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Treatment Dilemmas

How Might Socks Have An Impact On Daily Lower Extremity Issues?

After 20 years in practice, very little surprises me. I feel like I see almost everything come through my office, but one continually notable trend is the stream of poor quality socks I see on my patients. Every time I think I have seen the worst sock of my life, I find another one that is even more so. Sock problems come in all shapes and sizes; torn, worn through, frayed and mismatched are very, very common. This is just poor hygiene and support for the foot.

What I find even worse are socks that don’t fit right, have thick, horrible seams around the toes, bunch up in the arch, the heel or the toes and smell awful. Too often socks are ignored. They may be too small, slip off the heel, bunch up or so fit loosely you can spin them around without any real top or bottom. Why are socks a secondary consideration in our clothing choices? Why are socks not often considered as a helpful tool in foot and ankle support and pain relief? The answer is mainly because we do not educate our patients regarding the importance of socks, what to look for, what to avoid and how socks can potentially help with foot and leg pain.

This became an important issue for me and I began a long quest to figure out what is truly important in socks, how a sock should be constructed and what really matters. Over the course of a few years, I began to learn how socks are made, including areas for improvement, and began to gather my ideas about an ideal sock.

Key Considerations In Materials, Compression And Fit

In my experience, what matters and contributes to an ideal sock is a combination of the right materials, the right sock tension, a lack of irritation spots, arch support, blister prevention and odor control. Some of these factors already exist in socks on the market and are easy to find. Some have never been in a sock, but why?

I feel that the ideal material for a sock is a combination of a natural material in the weave, combined with a body yarn that is synthetic but offers stability, structure and support. Cotton and wool are two examples of a natural, potentially ideal weave of yarn for a sock. Both are excellent and offer warmth, which is more due to thickness than specific material. The structure yarn is often also a combination of polyester and nylon in differing amounts. In my experience, nylon has a dense feel and not much give, while polyester is moisture-wicking and also structurally sound. Spandex is often added but in very small amounts and is really not as important, in my opinion.

What about smell? Well, silver is often used as an anti-microbial weave material. However, my choice is to have the yarn soaked in an anti-microbial bath, which I find actually works better than silver, and can prevent odor and bacteria in any material. The perfect combination of material for a sock, in my opinion, is about a 50/50 ratio of cotton or wool to polyester and/or nylon. I find this will give a soft and comfortable feel with good structure and stability.

What about compression? That is the latest term that I hear from all of my patients. Well, I believe that one needs enough compression in a sock, but without too much squeeze preventing the muscle from working properly. This does not refer to medical socks for severe venous problems. I am talking about everyday compression to ease swelling, leg pain and keep you energized. That type of compression is usually at lower levels for most people and I find eight mm of mercury is great. This allows the socks to stay in place, squeeze without pain and can also reduce swelling.

A second point is, why do we wear compression socks that extend to the knee unless we have severe edema? The calf muscle is a natural compression device; as it pumps it milks fluid out of the leg. By wearing a tight compression sock to the knee, in my experience, we may limit the compression of the gastrocnemius muscle, which is not ideal. I find compression is great in the foot portion of a sock and also important to just below the calf. This may reduce swelling and possibly decrease muscle and foot fatigue while still allowing the calf muscle to work and stay functional. Again, the idea is not “more is better” but just “right is better,” which means when you take off your sock, you should find a lack of leg swelling and perhaps even signs of mild compression of the leg.

Seams are a real problem and come in all shapes and sizes. I most commonly find the problematic seams in the toe area, as that is the spot where the sock closes after it is woven. Poorly-made socks often have an ill-fitting, thick seam closure. A couple of other spots to watch out for are the heel seam area and around the top of the sock. All three of these are an issue and can cause blisters, cuts and irritation in shoes. I believe that a quality sock should not have any seams. The sock is closed with a special machine that makes a very fine seam, which is truly critical for comfort. If you have patients with diabetes, you already know that diabetic socks must be seam-free. But, why not use a seam-free sock for all patients? It just makes sense.

How Socks Can Better Address Blisters, Odor And Arch Support

Blister prevention can be tricky in a sock. Again, it truly comes down to the material used, the tension of the sock and making sure the sock fits properly and doesn’t move against the skin. Too loose and the sock will rub and irritate, as will thick stitching. Socks that retain moisture can cause blistering. That is why it is essential to use a combination of natural and synthetic materials in a good sock to wick moisture away from the foot. Blisters are a problem, but the right sock can help prevent them.

As we discussed in the materials section, odor can become a big issue. What some don’t realize is the unpleasant smell stems from microorganisms and therefore is a risk to foot health as well. If a sock holds bacteria and/or fungus, it causes odor but also causes high bacterial and fungal loads around the foot. Silver is a good sock material but, in my opinion, 

you truly need an entire sock made out of silver to make sense. Many companies put a few strands of silver in the sock for marketing, but this makes no difference. Look for a sock with a truly antimicrobial material, such as a pre-treated material as I previously discussed.

A final point for one to consider is arch support. For the past 30 years, arch support meant the little strip of elastic around the midfoot portion of the sock. We know this does nothing to actually support the arch other than compress the midfoot a bit. Why do we not do something about this? For years I would tape my patients’ arches if they had foot pain. This allowed me to see if an orthotic would help and reduced their foot pain quickly. When I sent a patient to our physical therapist, they used a single or double strip of kinesiology tape to support the arch, running it from under the first and second metatarsal to the bottom or back of the heel.

This intrigued me, and I began to think about including this in a sock. I applied for and secured two patents on an arch support system for socks. Getting a sock patent is not easy, and getting two was even harder. My patent is a five-layer dense material that supports the arch from the heel to the toes in the arch area only. Much like taping the arch, I find this sock material firmly holds the sock attached to the foot in the desired area and reduces foot pain and strain.

In Closing

After all this research, I thought to myself that these patents and all this hard work needs to go to good use. I created Archtek Socks (www.archteksocks.com), which includes dress socks with bold designs and are easy to match to outfits, scrubs and dress clothes. There is also an athletic line that is a bit more dense and has more arch support. The socks come in different styles but all have the patented arch support built into them. There is also a y-strap energy return system to the top of the sock which, in my experience, compresses and relaxes with each step, reducing foot muscle fatigue. These socks have targeted material combinations for each type of activity, no seams, leg compression that I feel is just right and also have an anti-microbial coating. I hope the application of these advances in development and technology lead to improved discussions with and outcomes for your patients.

Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles (https://www.footankleinstitute. com/podiatrist/dr-bob-baravarian).

Dr. Baravarian also discloses that he is the creator of Archtek Socks.

Treatment Dilemmas
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Bob Baravarian, DPM, FACFAS
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