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When you clicked on this article, you may have thought, “There’s no way I would ever wear compression stockings. They’re difficult to put on, uncomfortable, and unattractive.” Believe me, I understand. For many years I felt the same way. Fast forward nearly 15 years and compression stockings have become a part of my everyday wardrobe, no matter the occasion.

As a vascular interventional radiologist, I specialize in treating diseases of the arteries and veins in patients in their teens all the way up to those in their 80s and 90s. If there is one thing I’ve learned over the years, it’s that there are two things that none of us can escape — getting older and gravity.

In this article, I will highlight the health benefits of compression stockings and discuss who should and should not wear them.

What is the purpose of compression stockings?

The primary purpose of compression stockings (or compression socks) is to improve blood flow in the legs. Compression stockings improve blood flow in two ways. First, they improve the function of the muscle pump system in your calf. Second, they minimize pooling of blood in the dependent portion of your legs due to the effects of gravity.

How do compression stockings work?

Arteries carry blood from the heart and to the rest of the body. Veins return the blood from the rest of the body back to the heart. There are two type of veins in the leg — deep veins and superficial veins. Since blood flow in the veins must go against gravity, both types of veins have one-way valves to help push blood back towards the heart. Since the deep veins are “deep inside the leg muscles”, these veins get squeezed during walking as the muscles contract and this further thrusts the blood up towards the heart. Unfortunately, the superficial veins lie just underneath the skin and do NOT get the benefit of muscle contraction. They are completely reliant on the one-way valves to push the blood back towards the heart.

Fig 1: One-way valves in normal and varicose veins.

Compression stockings come in different strengths measured in “millimeters of mercury”, just like your blood pressure. The lowest strength ranges from 8-15 mmHg, are sold over the counter, and are often used in hospitals to reduce the risk of blood clots (aka deep vein thrombosis). The highest strength is 40-50 mmHg and is used for those with lymphedema or severe venous disease known as phlebolymphedema. The most common strength is 20-30 mmHg and is used for patients with chronic venous insufficiency (CVI).

What is chronic venous insufficiency (CVI)?

CVI is one of the most common vascular conditions worldwide. In fact, CVI is 2x more prevalent that heart disease and 5x more prevalent than peripheral arterial disease. CVI is due to blood flowing backwards in the superficial veins due to malfunctioning valves. This leads to blood pooling in the legs, especially in the calves and feet, leading to a variety of symptoms including:

• Leg swelling, fatigue, and heaviness
• Varicose and spider veins
• Restless leg symptoms
• Charley horses/night cramps
• Skin discoloration
• Venous ulcers

Fig. 2: Most common signs and symptoms of chronic venous insufficiency

What are the risk factors for CVI?

As previously mentioned, age and gravity are two factors that none of us can escape from. These two factors play a large role in CVI. In terms of family history, some studies have shown nearly a 50% risk of developing CVI in one’s lifetime if one parent has CVI and nearly a 90% risk if both parents have CVI. Pregnancy, prior deep vein thrombosis, obesity, inactivity, and occupations that require prolonged sitting or standing are additional risk factors for CVI. When you look at all the risk factors together, all of us have at least 2-3 risks factors for CVI. This explains why there is such high incidence of CVI with the vast majority of patients going undiagnosed in their lifetime.

CVI is 2x more prevalent that heart disease and 5x more prevalent than peripheral arterial disease.

What do compression stockings have to do with CVI?

Compression stockings have higher compression at the foot and ankle than at the knee or thigh. This “compression gradient” causes blood to accelerate from an area of high pressure to an area of low pressure thereby preventing blood from pooling in the legs. This reduces but does not eliminate the chances of developing CVI in the future.

Compression stockings are difficult and uncomfortable to wear. If they will not prevent CVI, why wear them?

In my experience, most people buy a cheap pair of stockings off the store shelf without getting measured properly and this leads to an uncomfortable and often painful experience. Compression stockings need to be fitted and sized correctly. I recommend that my patients get their first pair from a medical supply store where they can get measured and ensure the stockings fit properly. Subsequent pairs of stockings can be purchased on many discount internet stocking suppliers such as Discount Surgical.^* If worn daily, stockings should be replaced every 3-4 months as they lose their compression.

It is important to remember that it takes a few weeks to get used to wearing compression stockings. When I began wearing them nearly 15 years ago, I hated them. I quit wearing them a few times before I finally decided to wear them daily for 1 month. Now I can barely go a single day without them. After 20 years of standing in the operating room for several hours a day, my legs have never felt better! My legs do not feel heavy, fatigued, or get swollen. My energy level is excellent, and I can run after my children without any trouble.

Untreated CVI can lead to a lifetime of discomfort, pain, disability, and severely affect quality of life. While it is true that compression stockings cannot prevent CVI, they can minimize the severity of CVI and prolong the onset of symptoms. If your destiny is that you will develop CVI in your lifetime, wouldn’t you rather develop it later in life than in your 20s, 30s, or 40s?

Fig. 4: Untreated chronic venous insufficiency

So who should wear compression stockings?

In my opinion, nearly everyone on the planet! All of us are doing the two things that none of use should ever do – sit or stand. These two positions over the course of a lifetime lead to the development of CVI. Add in the other risks factors that were previously discussed and most of us are at risk for CVI. However, this is something that should be discussed with your healthcare provider as there are some patients who should not wear compression stockings. Patient with peripheral arterial disease, for example, should be very careful as to the strength of compression that they wear (if any) as compression stockings can make their symptoms of peripheral arterial disease worse and lead to poor blood flow to the legs. Other conditions such as diabetes and peripheral neuropathy may also not warrant use of compression stockings. However in general, the vast majority of the population are likely suitable candidates for compression stocking use.

Does this article encourage you to give stockings a try? Leave a comment below and share your thoughts about compression stockings.