Sock It to Me!
protective effect of hosiery on the feet
of patients with diabetes and arthritis.
Negative consequences that can develop or be exacerbated by wearing the
wrong sock include yeast, bacterial,
viral, and dermatophyte infections,
friction blisters, kyperkeratoses, capsulitis, bursitis, calcaneal fat pad atrophy,
tailor’s bunion, and sunungual hematoma, to name a few.
But while there is a bewildering
array of new styles, fibers, and knits
available—the result of a 1980s boom
in sock research and development—
Dennis Janisse, CPed, president and
CEO of Milwaukee, Wisconsin-based
National Pedorthic Services, notes
that there is
no helpful field
guide to sock
selection.
“When I started in pedorthics
we talked about
the foot, the foot
Janisse
orthosis, and the
shoe—but that other barrier wasn’t
really discussed,” Janisse says. “Now
we have an exciting number of options with many different properties—
moisture-wicking capabilities, a sock
inside of a sock to decrease shear and
friction inside the shoe, [and] socks
with extra cushioning and padding.
“I was involved in a study with
diabetes patients who had ulcers that
wouldn’t stay closed, and arthritis
patients who had been fit with shoes
and foot orthoses but still had issues,”
he continues. “The extra-cushion
socks were just fantastic; they made a
big difference in survival of the foot for
the diabetes patient and comfort for the
arthritis patient.”
Moisture is the enemy and, due to
the presence of more sweat glands per square inch than any
other part of the body, feet perspire
a great deal, says Elliott Crooks, a
footwear consultant at the Denver,
Colorado, Foot Solutions store.
Active perspiration in the foot area
can cause maceration between the
toes and some of the undesirable conditions listed earlier.
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Good Footwear Starts with Good Socks
By Judith Philipps Otto
S
ocks are high on the list of things we take for
granted. Whether it’s for orthotic patients or for
ourselves, we often select socks without giving the
choice much thought, and yet the lowly sock can
make a huge difference to its wearer’s comfort, attitude, and
safety—not to mention short- and long-term health, say
footcare experts.
Logic and experience, not to mention studies by the
U.S. military and other clinical researchers, document the
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Crooks
healthier and will last longer. The best and most durable
fibers are acrylic and COOLMAX® polyester.”
By wicking away moisture and keeping the foot dry, the
right socks can prevent problems with a hot, moist environment that breeds fungus and bacteria, Janisse agrees.
Unfortunately, one of the most widely
held misconceptions about socks is that
cotton socks are the best choice for dealing with that moisture problem, both
for normal and neuropathic feet, our
experts report.
James R. Christina, DPM, director
of scientific affairs for the American
Podiatric Medical Association (APMA)
Christina
says, “It was thought for a long time that
cotton socks were best, but there have been several studies
that have shown that while cotton socks absorb moisture
well, they don’t wick it away from the skin, so there’s actually an increase in blisters with the cotton sock. Several
published papers and studies have confirmed this point.”
Crooks calls this “The Great Middle School Athletic
Department Unconscious Conspiracy”—one that encourages students in organized sports activities to buy cotton
athletic socks because they’re cheap and easy to launder.
This habit stays with most wearers for life.
Favorable Fibers
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“As the interface between the foot and shoe or orthotic, the
sock needs to perform as well as possible—so fiber choice
is obviously important,” Crooks says. “Acrylics and polyesters are very good at not absorbing moisture but helping it
to move away from skin. COOLMAX is probably the best
of them because where most fibers are essentially round in
cross-section, COOLMAX is X-shaped in cross section,
and that additional surface area increases the efficiency of
moisture transport. Thermax® polyester is a hollow tube
that makes it very warmth-efficient. Silk, in comparison,
comes out of the silkworm as flat ribbons, so it’s exceptionally heat-efficient because it reflects heat back to the body.”
Wool, too, remains an excellent sock fiber choice—one
that retains its structure, insulation value,
and cushioning while absorbing moisture.
“As the interface between the foot and shoe or
It’s the most efficient choice for cold, wet
conditions, but check the tag to be sure it’s
orthotic, the sock needs to perform as well as
merino wool, which is bred for softness,
possible—so fiber choice is obviously important”
Crooks advises. Processed properly, merino
wool is also non-allergenic, as well as com—Elliott Crooks
fortable in a synthetic/wool blend sock.
Newcomer fibers like bamboo have also
become popular, partly because of their
When cotton gets damp, Crooks points out, it loses its soft, porous nature, silky texture, excellent breathability,
strength, its cushioning flattens out, it stretches, wrinkles, moisture-wicking capability, and also because, as online
folds, and loses its insulation value.
advertising touts, bamboo is naturally sustainable and
“A study done in the Cascades looked at appropriate renewable, uses virtually no pesticides or fertilizers, yet
types of clothing to wear in rainy, windy conditions at about it can grow as much as 36 inches per day—absorbing 35
40 degrees. It essentially concluded that if you were caught percent more carbon dioxide than a typical oak tree while
wearing a cotton sweatsuit, you’d be warmer if you stripped it grows.
it off and ran like hell, since the amount of water it would
Janisse mentions other new approaches in the marketplace;
absorb and hold against you would pull more heat off than for example, a sock with mohair woven into the footbed can
the environmental conditions!”
provide exceptionally high anti-shear, anti-friction value.
Crooks also notes that cotton has a significantly shorter “Some manufacturers are actually weaving Teflon® fibers into
lifespan than synthetic fabric; it becomes more abrasive and the sole of the sock for the same reason—to cut down shear
deteriorates with each wash-wear cycle.
and friction inside of the shoe. Shear friction contributes to
More durable blended-synthetic fibers absorb less while blisters, callusing, and even…ulcers.
wicking the moisture away from the
“Some are weaving silver and copper into the socks to
skin, so they maintain their cushion- utilize their antifungal and antibacterial properties. This
ing even when conditions are moist goes back to the time of the pharaohs, when Egyptians used
and humid.
copper pipes to transport water because of its ability to keep
“While natural fibers like cotton the water cleaner.”
are popular and claim to ‘breathe,’”
Like bamboo, copper and silver are woven into the sock
says David B. Higgins, consulting and won’t wash out like a spray or coating; they’re there
vice president at Dr. Comfort, Mequon, until the sock wears out, Janisse says.
Wisconsin, “fiber construction of speWeave can also play a significant role in a fiber’s perforHiggins
cially designed synthetic fabric is much mance, Crooks points out. Polyester fibers that are arranged
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“Good fit will improve compliance, protection,
and value. Socks that try to fit more sizes of
feet with fewer sizes of socks are almost always
inferior, regardless the price or…fabric content.”
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Fit Is Essential
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true measure of long-term value. Finding socks
that are anatomically shaped to the foot and leg
will fit best and last longer.
“The density [thickness] of socks is also an
important feature; too thick can cause shoe fit
compromise, too thin provides no protection
against friction and shear,” Higgins continues.
—David B. Higgins
“Padding in just the right places under the foot
is best.”
For normal, healthy but aging feet, a certain
in a tight, flat knit—as in the 1970s leisure suits, dress shirts, amount of strategic padding can be a plus, Christina points
and blouses—don’t breathe. When blended into polar out. “Some people have a loss of the protective fat padding
on the ball of the foot; that’s kind of a natural thing as we
fleece, however, it’s a totally different story.
He cites high-tech design techniques that are producing age…. Thorlos® and similar socks with a bit of extra padding
socks with efficient combinations of knit patterns, as well. in that area can be helpful.”
Fred Bernhardt, vice president of Comfort Products,
For example, he says the SmartWool® Adrenaline sock
features “extra cushioning under the toe and heel, ribbing Croydon, Pennsylvania, adds, “If the pedorthist has gone to
around the arch for added support, lighter mesh over the all the work of evaluating what footwear the customer should
top for greater breathability, a different mesh where the foot have, they don’t want a thickly padded or cushioned sock. If
transitions into the ankle for more efficient flex, and vertical you’re in a custom-molded shoe with a custom orthotic, that
is not required. They’re looking for ways to offload pressure
ribbing to hold up the top cuff.”
Although white socks are favored for wear by patients in the custom-molded shoe, and if they put on this padded
with neuropathic issues, as they more readily reveal any sock, it might actually do more damage than good.”
Crooks agrees, and points out that sock thickness can
blood or discharge from wounds that might otherwise
remain undetected, colors and patterns are becoming change shoe fit by a full size. With a heavier, more cushiony
sock, go with a half-size to a full-size larger shoe; if the shoes
increasingly popular.
“The belief held by a few older patients—that dye can are custom-made, select a thinner sock—like the one the
leach out of a colored sock and potentially be harmful if wearer chose for his or her original shoe fitting.
Just like with shoes, Crooks cautions, “You need to know
you have any type of foot problem—is a misconception,”
how particular [sock] brands run. Different manufacturers
Christina notes. “Today’s dyes are greatly improved….”
“Color isn’t the only way socks can be fun,” says Crooks, will tend to run large or small.”
He also warns that using thickly cushioned socks for their
whose personal favorite socks depict Godzilla destroying
Tokyo. “For someone who’s depressed about having to give thermal value in cold outdoor environments can achieve the
up pretty shoes for something that’s far more comfortable opposite effect. “For warmth, you need good circulation, so
not necessarily a snugger sock, as cultural wisdom dictates.
but ‘orthopedic’—a fun sock can be a real morale booster.”
Wearing heavy socks for more warmth may take a comfortable fitting shoe or boot and turn it into a snug fit. That
While the variety of fibers and designs are helping to reshape impacts the circulation and sets you up for cold toes.”
The correct approach, Crooks continues, particularly if
the sock industry, even a sock of ideal fiber and design can be
hazardous to the wearer’s health if the fit is wrong, Higgins the customer’s footwear fits tightly, is to go with a thinner
sock. “Make more room within the footwear so there’s no
points out.
“Socks are close fitting garments, ‘intimate,’ so fit is cru- restriction on circulation.”
Janisse points out the added risk of overly snug socks to
cial,” he says. “Good fit will improve compliance, protection,
and value. Socks that try to fit more sizes of feet with fewer patients with diabetes. “I have seen patients who have gotten
sizes of socks are almost always inferior, regardless the ulcerations or sores because they have a pair of shoes that
price or…fabric content. Look for socks that offer at least was fit for a nylon or…thin sock, but then they switched to
four sizes, from small to extra large, fitting no more than 2.5 a sock with extra cushioning because it was identified as a
diabetic sock—and they think that means it’s a better choice
shoe-size ranges with each.
“If the socks are loose, it can be uncomfortable in your for them. If the patient doesn’t have any sensation and they
shoe and, more importantly, dangerous to the insensitive begin wearing a sock that doesn’t give them enough room
foot, due to hot spots from pressure. If the sock is tightly fit- inside of the shoe, it actually could…cause more problems
ted, it can inhibit circulation. Loose fit or tight fit will also than it’s supposed to be fixing.”
cause the sock to wear out more quickly, so price is not the
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a sock within a sock, which absorbs friction between the
layers of fabric rather than between the foot and the single
layer of sock within the shoe.
“People forget that the neuropathically involved foot does
not perspire,” Bernhardt says. “Sometimes folks tend to get
quite involved on whether you have this wickability—and for
the neuropathically involved foot, that’s really a moot point.
“The problem is, there’s no one sanctioning body—no
one out there that says this is the perfect sock. There are
groups of pedorthists, doctors, etc., that seem to think they
have a better idea of what the right sock is. It’s becoming
fairly confusing for both the wearer and the manufacturer.”
Higgins agrees. “After having started the very first diabetic
sock brand in 1994,” he says, “I have watched this industry
grow to be over $200 million and still growing. I am still
alarmed by the false claims and poor quality of products
that circulate the market, simply to keep their cost low. This
is true in shoes as well as socks. When it comes to ‘at risk’
feet, hopefully our industry will take a much closer look at
what we put next to the skin of our customers/patients.”
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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.
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Higgins reassures diabetic patients with venous conditions
that they need not give up compression hosiery because of
the constrictive dangers, however. “Keep the compression
in the 15–20mmHg range, and only wear medically correct
compression socks made by FDA-registered brands. Always
ask your healthcare provider!” he says.
Relative to appropriate sock fit, he lists seams or toe
closure as another critical area, especially for diabetic or
insensitive feet. “Hand-linked seamless is best, but other
forms may be acceptable if carefully checked.”
Bernhardt also addresses the importance of seamless socks
when he discusses the special needs of neuropathic patients.
“My father and I have manufactured prosthetic socks
for 37 years; we realized that a lot of the new amputees we
served were derived from the diabetic population,” he says.
“Providing an amputee sock is a reactive response, so we
decided to focus more on the proactive side by developing
diabetic sock products.”
He explains that diabetic socks incorporate two main
features: a low compressive top, snug enough to hold the
sock in place, but not tight enough to constrict bloodflow;
and no seam in the toe area, which eliminates “the potential
for irritating and damaging toes in a manner that might not
be detected by persons with diabetes who…have a loss of
sensation.”
From the first terry sock that was cushioned throughout
from top to toe, to a sock with a seamless toe in both standard and extra-wide profile, designs have evolved to include
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Copyright 2011, Western Media LLC/The O&P EDGE. Reprinted with permission.