Compression Stockings: Who Should Wear Them and How

How compression works

Veins in the legs have one-way valves and are helped by the pumping action of the calf muscles. With age, valves weaken, veins stretch and muscles pump less, especially in people who sit a lot. Blood pools in the legs, pressure in the veins rises and fluid leaks into the tissues, causing swelling, heaviness, aching, skin changes and sometimes ulcers. A compression stocking applies external pressure to the leg, narrowing the veins and helping the valves to work, which improves flow and reduces swelling.

Graduated compression means pressure is highest at the ankle and lessens up the leg. That is the standard design for most medical stockings.

Who may benefit

A doctor may recommend compression stockings for:

• Chronic venous insufficiency and varicose veins, with aching, heaviness and swelling.
• Swollen legs from long sitting or standing, when other causes have been excluded.
• After deep vein thrombosis, to reduce swelling and symptoms, according to the doctor's advice.
• Venous leg ulcers, where special compression bandaging or systems are used under medical supervision.
• Lymphoedema, with specialist garments.
• Prevention of blood clots in some people at risk during long travel or after surgery or illness with bed rest, under medical advice.
• Postural low blood pressure in some cases.

They are not for everyone with swollen legs, and the cause of swelling must be known. See swollen legs in older adults.

Why a doctor should check first

This is the most important point in this guide.

Arterial circulation. Compression can be dangerous if the arteries supplying the legs are narrowed, as in peripheral arterial disease, which is common in older people with diabetes, smoking history, high blood pressure or high cholesterol. Compression on a leg with poor arterial supply may reduce blood flow further, causing pain, skin damage or even tissue death. Doctors check pulses in the feet and sometimes measure the blood pressure in the ankle compared with the arm (ankle-brachial pressure index, ABPI) before advising stronger compression. Warning clues of poor arterial supply include cold, pale or bluish feet, leg pain when walking that eases with rest, shiny, hairless skin, non-healing wounds and weak or absent foot pulses.

Cause of swelling. Swelling may come from the heart, kidneys, liver, thyroid, medicines, infection, a clot or lymphatic problems. Treating swelling with a stocking without finding the cause may delay needed treatment. For heart failure, compression should only be used on a doctor's advice.

Skin and nerves. Fragile skin, wounds, infection, rashes or loss of feeling (as in diabetes) raise the risk of injury from stockings.

Leg shape and size. An unusual leg shape may need custom garments.

Hand function. If your parent cannot put on the stocking, someone must help.

So: do not start compression stockings on your own for a swollen leg. See a doctor, and follow their advice about the type, the compression level and wearing time.

Types and compression levels

Knee-high stockings. Reach just below the knee. Suit swelling of the lower leg and the most common choice, and easier to put on than longer ones.

Thigh-high stockings. Reach the upper thigh, with a silicone band to hold them. Used when swelling or veins extend above the knee, but are harder to put on and may roll down.

Pantyhose or waist-high. Cover the whole leg and the waist. Less common.

Open-toe or closed-toe. Open-toe styles are helpful for bulky feet, bunions or when toes are sensitive, and for those who cannot feel their toes, since the toes can be checked.

Flat-knit versus circular-knit. Flat-knit garments are firmer, thicker and used for lymphoedema and difficult leg shapes; circular-knit stockings are lighter and common.

Compression class. Stockings are made in classes based on the pressure at the ankle, measured in mmHg. Class names and ranges vary between countries and standards (for example British, German or French classification). In general, lower classes give light support, mid-level classes for varicose veins and swelling, and higher classes for severe disease and lymphoedema. Do not choose a class on your own; ask the doctor or a trained fitter which class suits you. Higher compression is harder to put on and carries more risk if circulation is poor.

Anti-embolism stockings. Used in hospital to help prevent clots in bed-bound patients, with specific fitting rules. They are not designed for everyday use at home, but some people wear them after discharge as advised.

Travel and sports socks. Lighter compression. Not for treatment.

Features to look for

• Graduated compression stated on the label, with the pressure range.
• A recognised compression standard and clear sizing chart.
• Breathable fabric, which is important in humid weather: cotton blends and moisture-wicking microfibres.
• Seams that are flat and soft.
• A top band that holds without digging in or rolling down.
• Open or closed toe to suit.
• Ease of use, such as a stocking with a donning aid.
• Skin tone and colour choice, since people prefer stockings that blend in.

Cheap stockings from unknown sources may not provide the compression they claim; see spotting fake or poor quality care products.

Measuring and putting them on

Correct size and technique are essential. They are covered in compression stockings: measuring, sizing and putting them on. In brief: measure in the morning, when swelling is least, put on before rising or early in the day, smooth wrinkles, do not roll down the top.

Safe wearing habits

• Follow the doctor's instructions on how long to wear them each day, and whether to remove them at night. Many people wear them from morning until bedtime. Some conditions need night wear; do not decide yourself.
• Check your skin every day when you take them off, especially the heel, ankle, shin and toes. Look for redness, blisters, marks, rubbing or breaks in the skin.
• Check the feet and toes for colour, warmth and feeling.
• Do not fold, roll or bunch the top; this creates a tourniquet.
• Do not wear them if they cause pain, numbness, tingling, cold or discoloured toes, or a sudden increase in swelling above the stocking. Remove and contact a doctor.
• Wear the right sock under or over, as advised, and avoid wrinkles.
• Keep nails short and avoid rings, which can snag.
• Moisturise skin at night, not just before putting on the stockings, since creams can damage the elastic; see barrier cream and skin care.
• Replace stockings every few months, since elasticity wears out; many last three to six months with daily use and regular washing. Having two pairs allows washing.
• Wash according to the label, with mild soap, and dry flat away from direct heat or sun.

Compression and other health conditions

• Diabetes. Take special care; many people with diabetes have poor circulation or numb feet. Ask the doctor before use. See diabetic foot care at home.
• Heart failure. Only with medical advice; watch weight and breathlessness; see heart failure at home guide.
• Kidney disease. Swelling has different causes; ask the doctor.
• Skin conditions. Eczema and dermatitis of the legs are common with venous disease; a doctor or nurse may recommend creams and dressings; see skin conditions in older adults.
• Incontinence. Use protective measures if stockings are soiled; see incontinence and hygiene.
• Arthritis in the hands. Putting on stockings is hard. Donning aids and help may be required.

Warning signs: seek medical help

Contact a doctor immediately for:

• A swollen, painful, red or warm calf, particularly one-sided, which may be a clot;
• sudden breathlessness, chest pain or coughing blood, which may be a clot in the lung; this is an emergency;
• cold, pale, blue or very painful feet or toes;
• new numbness, tingling or severe pain under the stocking;
• a wound, blister or ulcer that does not heal, or looks infected, with redness, pus or fever;
• swelling that rapidly worsens, or occurs with weight gain and breathlessness (possible heart failure).

When to ask a professional

Ask a doctor before using compression stockings, to check the cause of swelling and the arterial circulation, and ask for a prescription or recommendation of type and class. A nurse or trained fitter can measure and teach how to put them on. A vascular specialist may advise for complicated cases. A pharmacist can advise on skin products and fit. A physiotherapist may add leg exercises.