As a number of people have stated, 2008 may have been the year of the compression stocking in endurance sports. This comment comes from notable folks and coaches in the triathlon community. For about 13 months, I have been studying these stockings and pulling up all reference medical articles and studies. My accident put that on hold. However, a few weekends I was up in Lake Placid, NY with my wife and a cycling friend. Lake Placid happens to host an Ironman-dot in the summer, so the town was flux with triathletes this time of year. It was kinda cool seeing that many athletic concerned individuals. Unfortunately, the brew pubs seemed to be empty at 9pm. I guess that's the difference between triathletes and winter snowbirds. During the winter time, Lake Placid's bars are packed past 9pm even on slow weekends. Recently, they were empty. But boy, the bike shops were hopping. Anyhow, I noticed a few other notable things while visiting. The most notable was the widespread use of compression socks. Even at "The Cottage" restaurant on the Lake, sort of an upscale outside pub, some of the women were wearing 2XU socks as a fashion piece. Gees, I got a smile out of that. However, a few things concerned me when inspecting some of these folks wearing them. Read on if you dare....
If your smart, you could just read Joel Friel's opinion on these socks over at trainingpeaks.com. Of note, not only was 2008 the year of the compression sock, but many triathlon online stores consider them their high selling item. Team Nike adventure racing admitted to wearing them in a long adventure race, but far as I can tell, that was only on an occasiona. A few years ago, a few elite marathoners were sponsored by one of the original companies, but they are still rare and not popular in marathons. However, triathlon seems to be different. As triathlon goes, many people will buy them if they even think they might be faster. I am like alot of them. If I can't out train them, I know I can try to out spend them. Scanning thru Ironman pictures, a number of people are bothering to take the time to put them on and bike or run in them. If you have ever put them on, you know how long they take to get on. Obviously, there is a craze going on. While in Lake Placid, I was biking and running by several hundred triathletes as the big tri clubs were in town like Tri-Life and Team Z, and alot of the midpackers and tail enders were wearing these socks. Legendary coach Joe Friel admitted he doesn't have a recommendation for these socks as of yet after reviewing a number of research articles. Which is basically my opinion on using them for exercise, but my real concern comes if they might actually impede a small cohort of people.
I pulled a few of those quasipositive athletic studies mentioned in writeups, and most of them are poorly designed studies. We have alot of good studies in the medical literature for varicosities and some of them show improved venous leg flow, IN THAT SETTING. Problem is, you cannot assume a treatment for a painful varicosity disorder will apply to the general athletic population, but that is what has happened. Compression stocking companies have glued to that term "improved venous flow." The pathophysiology of varicosities doesn't apply to normal vein physiology in the leg. If you read the stockings ads, some reportedly claim to improve oxygen transport, rid the muscle of waste products, improve run speed, and hasten recovery. Just for fun, scan the ads at nytro.com, all3sports, or any of the big compression companies. If you don't go out and buy a pair after reading all that stuff, you truly are not a tri or speed geek. Gees, I did, even though I knew it was all hogwash, but I did out of curiosity. Reminds me of being at a vitamin store where you go around reading all these reported amazing benefits, then they thrown in, "this statement has not been verified by the FDA." Billions of dollar a year are being spent on things that very likely have no benefit to us directly, or are known to be harmful. E.g. ginkgo bilbola is reported on bottles to improve memory and blood flow. The unfortunate thing is they don't mention the one thing we do know, that it increases bleeding time. Will it cause you to bleed to death, probably not, but it is enough of an issue that many surgeons ban it from their patients. Or like St. Johns Wort, that causes liver failure. I have seen one patient with that myself getting a liver transplant, but it's an unregulated industry and they can advertise what they want. In some respects, the same thing applies to the organic food craze. The question is, do compression socks make people faster? At this time, there is no direct evidence that supports that. But, obviously, they do something? What is it?
The reality is, scientifically, we have no idea if any of those things are true about compression stockings when reading those ads. Out of the numerous studies done came alot of implications. My main interest in this came about from a change in perioperative use of compression stockings. We are seeing them used less often in the setting of surgery. We have a far better device in preventing blood clots/DVTs by using pneumatic compression devices, which have been shown to release tpa, a substance that helps prevent hypercoagulability or blood clotting. So, medicine will be seeing less of use of compression stockings as the science isn't behind them anymore. In theory, they may prevent DVT's in some people, but in some people they may increase leg blood clots. So, in the operating room, we are always careful to fit the socks to people, and sometimes abandon them. Will buying a sock reduce your chances of a blood clot on a long air plane ride? Depends on how the sock fits. However, we know that without doubt moving your legs will help increase venous blood flow. It turns out, the best way to improve venous return is not throwing on a stocking, but doing a little activity, like walking or pumping the legs. Oooh, that sounds like "active recovery." We know that works.
We do know that compression stockings tend to help lessen the appearance of varicose veins. In someone who has large and painful varocosities, the compression stockings will help reduce pain. I have spoken with 3 different vascular surgeons about compression stockings and their use in athletic sports. Everyone one of them shook their head at the idea. Still, they have become popular. There must be something to them. Triathlon magazine did a short article about them, so I went ahead and sought out those brands. As typical as most articles, no bonafide research was shown. So, many months before my accident in january, I embarked on designing a study using ultrasound dopplers and dye flow studies to see if compression stockings actually improved arterial and venous outflow. Then I was gonna see if we could find a university to take hydrogen ion samples from venous outflot to see if their was a pH change in venous outflow catheters by wearing compression stockings during exercise compared to a cohort of nonstocking users. In theory, they can't improve arterial flow by simple physics. No study so far effectively proved they improve venous outflow in normal people which would help get rid of metabolic waste buildup. Or at last in any study I could find. So, someone should do the study. Most doctors think these socks might make arterial flow worse, especially if the stocks don't fit well. In fact, they are sometimes used to control postoperative bleeding. Compression does that. In theory, anything that impedes external bleeding could theoretically impair oxygen delivery. So, there lies the problem.... During the process of trying to do the study, I got no interest from the sock companies for doing such a study, but maybe I didn't go thru the correct channels. So, I went ahead and bought a total of 5 different makes. It was no cheap endeavour, as the triathlon promoted brands cost anywhere from $25-50. During this process, I got involved in an accident and lost interest in completing the study. Anyhow, I have tested them myself and can only report my subjective findings, which doesn't mean too much. And by the way, although I have yet to meet a single triathlete that claims they make them faster by the watch, but I have met a maybe a hundred nurses over the years who wear them everyday and reportedly love them, but those are usually a thin medical grade of stocking that feels very comfortable on the feet. Those are entirely different products from the athletic compression socks, but still in the same category.
On first wearing them for any long period, I had a problem with the socks. All of them have an upper thicker band at the top of the sock to keep them from falling down. Everytime I wore them, I had a compression mark under this band. To me, that is concerning, as that tighter constriction would actually impinge on venous return in my leg. Nearly all the socks that I own do that. It reminds me of the mark we get when putting a tourniquet on someone's arm to place an IV catheter. In reality, what the vascular surgeons told me is they can worsen venous return. Now, I have big calves from years of ice hockey, and possibly my legs behave different that someone elses. After a long workout or adventure race, they did reduce the visible swelling of the subcutaneous tissue, which by the way, sometimes returns when removing the socks. Part of the swelling occurs from higher dynamic pressures in the capillary and distal venous beds, microtearing of some of the vessels leading to fluid extravasation into the surroundings tissues, and mild inflammatory cascade in the tissue. These all lead to lower leg tissue swelling. It's erroneous to think that reducing the subcutaneous tissue swelling that we see under the skin leads to improved recovery. For recovery, we really only care about the muscle belly and it's supporting tissue structures. In reality, we have no idea if a compression stocking affects intramuscular swelling or somehow rids the muscle of waste. I suppose if someone would let us cut off their leg or collect muscle biopsies, we could evaluate this microscopically. The circumference of the leg will decrease, but is that from the muscle or all the surrounding tissues?
Part of the problem is a bunch of people are wearing them around thinking they really work, when we really don't know. That is a very powerful placebo, and placebo's do work. The mind is a powerful tool, in case ya haven't heard that. I can find a hundred ads or online forums claiming they do work. So, alot of people believe they work. Honestly, if you think you feel or look faster in them, you probably will be. If you think you recover faster in them and put them on as part of a recovery regimen, they will probably help, given you are doing other things in the process. However, the jury is still out. Very few top triathletes are wearing them because their coaches don't recommend them yet. Despite all my apparent negative ranting, I think their is something to these socks. That is why I am curious, and wish I could study it. The inherent problem though is they are merely a sock and sized to a persons foot. At least one of the companies I tried attempted to size them different according to the calf and not the foot. If they were to truly work, they would have to be sized on calf dimensions. That alone is probably very difficult. So, what I am saying, everyone will have a different response from them. I don't think anyone is gonna have a true randomized prospective trial proving they do something to make you faster as I'm not sure we could size them well enough to be a good study. So, in some respects, you have to try them yourself.
I will say, I have worn all 5 brands while cycling or running. They don't make me faster. My watch can tell me that within a degree of certainty, even if I didn't design a study. I'm still not sure if they look cool. Since I was probably an adventure racer first and a triathlete second, they do look like a cool pair of orienteering stockings. If you got a thumb compass, shoe cleats, and stockings, you would look totally hip at an orienteering meet. By the way, that is one sport where people don't care what other people wear. By the way, compressing stockings do work well orienteering in preventing some of the abrasions, especially on a really hot day when you don't want to wear a full nylon orienteering pant. Thin shin guards or foam pads also work well underneath them. My white Zoot ones probably wouldn't be a good choice for that as they would be coated in mud and blood. Trimex happens to make a nice orienteering stocking that feels just like a compression stockings.
To a varying degree, all my 5 socks help get rid of that unslightly subcutaneous edema from a very long race. I can't really say if they help me recover faster, as how would I effectively measure that? I haven't been able to notice any decreased lower leg soreness when wearing them, if anything, my calves and leg seem more tender after wearing them. However, I have found that 2 brands actually make my feet more comfortable after wearing them on a 24hr shift at the hospital. I have been doing 24hr calls for nearly 14 yrs, and i can tell a difference in my feet. I am not sure why they do that, but they do help decrease the soreness on the back of my heel and metatarsal area. I have a chronic case of plantar fasciitis, and they don't help that. Still, I wear them at work alot, and two of the socks keep my foot pads more comfortable. My guess is might have to do with prostaglandin production/inhibition, but I would never be able to know. However, that leaves me with a lingering question. They may seem to do something in the right person.
The other question: Do they help shint splints? The jury is mixed on this, depending on who you talk to or what study you read. In theory, if they reportedly help stabilize the anterior tibialis muscle, they might help prevent microtears along the tibia periosteum, which is the cause of shin splints. So, some orthodocs will recommend them in the acute setting of shin splints. The problem is they may potentially be counterproductive in long term use when you finally starting training or racing without them. However, this is one area they may help in the acute setting.
In the meantime, many of us don't expect someone to come out and really prove that they increase arterial blood and oxygenation of the tissues and make you magically run a sub3 hr marathon off a bike. Hardly anybody does that anyways, but if I was a smart sock company, I would pay someone who can to wear my socks. Even if I did the study looking at arterial and venous blood flow in athletes, it would of been faulty enough not to be publishable by any real medical journal. I only wanted to stir up the brains of scientists to see if a better sock could be produced. Possibly something like a ribbed fabric that had a gentle pulsating action created while running, possibly like the x-bionic clothing fabrics. A friend of mine from Johns Hopkins happens to be a leading researcher on pneumatic compression devices, so it's a curiosity. As regards to recovery, there are "theories" that getting rid of muscle tissue edema will quicken recovery. To that regard, that theory has some scientific sense. That is why some people, including Lance Armstrong and a few elite runners, spend varying amounts of time elevating their legs after a workout. Also, ice and or ice/cold baths can help do the same, although the jury is out whether or not ice baths truly work. Some data reported suggests not, but after really tough workouts, alot of endurance athletes swear that alternating cold and hot works. Alternating cold and hot temperatures baths in theory vasocontrict and vasodilate the lower leg vessels, helping flushing out waste products and hastening recovery. This pumping effect is even used by coaches, athletic trainers, physical therapists, and massage therapists when using alternating ice and heat therapy and has grown quite common. Many coaches believe the alternating cold and hot works better than a single ice bath, and that's based on a sound theory. A number of us who have tried both find they both help lessen stiffness and soreness after a long workout. Does this quicken recovery? Possibly, as less soreness and stiffness in theory is better,a lthough some studies suggest it may not truly quicken recovery. Which is another interesting point, then if studies are controversial, why are so many people doing ice and warm baths or ice baths alone. Maybe it's because the myth has been perptuated. Now, should you add recovery stockings to that mix. I really don't know. At least consider a massage therapist after long or hard days, as we know that works, likely even more so than ice and cold therapy. For me, the stockings have never reduced my qualitative soreness scale in my lower leg muscles. They certainly don't make me faster. However, my feet are less sore when wearing two of the brands. It wouldn't really be helpful mentioning which brands, as they would fit someone else differently.
Edited note: If someone out there can produce a legitimate study that I haven't come across, please forward the publication.
Answering one question already. Yes, I did do a study involving my individual legs as separate cohorts. One leg got the compression sock, one did not. Yes, there was some discussion over this among the legs as to what might be fair. Turns out, after carefully controlling the humidity, temperature, and windspeed at 5 ft of altitude on a 400m track, the right leg with the compression sock was slightly faster than the left during 6 min mile 400 repeats on 1:30. Anyhow, the left leg was slightly pissed off, as she lost by 15 seconds on averaged while doing a set of 10 repeats. Her claim was that the prior day, the single leg drills (SLD) on the bike trainer were unfair, and she was still tired, still recovering, and worked harder than the left leg. She wanted a rematch during a taper.
Bill-I appreciated your information about compression stockings. I am an OR nurse myself and do wear the ted stockings when at work and I feel it helps my legs feel less heavy when I go out for a run after a long shift on my feet. I realize of course that this could just be the placebo affect as mentioned above - but I continue to do it because my runs seem less sluggish.
Also, I recently had an adductor strain after a 5K. While recovering from it, I felt it helped with the soreness to wear compression tights during my run. I don't think it was anything to do with circulation, but rather a mechanical function in that it prevents my muscles from moving around as much.
Posted by: Jennifer Merschel | September 07, 2009 at 02:33 PM
It seems like there is a legion of OR nurses wearing ted stockings out there.
There is some evidence that compression helps with shin splints during the acute phase. Also, athletic trainers have been prescribing compression devices for various muscle pulls for the last few decades. Maybe it is from the mechanical function like you suggested. My guess is it helps decrease sheer forces while running.
Posted by: Bill | September 09, 2009 at 08:03 AM
That was inspiring,
Great advice about endurance stocks...
Thanks for writing, most people don't bother.
Posted by: UK Software companies | January 21, 2010 at 01:30 AM
I know a way that you can measure recovery... I know the CEO of a company here in the UK that measures recovery for athletes.
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