma concentrations of D-dimer, TAT, and t-PA did not differ between groups at baseline. Consistent with findings from previous studies, we observed parallel increases in markers of coagulation and fibrinolysis immediately following strenuous exercise, specifically, exercise-induced increases in D-dimer, TAT, and t-PA. Of note, these parallel increases of coagulation and fibrinolysis did not differ between recreational Hartford marathoners and elite Boston marathoners who trained more and performed faster, reinforcing the negligible impact of differences in training history and race time on exercise-induced hemostatic activation. Average t-PA across all three time points was lower in the compression sock group than the control group (p = .04).  Similarly, average TAT across all three time points was lower in compression sock group compared with the control group, with a trend toward statistical significance (p = .07); however, plasma D-dimer did not differ between the groups across all three time points (all p > .2).

Because runners were not wearing compression socks at baseline, and there were no differences in hemostatic markers at baseline between groups, the findings related to t-PA and TAT suggest a significant effect of wearing compression socks on immediate and 24-hour post marathon hemostatic markers—specifically that overall hemostatic activation following a marathon was lower with compression socks than with typical athletic socks. Most importantly, compression socks did not appear to adversely influence markers of hemostasis during a marathon and thus they appear safe for overall use in runners.

Given that prolonged travel (greater than four hours) activates the coagulatory system, and many marathoners travel long distances to an event, the use of compression socks as a preventive measure should be considered, assuming they are tolerable and properly fitted.However, the efficacy of compression socks still remains to be tested in combination with travel, as the athletes in this study traveled local, short distances to and from the marathon.

We caution that there is a need for larger studies, as well as studies of hemostatic alterations following a marathon in combination with other risk factors (eg, oral contraceptive use, prolonged travel, and genetic predisposition for VTE). We maintain a DVT registry of athletes who have had a history of VTE after competition to better identify individual risk factors that may contribute to this phenomenon.

Performance, recovery and VTE risk

Runners in the sock group were given compression socks and instructed to wear them throughout the duration of the marathon.

Athletes wear compression socks for a variety of reasons beyond reduction of blood clot risk, and thus their influence on noncoagulatory outcomes deserves further mention. Compression socks are increasingly popular with athletes due to perceived enhancement of exercise performance and recovery. To date, the research regarding the efficacy of compression socks to enhance performance, aid in recovery, or both has been equivocal. This is partially due to the difficulty of conducting placebo-controlled trials and the use of subjective qualitative reporting as primary outcome measures. Studies that have measured objective physiological markers of muscle damage (ie, creatine kinase, a marker of muscle damage, and lactate, a metabolic byproduct) have been limited and inconclusive, perhaps because the studies are vastly heterogeneous in terms of a) the type of compression garment used (eg, whole body, sleeves, knee-high compression) and b) the modality of exercise being tested (eg, resistance or aerobic).

Hypothetical mechanisms underlying performance and recovery benefits of compression socks differ depending on their timing of use (ie, during or after exercise), but are similar in that all theorize that the mechanism of action targets components of Virchow’s triad.

Compression socks worn during exercise are thought to reduce microtrauma and enhance venous return by applying an external circumferential pressure gradient that reduces swelling space, improves blood flow, and in turn improves performance.

Compression socks worn during recovery are thought to accelerate metabolic waste clearance, attenuate edema and swelling, and improve oxygen delivery to muscle.

A recent meta-analysis incorporating 12 studies found a favorable effect of compression socks for enhancing recovery from muscle damage, based on creatine kinase and reduced severity of delayed onset muscle soreness. However, of the studies included in the meta-analysis, not one sought to examine the influence of compression socks in response to a sustained aerobic event (eg, marathon or triathlon), making the interpretation of the findings difficult to apply to endurance athletes.

A separate systematic review concluded the available literature does not fully support or refute the use of compression socks for improving performance or recovery. For example, three studies found no difference in running performance while wearing compression socks,while one demonstrated improvements in running speed and performance.

To the best of the authors’ knowledge, there are only two randomized controlled trials that examine performance and recovery in marathon runners.4 One found compression socks worn for 48 hours after a marathon were associated with a 5.9% improvement in functional recovery (ie, time to exhaustion on a treadmill two weeks after a marathon). The other reported that compression socks worn during a marathon did not result in better race performance or lower markers of exercise-induced muscle damage, as assessed via serum myoglobin and creatine kinase concentrations before and after the event.

Conclusion

In conclusion, with the exception of one study, the data do not appear to reveal any adverse consequences of compression socks, and in some cases suggest socks may result in psychological advantages that translate into performance gains. Assuming that socks are properly sized, marathoners can consider compression socks a sports garment that has preliminary evidence to support its use for preserving hemostatic balance during exercise and hastening recovery from exercise, but not for enhancing performance.

Runners should be aware of manufacturer specifications and proper sizing techniques. Although a minimum threshold of pressure applied at the ankle is not yet clearly defined in the literature, compression socks should be graduated (ie, lower pressure at the ankle gradually increasing to higher pressure at the knee). Lastly, socks should be sized according to calf circumference, not shoe size, to avoid excessive pressure at the calf and to potentially increase the risk-benefit ratio. By following these specifications, athletes may be reassured that compression socks likely do not harm athletic performance and recovery, which is critically important given the time and effort associated with training and performance.

Amanda L. Zaleski, MS, is an exercise physiologist in the Department of Preventive Cardiology in the Henry Low Heart Center at Hartford Hospital in Connecticut and a doctoral student in the Department of Kinesiology at the University of Connecticut in Storrs. Beth A. Taylor, PhD, is the director of exercise physiology research in the Department of Preventive Cardiology in the Henry Low Heart Center at Hartford Hospital and an associate professor in the Department of Kinesiology at the University of Connecticut. Her interest in blood clot risk arose from the experience of her older sister, who experienced a DVT and PE after running a half marathon and flying home to Seattle, WA, from Hartford, CT.

Disclosure: Amanda Zaleski has received funding from the CT Space Grant Consortium Graduate Fellowship, Hartford Hospital, and the American College of Sports Medicine NASA Space Physiology Grants for her ongoing research to examine risk factors associated with VTE in active individuals. In addition, she discloses product sponsorship from 2XU Compression Socks.

More Reading On Compression Socks And Do They Really Work? By Kelly Dunleavy O’Mara

“There is no doubt that many runners trust compression garments,” said Ajmol Ali, a PhD in the Sports and Exercise Science Department of Massey University. Ali has conducted a number of studies on the garments with mixed results.

For decades, medical-grade graduated compression socks have been used to combat deep vein thrombosis, or the formation of blood clots. By increasing the circulation and blood flow, research has found the socks to be effective for bed-ridden and inactive patients.

RELATED: Did Meb’s socks help him PR?

Research on the effectiveness of compression garments in athletic pursuits, though, has been hit or miss.

“Very little evidence exists (ie. two to three studies out of 15-plus) from a sport and exercise perspective that compression garments improve performance when worn during exercise,” said Rob Duffield, a professor at the School of Movement Studies at Charles Sturt University.

One study found that when 21 male runners did two step tests – one with compression socks and one without – they were able to go slightly longer wearing the compressions before exhaustion. There have also been some small increases seen in anaerobic threshold, particularly in cycling, and in jumping performance. The theory is that the tights prevent oscillation of the muscles sideways and promote muscle efficiency.

But, Ali noted that many of the studies that have found increases in performance did not use a placebo or control, making it nearly impossible to tell if the increases were really from the compression or from the athlete’s perception of the compression.

And, countless other studies have found no differences in running times, VO2 max, oxygen consumption or heart rates between athletes wearing the socks and those who weren’t.

“Most of the research shows that there are no performance benefits,” said sports physiology professor Elmarie Terblanche, from Stellenbosch University in South Africa.

Terblanche, however, said that most studies are done in the lab. She recently conducted the first real-world study, following athletes running the Two Oceans ultra-race in South Africa. What she found was that the athletes who raced in compression socks, versus those in regular knee-high socks or those without either, had significantly less muscle damage and were able to recover more quickly, with some even ready to train again three days later. Those wearing the socks also ran on average 12 minutes faster.

“Considering that they ran one of the most difficult ultras in South Africa, this was significant,” she said.

Terblanche recommends that athletes wear the socks for long sessions and for the 24 hours following. While she acknowledges her study can’t be considered conclusive, because there’s always a chance for a placebo effect in the real world scenario, the recovery findings are in line with other research.

Multiple studies, including one done by Ali, have found decreases in muscle soreness and perceived fatigue. Some possible increases in blood flow and lymph removal during the recovery period have also been found – though other studies found that wearing the socks after workouts had no greater recovery effect than taking an ice bath.

It was the recovery benefits that won over Chris Solinksy, the former American 10,000m record-holder, who wore compression socks when he became the first American to break 27:00 two seasons ago.

“I found I was able to come off the workouts much, much quicker,” said Solinksy. He wears the socks during hard workouts and races, and finds he recovers faster. He also originally thought he raced faster in them, but that proved not to necessarily be true.

Solinksy isn’t too worried, though, about how exactly it works or what the science says. He knows he likes it.

“I’m kind of a simplistic barebones type of runner,” said Solinksy.

RELATED: What’s up with Solinsky’s socks?

For athletes to get the full benefit, the compression needs to be graduated (tighter at the ankle and decreasing to the hip), fit the individual, and have 22 – 32 mmHg of pressure. There haven’t been any differences found in brands. And, Terblanche said she hopes to study next how compression garments hold up with use.

To a degree, if there’s no harm done – as long as it’s not too tight or irritating or causes blisters – then it hardly matters whether the benefits are in the athlete’s head or not.

“If athletes like wearing them, and feel that the garments are helping their performance and/or recovery (whether it is a true effect or simply a placebo effect), then I don’t see any harm in recommending them,” said Ali.

About The Author:

Kelly Dunleavy O’Mara is a journalist/reporter and former professional triathlete. She lives in the San Francisco Bay Area and writes for a number of magazines, newspapers, and websites. You can read more about her at www.sunnyrunning.com.

I think it is safe to say that if you are a serious runner who is over 40, custom Orthotics and Compression Stockings are a good investment. Both of them won’t cost as much as a good Driver for Golf. Personally I can state that I wear custom orthotics and run, mostly on a treadmill, I do have less foot and knee pain. I don’t travel to compete but I will start wearing compression socks on any long drive or flight. I feel that this will be a safe practice to start. After reading these articles, how do you feel about foot orthotics and compression stockings?

Vericose-Ropey-Spider, Veins 

“Varicose” is derived from the Latin word “Varix”, meaning “Twisted”.

Varicose veins are caused by gravity and faulty valves within the vein. When blood flows into the feet the heart has to pump it uphill, against gravity. Within the veins are valves they act as  backflow preventers, in theory the same as a basement sump pump. The sump pump pushes the water upward and past the backflow preventer valve, so when the pump shuts down no water can flow backwards into the basement. The heart never shuts down unless were dead, so imagine the heart pumping blood upward in the leg and a valve is stuck open, some of the blood is always leaking back towards the foot and as a person gets older the heart (pump) and the valves gets weaker. The blood begins to pool in the veins, the veins bulge from the added pressure and transform into varicose veins.

There are other reasons valves (there are many valves in a vein) will becomes faulty, Added pressure, this is why pregnant women, people who are on their feet constantly are prone to them and let’s not forget genetics, you just might be cursed.

The good news is that the varicose veins you see are the outer/superficial veins in the leg. They only carry 10% of the blood. This is why surgery is not always recommended. Many times there is not a health threat but more of a vanity issue. In no shape or form can they be called appealing. The bad news is that 50% of people over the age of 50 have them. Women are 3 – 4 times more likely to get them than men.

The big worry is, if you have varicose veins on the outside/superficial part of the leg, do you have them in what is called the “Deep Veins” that carry 90% of the blood? Deep Vein Thrombosis is when a Deep Vein clots.

Your Doctor will inform you if surgery is needed, sometimes even superficial veins can be painful. There are many different procedures available today.

Many times conservative treatment is recommended, which usually consists of:

  • Lifestyle Changes that is pretty much standard for any illness – Lose weight if you are overweight and exercise
  • Avoid standing to long
  • Avoid sitting to long
  • Avoid crossing your legs
  • Elevate your legs above your heart when sleeping or at your desk
  • Eliminate salty foods
  • Eat more fiber
  • Drink lots of water, this will help prevent blood clots
  • Wear compression stockings, they will relieve swelling and help the blood flow upward towards the heart. This is accomplished by gradient pressure.

 

 

 

Congestive Heart Failure and Compression Stockings.

The heart is a pump that moves blood throughout our bodies. This is called circulation. When the heart becomes weak or damaged it will circulate less blood than needed. When this happens fluid will accumulate in the body, we will talk about the legs in this article. Why do people get Congestive Heart Failure? Many times it’s like a car engine that has 200,000 miles on it. It is just tuckered out and needs to be pampered. If your legs are swollen when you go to the doctor, one of the things they often prescribe are compression stockings. Most likely knee high, these are made for both men and women. For women there are many fashionable sheer, thigh and full length panty hose styles that are also available. It’s important to take measurements in the morning for the size that you need, this is because the legs will be closest to their normal size. Our site shows where and how to take measurements for specific types of compression stockings. How important are compression stockings? Below are real life answers from people that wear compression stockings. Caring.com has a lady whose legs swelled so large that they developed blisters. Here is the story.

What can be done for swollen legs due to CHF?  

11 answers | Last updated: Nov 25, 2015

A fellow caregiver asked… Mom has had congestive heart failure (CHF) for many years. For the past month, her legs are so swollen she cannot bend her knees and now has small blisters forming at the ankles. She has been admitted to hospital many times for an IV diuretic. This usually takes care of the ankle swelling, but now that the whole leg is swollen it doesn’t do anything for the legs. It does, however, help her breathing which is probably why she is getting the IV in the first place. What can be done for the blisters and is this “to be expected” at this stage? Mom is 87.

EXPERT ANSWERS:

17044-latrella strimike

Carolyn Strimike, N.P. and Margie Latrella, N.P. are cardiac nurse practitioners specializing in the prevention of heart disease and stroke. They have over 40 years of nursing experience in Cardiology between them. The main goal of their work is to counsel, motivate and empower women to adopt healthy lifestyle choices.

Leg swelling due to congestive heart failure is very common. The swelling is due to excess fluid that backs up because the heart muscle is weak and cannot pump well. Diuretics are the usual treatment because they help the body get rid of excess fluid. There are numerous diuretics that can be used. If one diuretic is not working they can be used in combination along with other therapies. We would recommend that you consult with a wound care specialist to treat the blisters. Elevating your mom’s legs, limiting salt and fluid intake and wearing support stockings may help relieve the leg swelling which may in turn help the blisters heal.

COMMUNITY ANSWERS:

Kmfk15 answered…

I agree with the above answer, however salt doesn’t only mean table salt. All prepared foods are very high in sodium. Stay away from them. As far as the water blisters go I would see a dr. and he will recommend unna booths, elevation and home nurses for caring for the unna boots Good luck.

Mrs dunn answered…

Your mother’s doctor needs to also review the medications she is taking. The blistering can be a side effect of some common medications used for heart failure. In addition is is not uncomon to find that treating common skin fungus, in many cases with over-the-counter medications can control or prevent such blistering. It will require especial care to make sure that bedding, socks or stockings, and towels are kept scrupulously clean and changed daily.

Magedzaki answered…

Such cases are considered advanced stage of HF, and most probably those pt’s are already on combination diuretics, a matter which must be managed very cautiously, because of diuretic’s side effects(hypotension and electrolyte imbalance) so edema of lower limbs in such cases is helpful for the heart, as it might be considered a deloading factor for the already overburdened heart. The right thing is to consult the doctor about the right management of those extremely fragile patients , and the correct way of managing locally those blisters. dr. maged zaki

Deborah11155 answered…

Need to take care not to use Unna Boots without an ABI (measurement)obtained from MD or WOCN. This treatment should never be used haphazzardly. Also, compression should be used only with MD recommendation, especially with patient in active CHF. The edema (swelling) could travel upwards with the compression, causing increased cardio-pulmonary complications. Deborah T., RN, HCS-C, COS-D, SCHN.

Malind in black 01.jpg Msmalinda1947 answered…

I have CHF, and have blisters forming on both of my legs. Been to the ER room several times, as they got infected. What they did and told me to do, wash the infected areas several times a day, add a antibacteral suave on the wounds, cover in patches, cover that in gauze and then they gave me 2 very strong stretch gauze to wrap my legs very tightly to make the swelling go down. Did that for weeks. Let me tell you, this is NO a easy thing to control. I have scars on several parts of both legs, around the ankles mostly the size of your fists, and yet, little bumps form, and they start a new blister. It took me 2 years to heal from 4 blisters and now, I see another opened up, so back to the treatment, again. Best thing to do, is to keep legs elevated as much as possible, do walking instead of sitting around, and use those compression socks, day and night. It is no easy way, and you probably will never get free of blisters, they seem to make their way back, eventually.

Skee answered…

I have “Lymph Edema” and went through the swollen leg trauma where my legs actually swelled so bad that they would erupt and leak fluid from them.Aside from wearing the tight wraps applied by a Therapist and the method he used in therapy that he performed,elevating the legs did the trick.I now have legs that are normal size as long as I continue to wear the “Compreson Stockings”.

Dakamom answered…

My Mom had CHF for many years. She had the type of swelling Skee described above. The compression stockings are critical, though I am guessing they are already part of your Mom’s regimen. I would absolutely be in touch with her doctor about the level of swelling you are seeing. CHF is progressive, so it may be normal, but it needs to be managed by her doctor.

A fellow caregiver answered…

AS a home visiting nurse I have treated many pts with this problem. It is life long. Therapy involves diuretics, compression, moderate exercise (walking), and leg elevation.

Loulabelle answered…

Could it possibly be Bullous Pemphigoid? I’m a carer and I think one of my clients has been suffering with this for a while. Its an auto immune disease that effects over 70’s and can be brought on through the use of diuretics ( this is when my clients problem first started). The first symptoms may be small patches of itchy skin/ pink rash, before quite large bulbous blisters develop- blisters can occur on arms, legs, armpits or groin, or just one area such as the lower leg- which is currently where my client is suffering with it. Steroid medication such as Prednisolone and steroid creams are said to help, but it is difficult to get the right balance, and, as the disease can last between 1-5 years, the side effects that the steroids could possibly cause may be an issue. My own personal opinion is all the medication including the diuretics she is taking are likely to cause an autoimmune issue due to all the foreign bodies entering her system teamed with the fact she now eats very little, however the medications are all needed for some other aspect of her health so it is just a catch 22 really…

Okiesmom answered…

I had badly swollen legs with blisters forming and draining. I kept my legs clean and used cotton balls and rubbing alcohol to clean them several times a day. They have healed and I have not had a problem with blisters for at least two years.

Along with elevation of the legs, compression stockings are commonly used by people with Congestive Heart Failure to prevent Edema in the legs (water retention). The legs are prone to blood pooling and blood clotting. Compression stockings apply a gradient pressure, this means firmer pressure at the bottom that gradually decreases as the stocking goes up the leg. This effectively forces the fluids upward towards the heart. Pressure stockings are rated in mmHG, what is important is that you understand that the higher the number the greater the pressure. Example: a 30-40 mmHG stocking is stronger than a 10-20 mmHG stocking.

Most commpression hose wearer’s recommend buying a quality brand of compression stockings. The comfort and durability more than make up for any price savings. If your feet and legs have sores, it is advisable to buy a pair with silver in the compression stockings, yes microfibers of silver are woven throughout the stocking, this provides an antimicrobial feature and should help reduce infections.

When Choosing a Compression Stocking Dr. Ichinose (Director of Vein Services at Oklahoma Heart Institute at Hillcrest Medical Center) Advises:

First, all compression socks are NOT created equal. “The quality of the material, the sizing, the durability and the amount of compression or pressure the garment provides all culminate into the final product,” explains Dr. Ichinose. “Some very economical support hose are not sized by careful measurement of your leg.  They are labeled small, medium and large, however the amount of compression provided is not known.”

Dr. Ichinose advises patients to know two important things before selecting compression socks: the amount of compression and the size needed. Your health care provider will advise the compression level you need, as well as measure your leg to make sure you are fitted in a proper compression sock. However, you can also measure yourself for compression socks. In the morning before swelling occurs, measure the circumference of your ankle (around your ankle), the circumference of your calf and the length of your calf (from the knee to the heel sitting with your legs at a 90 degree angle). Use the sizing guide on the compression sock packaging to find the right fit for you. If you have any questions about the compression level appropriate for you, talk to your health care provider. Compression levels range from mild compression to extra firm compression:

Mild compression 15-20mmHg:  Prevention and relief of minor to moderate varicose veins, relief of tired aching legs, relief of minor swelling of feet and legs.

Moderate compression 20-30mmHg:  Prevention and relief of moderate to severe varicose veins, treatment of moderate to severe lymphatic edema and management of active ulcers or post thrombotic syndrome.

Firm compression 30-40mmgh: Ulcer management, post thrombotic syndrome.

“The amount of compression provided by a pair of socks will vary depending on the size of the leg in relationship to the size of the garment,” shares Dr. Ichinose. “Patients commonly complain that the compression socks cut into their leg.  Usually it is because a large leg was placed in a garment too small for the leg.”

History of Venosan

History of Venosan Stockings Daniel Kuenzli started Venosan in 1989 and has grown the company at an incredible rate. Just like he pushed a Ferrari 428 Challenge to 239.5mph only 3.3 mph off the winner, at the:
2012 FERRARI CHALLENGE TROFEO PIRELLI COPPA SHELL (Event maximum speed)
The original company was started in a small town in Sweden, St. Gallen by Julius Salzmann in 1883. Today that company is called Salzmann AG and Venosan is a subsidiary. Max Kuenzli, Daniel Kuenzli’s father had been working for SALZMANN since 1945. Then in 1954 a tragic accident changed the Fate of Max and Daniel Kuenzli. Walter Salzmann the son on the founder Julies Salzmann was killed in a plane crash while on his way to a business trip. The business went to his brother and two sisters but they were not actively involved in the company. This is when Max Kuenzli took over management. He also became a shareholder along with the brother and sisters of Walter Salzmann. A new company was founded Salzmann AG St. Gallen. In 1971 Max Salzmann buys all the remaining shares from the Salzmann Siblings. I see Daniel Kuenzli as a Donald Trump kind of success story. Did he start from poverty, no his father was successful, but he took a small fortune and turned into a massive fortune. He also had to start from the ground up, no executive job for him, he started by selling compression stockings from one doctor’s office to the next. I believe that this kind of beginning has kept him grounded (except when he is driving his Ferrari) in 1990 he took over full Management from his father Max although Max remained on as President of the Board of Directors until his death in 1994. Under Daniel Kuenzli’s tutelage Salzman AG has expanded too many other Countries and has approximately 500 employees. In 1993 Venosan opened in the Asheboro North Carolina a state that is famous for their textile industries. One of their greatest accomplishments is that their hosiery has compression qualities but is stylish and sheer. Many times undetectable from standard sheer brands. Most other brands sell the same sock for Men and Women where Venosan often has different fabric contents for men’s and women’s even if they sell by the same name. This is because of their extensive testing and long history of making compression stockings. Why look for other stockings they have been doing this since 1883.

Diabetic Shoe Vs Therapeutic Shoe

These Shoes are virtually the same and often called by other names, such as Orthopedic Shoes, Ortho Shoes, Orthotic Shoes, Ultra Depth, Extra Depth, Depth Shoes, Ultra-Wide, Extra Wide, Sugar Shoes, Medical Shoes, Custom Diabetic Shoes, Custom-Molded Shoes and Orthotic Insert Shoes. A Diabetic Shoe can be all of the above but all of the above can’t always be a Diabetic Shoe. Diabetic Shoes have meet certain manufacturing standards.
1. They must not have any seams with stitching inside that can scratch or tear skin.
2. A Larger Toe Box, this prevents injury from friction.
3. The collar around the ankle of the shoe is padded to prevent blisters.
4. The Shoe offers stiffer protection in the front, to prevent stubbing.
5. Soles are made of a non-skid material for better traction.
6. They are fitted with a special diabetic shoe insert, this insert is smooth and soft to prevent injury to the foot.

If I need an Orthotic Shoe for Knee Pain then why buy a Diabetic Shoe?
1. If you need an Orthotic Shoe Insert you are going to need the Extra Depth and Width.
2. If you have Hammer Toe, Claw Toe, Morton’s Toe, etc. you will need the Larger Toe Box and the no seam feature.
3. Everything else is a bonus.

Understanding Compression Stockings (CS)

How Compression Stockings Work.
Compression Stockings exert graduated pressure on the skin, the pressure is firmer at the foot or ankle and gradually decreases as it goes up the leg. The purpose of this is to force the fluids upward. Picture a long water balloon, if you squeezed at the top it would force the water downward, squeeze in the middle and the water is forced both downward and upward, but squeeze at the bottom and the water will move upward.
When do I need Compression Stockings? There are many reasons but in general, if blood or fluids are settling or pooling in the feet and legs. Varicose Veins and congestive heart failure are common reasons. Sometimes a person is holding water from too much salt intake. Compression Stockings are often used by people who sit or travel a lot. This lessens the risk of a Deep Vein Thrombosis (Clotted Artery).
What kind of Compression Stocking do I need?
There are many varieties from knee high, to thigh high to full panty hose. Knee high are the most common. Consider using the thigh high if your thighs remain swollen after the knee high is used. Many Women wear full length pantyhose. There are open and closed toe varieties. Open toe are used by people who want to wear a sock underneath and some people prefer these because they are easier to put on. There are stockings that just cover the calf, athletes and runners prefer these. CS are made for men and women alike, men usually prefer knee high stockings, and they come in many colors that can be worn just like socks with any outfit. Women CS have a larger variety, including sheer which cannot be differentiated from normal hosiery. There are compression stockings designed for diabetics, these usually contain silver which helps wick away moisture.
Below is a Venosan Chart that recommends different stockings for different issues (Note the higher the number the more compression, a 30 mmHg is stronger than a 15mmHg)
The appropriate compression level for a stocking is based on the symptoms it is trying to alleviate. Use this chart to determine which compression level is best for you.
15-20 & 18-22 mmHg
-Tired, Aching Legs
-Minor Ankle, Leg & Foot Swelling
-Minor Varicosities
-Minor Varicosities During Pregnancy
-Travelling On Long Flights Or Automobile Trips
20-30 mmHg
-Moderate To Severe Varicosities
-Moderate To Severe Varicosities
-During Pregnancy
-Moderate Ankle, Leg & Foot Swelling
-After Sclerotherapy
-Helps To Prevent Recurrence Of Venous Stasis Ulcers
30-40 mmHg
-Severe Varicosities
-Severe Varicosities During Pregnancy
-Severe Ankle, Leg & Foot Swelling
-After VNUS Closure
-After Venous Laser Ablation
-After Vein Stripping
-After Ambulatory Phlebectomy
-Helps To Prevent Recurrence Of Venous Stasis Ulcers

Some products are targeted specifically to treat the symptoms of diabetes, such as SilverlineDB. The other products are listed here based on their compression:
15-20 mmHg
-Legline
-SportsLine
-MicroFiber Line for Men
-MicroFiber Line for Women
18-22 mmHg
-SupportLine for Men
-SupportLine for Women
20-30 mmHg
-Legline
-MicroFiber Line for Men
-Silverline Gentleman
-Ultima
-Ultraline
-Ultraline Silver
30-40 mmHg
-Ultima
-Ultraline
-Ultraline

When Taking measurements for your size, do this first thing in the morning. Fit the Compression Stocking first thing in the morning, this is when your legs will have the least amount of swelling. Never fold the top of the stocking over onto itself, this could double the pressure at the top and can create a restriction if blood flow. Always remove them before bed.
Venosan Recommends These Application Techniques
1. Make sure that neither your feet nor your legs are wet or even damp. Talcum powder can be helpful if necessary.
2. Turn the leg of the stocking inside out down as far as the heel, i.e. except for the foot, the inside of your VENOSAN® stocking must be facing outwards.
3. Use both thumbs to stretch the foot of the stocking open and pull your VENOSAN® stocking over your foot.
4. Grip the upper edge of the stocking and pull it over your heel.
5. Once all the leg of the stocking is above your ankle, reach inside with both thumbs and massage the fabric up your leg with a zigzag movement.
Since your VENOSAN® stockings are made of highly elastic material it is very important that you do not pull the top seam up as hard as you can. The stocking has to be massaged upwards in a series of side-to-side movements as described under 5 above.
Venosan Recommends These Techniques for Taking the Stockings Off
1. Pull the top seam of the leg part downwards as far as your ankle.
2. Push both thumbs between the knitted fabric and your leg and ease it over your heel.
3. Pull the stocking slowly over your foot.

Venosan Recommends This Process for Washing
Regular washing will not damage your stockings.
• You can simply wash your VENOSAN® stockings in the washing machine at any temperature up to 40°C and treat them like any other ordinary synthetic fibre underwear.
• You can reduce the drying time by placing the washed stockings on a thick towel up tightly, and firmly pressing out excess moisture.
• Do not dry on a radiator or in the sun.
• Do not use any fabric softeners, optical brighteners or stain removers (such as turpentine, benzine etc.).
• Clean the silicone bands on self-supporting tops with alcohol regularly to improve adhesion.

Recommended Life Of A Compression Stocking Is Up To Six Months.