Best Practice Statement
Compression hosiery:
A patient-centric approach
Understanding medical
compression hosiery
construction
Individualised
hosiery selection
Shared decision-making
THIRD EDITION
WUK BPS
2021
BEST PRACTICE STATEMENT:
COMPRESSION HOSIERY:
A PATIENT-CENTRIC
APPROACH
(3RD EDITION)
PUBLISHED BY:
Wounds UK
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© Wounds UK, June 2021
is document has been developed
by Wounds UK and is supported by
an educational grant from
medi UK.
e views expressed are those of the
Expert Working Group and Review
Panel and do not necessarily reflect
those of medi UK.
How to cite this document:
Wounds UK (2021) Best Practice
Statement: Compression hosiery: A
patient-centric approach (3rd edn).
Wounds UK, London. Available to
download from:
www.wounds-uk.com
EXPERT WORKING GROUP:
Jacqui Fletcher OBE (Chair), Independent Nurse Consultant
Leanne Atkin, Vascular Nurse Consultant, Mid Yorkshire
NHS Trust; Lecturer, University of Huddersfield
Louise Bolton, Tissue Viability Lead Nurse, Anglian
Community Enterprise CIC
Alan Elstone, Vascular Nurse Specialist, Derriford Hospital,
Plymouth/Advanced Clinical Practitioner, University Hospitals
Plymouth NHS Trust
Patryk Gawrysiak, Specialist Physiotherapist in
Lymphoedema, St. George’s Hospital, London
Caitriona O’Neill, Director of Clinical Services & Clinical
Lead for Lymphoedema, Accelerate CIC
Georgina Ritchie, Deputy Director of Education, Accelerate
CIC
REVIEW PANEL:
Philip Stather, Consultant Vascular Surgeon, Norfolk and
Norwich University Hospitals, NHS Foundation Trust
Peter Vowden, Honorary Consultant Vascular Surgeon,
Bradford Teaching Hospitals NHS Foundation Trust; Visiting
Honorary Professor, Wound Healing Research, University of
Bradford
Alison Hopkins MBE, Chief Executive, Accelerate CIC
Document summary
■ Medical compression is an effective and powerful therapy.
■ Compression hosiery has evolved considerably over the
last few years and is now a progressive therapy that exists
beyond Compression Class I and Class II British Standard
hosiery.
■ It is important to be familiar with the National Wound Care
Strategy Programme (2020) guidelines and follow the
recommendations in practice.
■ It is important to be familiar with the types of compression
therapy used in clinical practice, the conditions that can be
treated, and the garments available on local formulary.
■ It should be possible to find compression therapy for
everyone with a thorough holistic assessment and taking
into account individual patient preferences.
■ Effective communication and shared decision-making
between the clinician and the patient and/or caregiver are
key to identifying the ‘best’ hosiery for the patient and to
ensuring concordance with care. Listen and understand
their concerns, expectations and motivations with regard to
their presenting condition(s). Avoid using terms the patient
may not understand.
e third edition of the Best Practice
Statement on Compression Hosiery focuses
on improving the patient experience of
medical compression hosiery for the lower
leg, which include socks and stockings, by
understanding the patient’s perspective and
fostering a patient–practitioner partnership
for supported self-management.
It is often easy to label a patient ‘uncooperative’
or ‘non-concordant’ if the outcomes of
treatment are not as anticipated. However,
it is unlikely that any patient is truly non-
concordant, rather, they have not yet received
the right treatment, education, support and
follow-up for their individual needs. Clinicians
should employ a positive, confident, competent
and knowledgeable attitude when discussing
medical compression therapy with patients,
which may help to influence the patient to
become interested and engaged with their
treatment.
e COVID-19 pandemic has accelerated
initiatives towards greater patient and carer
supported self-management (NHS England
and NHS Improvement, 2020). Consultations
have increasingly been undertaken by
telephone and video call, and patients have
been able to text or send photos directly to
their clinician. Evidence shows that when
people are supported in self-management,
they benefit from better health outcomes,
improved experiences of care and fewer
unplanned care admissions (NHS England
and NHS Improvement, 2020). A growing
number of people with wounds are willing
to participate in supported self-management
if they are given the right support and tools
(Adderley, 2020).
An Expert Wound Group met online to
discuss the advances in medical compression
hosiery since the second edition of the Best
Practice Statement: Compression Hosiery
(Wounds UK, 2015) and to agree on Best
Practice Statements to guide compression
hosiery selection for patients. Best Practice
Statements are accompanied by Patient
Expectations to encourage shared decision-
making and foster a supportive patient–
practitioner partnership at every stage of care.
e document is designed to be simple
and user-friendly, and to put the patient
at the centre of assessing for, selecting,
prescribing and delivering care with medical
compression hosiery.
Jacqui Fletcher OBE, Chair
1
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
Fo reword
Progress since the
second edition
(page 4)
Glossary
(page 2)
Chapter 1: Principles of assessment (page 5)
- Factors that influence medical compression
hosiery selection
Chapter 2: Medical compression hosiery
construction explained (page 7)
- The role stiffness plays in compression hosiery
garments
- Myths and truths surrounding round-knit
versus flat-knit hosiery
Chapter 4: Encouraging shared
decision-making (page 13)
- Practical guidance on partnership working and
concordance alongside the patient
Chapter 3: Patient considerations during medi-
cal compression hosiery selection (page 10)
- Clinical and patient-related factors that
impact on hosiery selection
Chapter 5: Measuring and sizing (page 15)
- Myths and truths surrounding off-the-shelf
and made-to-measure hosiery
- FAQs on fitting medical compression hosiery
Chapter 6: Key elements of supported
self-management: Hosiery application, removal
and care and skin care (page 17)
- Quick guide for good medical compression
hosiery fit
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
2
Ankle –brachial pressure index (ABPI): A
screening tool to determine the presence and
extent of peripheral arterial disease (PAD). e
result of the ABPI rules out PAD, but it does
not confirm whether a patient will benefit from
compression therapy – meaning that an ABPI
cannot diagnose venous insufficiency or the
cause of oedema.
Chronic venous insufficiency (CVI): A
condition whereby blood pools in the veins,
straining the walls of the vein and making
it difficult for blood to return to the heart
from the legs. It can be caused by venous
hypertension or venous obstruction/occlusion,
such as a deep vein thrombosis.
Compression: A treatment whereby the
application of external pressure counteracts
the loss of capillary fluid by squeezing fluid
into the veins and lymph vessels. Compression
therapy improves venous return to the heart
and initiates a variety of complex physiological
and biochemical effects involving the venous,
arterial and lymphatic systems. e effects
of compression can be dramatic, reducing
oedema and pain while promoting healing of
ulcers caused by venous insufficiency (Harding
et al, 2015).
Compression bandages: A type of
medical compression garment that is
composed of either inelastic (short-stretch)
elements, elastic (long-stretch) elements
or a combination of both. Bandaging is
most often used to treat active venous
ulceration and should be worn 24 hours a
day. Bandaging can also be used for ongoing
maintenance, for those unable to tolerate
hosiery or those with complex conditions
such as lymphoedema, especially when the
legs are large and have skin folds. For these
patients, full-leg bandaging may be required
to control oedema and maintain the shape of
the leg (Anderson and Smith, 2004).
Compression classes: e pressure measured
at the ankle is used to classify medical
compression hosiery into compression classes
(e.g. 1, 2, 3). e stiffness of the compression
hosiery material affects the compression class.
Compression hosiery: e most widely
used form of compression in the long-term
management of lower limb lymphoedema
and oedema. Hosiery can also be used
to manage conditions associated with
CVI (NICE, 2012). Medical compression
hosiery options vary in stiffness, levels of
compression delivered, fabric, colour, size,
length, and whether they are closed or open-
toe. Medical compression hosiery is a single
garment and can be selected off-the-shelf or
made-to-measure for the patient.
Compression hosiery kits: A type of
medical compression therapy most
commonly used for the management and
healing of venous leg ulceration. Kits consist
of two medical compression garments
designed to be worn one on top of the
other. Hosiery kits are designed to be worn
24 hours a day but the outer layer can
be removed at night, although this is not
essential. Hosiery kits are most commonly
available in off-the-shelf sizes but can also be
made-to-measure.
Compression standards: National
and international standards for medical
compression hosiery have been developed to
ensure compression stockings and socks meet
certain technical parameters, such as testing
methods, yarn specification and durability
(Lymphoedema Framework, 2006). ere are
a variety of quality standards against which
compression hosiery can be categorised:
■ British Standard Compression (Specifica-
tion 40; BS 661210): e British Standard for
compression hosiery has three classes that
indicate the level of compression provided by
the garment. BS40 measures the compression
delivered by the medical compression gar-
ment at the ankle, knee and top of thigh and
has a 3-month guarantee (Partsch, 2003).
■ German RAL (GZ 387/1) Standard: e Ger-
man standard is measured at 5cm increments
up the garment to ensure graduation and has
a 6-month guarantee (Földi and Földi, 1983).
■ French Standard (ASQUAL) (AFNOR NF
30.102A): e French Standard is measured at
the ankle (Levick, 2003).
Compression wraps: A type of medical
compression garment considered for the
management of lymphoedema and other
disorders of the circulatory system. Available
in a variety of forms, these devices consist
Glossary
3
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
of fabric sheets made from one or more
components with limited extensibility. e
wraps are applied to affected limbs and
held in place with hook and loop fastenings
(omas, 2017).
Interface pressure: e pressure between
the skin and the compression garment.
Measuring pressure at the interface during
both lying and standing indicates how the
compression garment reacts to muscular
activity. e interface pressure was
previously described as the sub-bandage
pressure.
Lymphoedema: e accumulation of
fluid in the tissue spaces. It may present
as swelling of one or more limbs and may
include the corresponding quadrant of
the trunk and other areas, e.g. head, neck,
breast or genitalia. It arises from congenital
malformation of the lymphatic system
(primary lymphoedema), or damage to
lymphatic vessels and/or lymph nodes
(secondary lymphoedema) due to cancer
treatment, infection, inflammation,
venous diseases, obesity, trauma and
injury (Lymphoedema Framework, 2006).
Lymphoedema is a progressive disease of
four stages: latency stage (stage 0), mild stage
(stage 1), moderate stage (stage 2) and severe
stage (stage 3) (International Society of
Lymphoedema, 2016).
Oedema: Swelling caused by the accumulation
of fluid in the extra-vascular tissue. Oedema
usually affects the feet, ankles and legs,
although it can occur anywhere in the body.
e cause of oedema should be identified
before beginning treatment. Bilateral oedema
is indicative of systemic conditions such as
cardiac failure, protein reduction and venous
insufficiency, standing or sitting in the same
position for too long, eating a large amount of
salty foods, being overweight, being pregnant,
malignancy or taking certain medicines.
Unilateral oedema is more often due to local
causes, such as deep vein thrombosis or
cellulitis.
Chronic lower limb oedema is a persistent,
abnormal swelling of the leg. Chronic oedema
has an ongoing effect on the viability of the skin
leading to complications, such as infection,
cellulitis, fluid leakage and ulceration (Bianchi
et al, 2012; Harding et al, 2015). Chronic
oedema can be considered a surrogate marker
for lymphoedema.
Static Stiffness Index (SSI): e difference
between standing and resting pressure
characterises the efficacy of a specific
compression garment to narrow the venous
lumen and encourage venous return (Partsch
et al, 2016). e Dynamic Stiffness Index (DSI)
is the change in the pressure between the
limb and garment (interface pressure) when
a person activates their calf muscle through
movement, such as walking or exercise. e
DSI demonstrates the garment’s ability to resist
calf muscle expansion and to generate working
pressure increases. e higher the SSI and DSI,
the stiffer the garment.
Stiffness: A measure of flexibility and the
ability of the bandage or hosiery to oppose
the muscle expansion during contraction
(Mosti, 2012). e yarn used and the technique
employed to knit the fabric will impact the
stiffness of the fabric. e less stiff the material,
the lower the pressure peaks during exercise.
Inelastic bandage and multi-layer bandage
systems generally have a higher SSI when
compared to compression hosiery (Vowden et
al, 2020).
GLOSSARY
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
4
Since 2015 and the second edition of the
Best Practice Statement there have been
the following areas of progress in medical
compression therapy.
National Wound Care Strategy
Programme guidance
In England, the National Wound Care
Strategy Programme (NWCSP, 2020)
has produced recommendations for the
immediate and necessary care of patients
who have one or more wounds below
the knee. e recommendations include
guidance on wound and skin cleansing,
application of a simple low-adherent
dressing and the use of mild graduated
compression for leg wounds if there are
no red flags to contraindicate compression
(Box 1).
Medical compression is a powerful,
active therapy that is part of the toolkit
for the management of chronic oedema,
lymphoedema and venous insufficiency.
In the absence of red flags (Box 1), mild
compression (around 20mmHg at the
ankle) should be considered the first-line
initial treatment for people who have one
or more wounds below the knee and not on
the foot (NWCSP, 2020). e patient should
receive a full holistic assessment if clinically
required or if there is evidence of venous
and/or lymphatic disease, with a view to
increasing the level of compression within
14 days. is is clear national guidance that
healthcare professionals should encourage
compression uptake among patients; failure
to provide a patient with appropriate care
may be seen as a harm.
Increasing range of medical
compression hosiery
Compression hosiery has evolved
considerably over the last few years and is
now a progressive therapy that goes beyond
Class I and Class II British Standard hosiery.
ere is now a greater variety of medical
compression hosiery available in terms of
style, which increases the expectations of
what can be achieved for patients. However,
variations in styles can lead to inconsistency
in the way medical compression garments
are selected and prescribed (NICE, 2012).
Patients may attend appointments having
already looked at the options online, but
it is important to remember that not all
medical compression hosiery are available
on every Trust’s formulary. erefore,
clinicians should be familiar with the
garments that they have available in order
to select the most appropriate garment for
the patient.
NHS Long-Term Plan
e NHS Long-Term Plan (2019) is a
commitment to facilitating measurable
improvements in population health and
to reduce health inequalities. In wound
care, the NWCSP (2020) recommends
greater awareness of the importance
of early intervention of compression
therapy or endovenous intervention. is
is to be achieved through greater public
awareness (e.g. public-facing campaigns
such as Legs Matter https://legsmatter.org)
and community, primary care, vascular,
tissue viability and lymphoedema services
promoting the same prevention and early
intervention messages.
Clinicians should stay
updated with evidence
and guidelines on the use
of medical compression
therapy. Clinicians
should be familiar with
the different types of
compression systems
and know when and how
to access and use them.
Failure to provide a patient
with appropriate care
should be seen as a harm.
Best Practice
Statement
Medical compression
is an active therapy and
will help to reduce your
symptoms. You should
expect your clinician to be
confident, competent and
enthusiastic about medical
compression. ey should
be familiar with different
types of compression
(e.g. compression hosiery,
stockings, bandages and
wraps), so that they can
offer treatments that
suit you.
Patient
expectation
Box 1. National Wound Care Strategy Programme (2020) guidance for people with
leg and foot wounds
People with leg and foot wounds should not be
treated with compression if they have any of the
following red flags:
• Acute infection of leg or foot (e.g. increasing
unilateral redness, swelling, pain, pus, heat)
• Symptoms of sepsis
• Acute or chronic limb-threatening ischaemia
• Suspected acute deep vein thrombosis
• Suspected skin cancer.
If red flags are present:
■ Treat suspected infection in line with
NICE (2020) antimicrobial guidelines
■ Immediately escalate to relevant
clinical specialist
■ For people in the last few weeks of life,
seek input from their other clinicians
to agree an appropriate care plan.
PROGRESS SINCE THE SECOND EDITION
5
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
CHAPTER 1: PRINCIPLES OF ASSESSMENT
Medical compression hosiery is the most
widely used form of compression in the long-
term management for a number of condi-
tions, including lower limb lymphoedema
and oedema, and conditions associated with
chronic venous insufficiency (CVI: NICE,
2012). Venous disease can be categorised us-
ing the CEAP classification (Lurie et al, 2020;
Table 3, page 12) to differentiate between
mild (thread veins or telangiectasia) and
severe (chronic skin changes/ skin discoloura-
tion/ulceration). Untreated CVI can also lead
to oedema formation. ere are many causes
of chronic oedema, but they largely fall into
four main categories:
■ Lymphoedema (both primary and sec-
ondary)
■ Lipoedema
■ Dependency oedema
■ Lymphovenous or phlebolymphoedema
(Green and Mason, 2006).
Many of the signs and symptoms of chronic
oedema — including dermatitis, distortion
of limb shape, episodes of cellulitis, develop-
ment of hyperkeratosis, non-pitting when
pressure is applied and hyper-pigmentation
of the skin — may be indicative of these
potential venous or lymphatic conditions.
erefore, it may be difficult to differenti-
ate between venous and lymphatic diseases,
highlighting that a full, holistic assessment is
required for patients with chronic oedema
(Wounds UK, 2015).
An accurate assessment of the patient, their
preferences, the severity of the disease pro-
gression, and any complications or comorbid
conditions will inform the treatment pathway
and compression garment selection. If gar-
ments are to be used safely, all patients need
to be able to report concerns they have with
their medical compression hosiery; this is
especially important where there is neuropa-
thy or cognitive impairment. e provision
of compression hosiery relies on the patient’s
protective sensation and their ability to rec-
ognise problems; where this may be an issue,
more regular review of the patient may be
required.
Selecting the correct
medical compression
hosiery should be based
on a thorough assessment
of the patient’s presenting
symptoms and knowledge
of how the products work.
Best Practice
Statement
Assessment for medical
compression should
include full assessment
of your limb, other
conditions, home life,
personal preferences, your
willingness to be involved
in care, and your ability to
apply and remove medical
compression hosiery.
Patient
expectation
MYTH
P
Compression up to 20mmHg can be
applied in the absence of red flags
without any form of arterial assessment
(NWCSP, 2020). An ABPI assessment
is recommended before commencing
compression therapy greater than
20mmHg. e role of the ABPI
assessment is to screen patients to rule
out PAD. Compression selection should
be based on the clinical assessment,
patient expectations and aim of
compression therapy in combination
with the ABPI result.
e ABPI result will indicate the
compression class or level that the patient
requires..
TRUTH
Holistic assessment
A detailed history should include past
medical and surgical history, family history
and history of limb or skin trauma. Current
medications (e.g. ACE inhibitors, inmmuno-
suppressants, steroids), concurrent illnesses
and the patient’s limb, circulation and skin
should also be assessed to identify the cause
of venous insufficiency or chronic oedema
and underlying disease process (Lymphoe-
dema Framework, 2006).
e NWCSP (2020) offers guidance on the
key elements of assessment that will guide
first-line intervention and provides red flags
for when compression therapy should not be
initiated (Box 1, page 4).
Vascular assessment
e ankle–brachial pressure index (ABPI)
result along with the patient’s history and
other elements of the assessment process can
be used to rule out the presence of significant
peripheral arterial disease (PAD). ere is a
common misconception that garment selec-
tion relies solely on the compression class or
mmHg and the result of the ABPI.
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
6
Instead, the results of the ABPI may influence
compression selection, and, it is important to
remember that, in the presence of significant
PAD, compression therapy can be dangerous
and should only be used at the recommenda-
tion of a vascular specialist. For more infor-
mation on the role of ABPI, see Best Practice
Statement: Ankle–brachial pressure index
(ABPI) in practice (Wounds UK, 2019a).
If an ABPI cannot be obtained, for instance,
the patient is unable to lie flat, or has oedema-
tous legs, pain, fragile skin or calcified vessels,
the arterial supply needs to be assessed in
other ways, for example toe pressure, pulse
auscultation and pulse palpation. If it is not
possible to obtain an ABPI initially due to
oedema, then it may be helpful to apply
compression therapy at 20mmHg to manage
the oedema and attempt to obtain an ABPI the
following week.
e BLS (2019) Position Document offers
further guidance on how to assess limbs in the
presence of oedema.
Treatment plan
Results from the mediven® observational study
found that patients’ individual factors were
rarely taken into account when prescribing
medical compression garments (Schwahn-
Schreiber et al, 2016). Just as medication
dosage is prescribed according to the needs
and characteristics of the individual, selection
of compression therapy should be based on
careful assessment of the patient’s individual
needs and condition identified in the holistic
assessment, taking into consideration patient
choice (Figure 1).
Figure 1. Factors that inuence medical compression hosiery selection.
1. PRINCIPLES OF ASSESSMENT
Medical compression
hosiery selection
Holistic
assessment
identifies level of
compression needed
to treat underlying
cause/symptoms
Arterial
assessment
e.g. ABPI, toe
pressure, pulse
palpation
Individual
patient factors
identified
during holistic
assessment, e.g. BMI,
mobility,
limb shape
Patient
choice
e.g. style, colour,
ability and willingness
to self-manage
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 7
CHAPTER 2: MEDICAL COMPRESSION HOSIERY
CONSTRUCTION
Medical compression hosiery must be se-
lected based on the outcomes of the holistic
assessment, patient preferences and the goals
of treatment. Product selection should also
take into account limb size and shape, skin
condition, allergies and sensitivities, patient
considerations (e.g. dexterity, psychosocial
issues) and the garment itself.
Construction of compression hosiery
e type of yarns and knitting techniques
used to manufacture medical compression
hosiery affects the stiffness or elasticity of the
garment. e material used to make compres-
sion garments is produced by knitting two
types of yarn together:
■ Inlay yarn – produces the compression
■ Body yarn – delivers the thickness and
stiffness of the knitted fabric (Clark and
Krimmel, 2006).
e arrangement of the inlay and body yarn
will produce either flat-knit or round-knit
fabric, which impacts on the material’s prop-
erties and indications for use (Table 1, page 8).
Flat-knit fabric tends to be relatively thick,
stiff and inelastic, which lets it lie across skin
folds without cutting into the skin. Flat-knit is
usually used for ‘made-to measure’ garments
because it can be more readily adapted to
limb shape distortion. ‘Off-the-shelf’ medical
compression hosiery is available in standard
sizes and tends to be manufactured from
round-knit fabric.
Elasticity and stiffness –
How compression works
Inelastic compression systems generally
have a higher Static Stiffness Index (SSI)
compared to elastic compression systems.
Stiffer compression systems have higher
working pressure peaks and can be more
comfortable than more elastic garments
with a lower SSI as they support the leg
and provide ‘strong wall stability’.
Conversely, the leg muscles contract and
change shape during walking and exer-
cising, so compression garments have to
provide some elasticity to allow this move-
ment while still supporting calf action and
counteracting the gravitational effect of
standing.
Compression standards
Medical compression hosiery is a medical
device, so it is measured against set cri-
teria to describe the support or compres-
sion applied to the lower leg. Standards
provide confidence about the quality and
life span of a product. It is important to
know how long a product is able to give
therapeutic levels of compression to avoid
putting patients at risk of sub-standard
care (Lymphoedema Framework, 2006).
For medical compression hosiery, there
are three internationally recognised qual-
ity compression standards – British Stan-
dard, German RAL Standard and French
Standard (Table 2, page 9).
ere is no independent quality European
standard, but the German RAL Standard is
widely accepted as the basic requirement
Practitioners should
understand the range
of medical compression
hosiery garments available
and understand how
the construction of the
garment affects clinical
efficacy.
Best Practice
Statement
Using language you
understand, the clinician
should be able to explain to
you the different medical
compression hosiery
garments available and help
to find the best garment to
suit your individual needs.
Patient
expectation
MYTH
Flat-knit medical compression hosiery
often requires a few more measurements,
but, for patients with chronic oedema/
lymphoedema, it is the optimal therapy
and should be considered once the initial
reducible oedema has been decreased.
Flat-knit medical compression hosiery should
be used as a ‘last resort’ for patients as they
are difficult to measure patients for and
mistakes are expensive and wasteful.
TRUTH
TRUTH
MYTH
Stiff or inelastic medical compression
hosiery provides higher working pressure
peaks while the patient is walking or
exercising but is comfortable at rest.
Stiffer medical compression hosiery is
sometimes perceived as uncomfortable.
TRUTH
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
8
Table 1. Features of round-knit and flat-knit medical compression hosiery
Feature Round-knit compression hosiery Flat-knit compression hosiery
Seam Seamless With seam
Manufacturing
Knit Knitted on a round cylinder Knitted in flat rows
Stitches per row Constant Variable
Shape Shaped by variable mesh size and pretension of the inlaid
elastic thread
Shaped by variable number of stitches with the elastic thread
laid in
Stretch High Low
read structure
Elastic thread Not covered Covered
Working pressure Low High
Effect Effect on veins to improve venous return Primary effect is to increase tissue pressure
Secondary effect is on the veins to improve venous return
Measurement When measuring the patient’s limb, measure the surface
circumferences
When measuring the patient’s limb, there is a degree of
interpretation required as the garment is designed to sculpt the
limb rather than necessarily match the size and shape presented
Uses Generally used for off-the-shelf hosiery, although it can be used
for made-to-measure hosiery
Commonly used for made-to-measure hosiery
Indications Typically for patients who have venous insufficiency or mild
lymphoedema
Most suitable where there is no or minimal limb distortion due
to oedema (Anderson and Smith, 2014)
Typically for patients who have chronic oedema/lymphoedema
due to the action on the limb, and its ability to be knitted to fit
any limb shape
If round-knit is causing problems for the patient, consider flat-
knit, which can be more comfortable and easier to apply
Images used with permission of medi UK©.
2. MEDICAL COMPRESSION HOSIERY
9
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
for certifying medical compression stock-
ings (BSI Standards Publication, 2018).
Clinicians should check that the medical
compression hosiery they are using has
a quality standard as this will guarantee
the stocking offers the correct ‘dosage’
of mmHg and that it delivers consistent
graduation of pressure levels, i.e. higher
at the ankle, and reducing throughout the
length of the stocking.
Compression class
e elasticity and stiffness of the textile
has a great impact on the haemodynamic
efficacy of a garment (Bjork and Ehmann,
2019). e stiffness of the compression ho-
siery material affects the compression lev-
els exerted by different types and classes of
hosiery. e compression measured at the
ankle is used to classify the hosiery into
compression classes; however, the pres-
sure range used to define each class varies
between the different standards, and
different techniques are used to measure
the levels of compression (Lymphoedema
Framework, 2006) (Table 2). As a result,
when selecting medical compression
hosiery, more emphasis should be given to
the compression dosage (mmHg) required
for the patient’s individual needs rather
than the compression class of the garment.
2. MEDICAL COMPRESSION HOSIERY
Table 2. Classes and standards of medical compression hosiery
Compression standards
Compression class British standard 40
(BS 661210) 3-month guarantee
(Partsch, 2003)
French Standard
(AFNOR NF 30.102A)
(Levick, 2003)
German Standard
(RAL GZ 387/1) 6-month guarantee
(Földi and Földi, 1983)
Class 1 mild
compression
14–17mmHg 10–15mmHg 18–21mmHg
Class 2 moderate
compression
18–24mmHg 15–20mmHg 23–32mmHg
Class 3 strong
compression
25–35mmHg 20–36mmHg 34–46mmHg
Class 4 extra strong
compression
Not available >36mmHg >49mmHg
MYTH
In most clinical situations, it is important
to consider a holistic approach (e.g. BMI,
limb shape, disease severity, patient
preference and ability) before deciding
what medical compression hosiery
garment will provide the right compression
dosage (mmHg) for the patient.
When choosing a medical compression
garment, the compression class and
compression dosage (mmHg) are the most
important aspect to consider.
TRUTH
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
10
CHAPTER 3: PATIENT CONSIDERATIONS DURING
MEDICAL COMPRESSION HOSIERY SELECTION
Different types of hosiery should be used
at different stages of disease progression,
depending on the conditions and symptoms
present, and whether or not oedema is pres-
ent. Compression garments are not a ‘one-
size-fits-all’ prescription.
Role of compression in oedema
Any form of oedema (i.e. oedema, chronic
oedema or lymphoedema) is a cause of con-
cern, and patients with oedema should seek
help as soon as possible and not wait until
issues have developed. Patients with signs and
symptoms of lymphatic insufficiency should
be prescribed appropriate hosiery as early as
possible to manage the underlying condition
and prevent disease progression (Anderson
and Smith, 2014). Without appropriate treat-
ment to reduce the oedema, the affected tis-
sues become progressively hard, fibrosed and
non-pitting, and the oedema fails to reduce
on elevation. Patients with oedema will have
an altered leg shape, which may include large
skin folds especially around the ankle and
knee making it difficult to ascertain where the
knee joint is. is can be exacerbated if the
individual is overweight.
In patients with chronic oedema, the key
function of hosiery is ongoing maintenance
(Wounds UK, 2015). Compression com-
bined with exercise increases lymph flow and
venous return, thus reducing the volume of
oedema. In addition, compression increases
the blood flow into the microcirculation,
which may improve wound healing and help
soften thickened or ‘woody’ tissues (Elwell,
2014). A made-to-measure medical compres-
sion hosiery garment may be more practical
for people with oedema as it can be measured
to the patient’s limb size and shape.
Toe oedema
Toe oedema can be a natural occurrence in
chronic oedema, but it can also be induced by
incorrectly applied compression bandaging
that leaves the toes, and often the forefoot,
vulnerable without compression (Elwell,
2014). Oedema management requires ongo-
ing maintenance, so if toe oedema is initially
resolved with bandaging, the patient will need
to be monitored and compression continued
with compression hosiery.
Medical compression hosiery is available
as open-toe or closed-toe garments. In the
close-toe option, the toe compartment of the
hosiery does not provide sufficient compres-
sion at the tip, but it does provide contain-
ment. It is important to protect the toes;
this can be achieved through the use of toe
gloves or caps, depending on the extent of the
oedema, patient choice and ability to apply
(Elwell, 2014). Toe gloves can be used with
open-toe or closed-toe hosiery.
Open-toe hosiery is frequently considered
easier to apply due to the fact they are often
supplied with a `silk-like slipper` device to aid
application. A patient may require open-toe
hosiery because:
■ e patient has arthritic or clawed toes
■ e patient has a fungal infection
■ e patient prefers to wear a sock over
the compression hosiery
■ e patient has a long foot size compared
with calf size (hosiery with longer foot-
size options are available, if necessary)
■ e patient requires regular podiatry/
chiropody appointments
■ ere is no oedema present in the toes,
and the patient prefers open-toe hosiery
(NICE, 2012).
Role of medical hosiery for patients with
venous insuciency
e therapeutic aim of compression for venous
insufficiency is to provide the highest level of
compression possible that is tolerated by the
patient. National guidelines (NWCSP, 2020)
suggest the use of 2-layer compression kits that
offer a minimum of 40mmHg as first-line, cost-
effective treatment of venous leg ulceration.
Compression hosiery is most commonly
used by patients with venous insufficiency
for either primary prevention or post-ulcer
healing to control oedema and reduce venous
hypertension.
People with healed venous leg ulcers and no
symptoms of arterial insufficiency should
be prescribed medical compression hosiery
and reviewed 6-monthly for replacement
compression garments and ongoing advice
about prevention of recurrence (SIGN, 2010;
NWCSP, 2020).
e patient’s clinical
presentation and
preferences should be
assessed during hosiery
selection (e.g. presence
of oedema, venous
insufficiency and their
body size, limb shape,
size and shape of foot and
manual dexterity).
Best Practice
Statement
Your clinician should
identify the medical
compression hosiery that
is best for your clinical
individual needs. Your
compression garment
should be comfortable to
wear. If it is uncomfortable,
an alternative garment
should be chosen.
Patient
expectation
11
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
3. CLINICAL CONSIDERATIONS
Patient-related factors
Ultimately, the hosiery selected should be
the patient’s choice. e practitioner’s job is
to explain the available options and direct
the patient towards the clinically optimal
choice. One of the most important factors
with regard to hosiery selection, partnership-
working and concordance is understanding
the patient’s motivations and what is
important to the patient in their life.
e practitioner should listen to the patient
and identify and understand the issues that
may result in non-concordance (Wounds
UK, 2015). Figure 2 summarises the patient-
specific factors that should be taken into
account when deciding which medical
compression hosiery to use.
Table 3 (page 12) offers suggestions for
medical compression hosiery and additional
treatment to manage the symptoms of venous
insufficiency and oedema/lymphoedema.
ere are tools available that can help guide
hosiery prescribing, for example, e Hosiery
Hunter® tool focuses on the patient’s disease
progression and clinical symptoms, BMI and
limb shape (Wounds UK, 2019b).
Skin condition
See tips for skin care
under compression
hosiery
(page 19).
Obesity
Consider wrap systems
or stiffer flat-knit hosiery
that has a higher SSI and
‘strong wall stability’
to hold the tissue.
Also consider hosiery
application aids
(page 17).
Low dexterity or
mobility
Consider supplying
patients with an aid
to ease application
(page 17).
Patient preference
e.g. style,
appearance, colour.
Figure 2. Patient factors to
consider during garment selection.
Consider limb shape
Bandaging, wrap
systems or a stiffer flat-
knit compression hosiery
to reshape distorted limb
shape and skin folds.
Patient motivation
Ask the patient what
is important to them
and what impact
treatment has on
their daily life.
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
12
3. PATIENT CONSIDERATIONS
Table 3. Suggestions for medical compression hosiery and additional treatment for venous insufficiency and oedema
Clinical indications Medical compression hosiery suggestion Additional treatment suggestions
Venous insufficiency: CEAP classification (Lurie et al, 2020)
C0 No visible or palpable signs of
venous disease
C1 Telangiectasias or reticular veins
No treatment required No treatment required
C2 Varicose veins
C2r Recurrent varicose veins
C3 Oedema
■ Round-knit, off-the-shelf, RAL Standard
compression
■ CCl 1 (18–21mmHg) or CCl 2 (23–25mmHg)
may be most appropriate
■ For patients who do not fit in standard sizes,
made-to-measure round-knit RAL Standard
options should be considered. If there is
significant shape distortion, flat-knit, made-
to-measure hosiery in CCl 1–3 should be
considered.
■ Daily skin care and emollient regimen to main-
tain skin integrity
■ Simple ankle/calf exercises to enhance the calf
muscle pump function
■ Increased activity/mobility, such as short walks
or water exercises (e.g. walking in shoulder-
high water, aqua-aerobics or aqua-cycling, but
not swimming). A GP gym referral scheme
may be available in some areas
■ Limb elevation on resting
■ Weight loss/maintenance (referral to dietitian
or bariatric services)
■ If oedema is venous related and is persistent or
worsening, patients should be seen by a vascu
-
lar specialist to explore venous intervention to
aid symptoms (NICE, 2021).
C4 Changes in skin and subcutaneous
tissue secondary to CVD
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie
blanche
C4c Corona phlebectatica
C5 Healed ulcer
■ Round-knit, off-the-shelf, RAL Standard
compression
■ CCl 2 (23–25mmHg) may be most appropriate
■ For patients not fitting in to standard sizes,
round-knit, made-to-measure, RAL Standard
hosiery should be considered.
C6 Active venous ulcer
C6r Recurrent active venous ulcer
■ 2-layer compression hosiery kit or compression
bandaging providing a combined 40mmHg
should be used.
Oedema classification (International Society of Lymphology, 2016)
Chronic oedema/lymphoedema
stage 0–2 (latency, mild or moderate)
■ Round-knit, off-the-shelf, RAL Standard
compression may be suitable in early stages
■ Flat-knit, made-to-measure, RAL Standard
hosiery should be considered in most cases
■ CCl 1–4 may be most appropriate according
to the holistic assessment of the individual and
their circumstances.
■ Daily skin care and emollient regimen to main-
tain skin integrity
■ Simple ankle/calf exercises
■ Avoid sitting with leg dependant/sleeping in
the chair at night-time; this may undermine all
compression treatment/management
■ Increasing activity/mobility, such as short
walks or water exercises (e.g. walking in
shoulder-high water, aqua-aerobics or aqua
cycling, but not swimming). A GP gym referral
scheme may be available in some areas
■ Limb elevation on resting
■ Consider simple/manual lymphatic drainage.
Chronic oedema/lymphoedema
stage 3
■ Flat-knit, made-to-measure, RAL Standard
compression hosiery with a high SSI is often
the most suitable
■ CCl 3 (35 –45mmHg) or CCl 4 (>49mmHg)
may be most appropriate; however, CCl 2
(23–35mmHg) may be considered according
to the holistic assessment of the individual and
their circumstances.
■ As above for chronic oedema/lymphoedema
stage 0–2
■ Weight loss/maintenance (referral to dieti-
tian or bariatric services).
CCl: Compression class, CVD: Cardiovascular disease.
13
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
Patient adherence to compression therapy
is often poor, but it is unhelpful to label
patients as intentionally non-adherent
(Green and Jester, 2019). Rather than
dismissing the patient as non-adherent to
treatment, instead listen to the patient’s
concerns and motivations with regard to
the presenting condition. To help to facili-
tate shared decision-making, use language
that is appropriate for the patient and cre-
ate an open, accepting environment that
allows the patient to share their own story.
It is acceptable to discuss compromise, as
this may keep the patient engaged and can
help ease patients into accepting long-
term treatments, such as medical com-
pression hosiery. Patients also need to be
aware that their choice cannot always be
fully accommodated, and that there may
have to be some balance between clinical
need and patient preference. Treatment
can be modified to use a lower compres-
sion if high compression is not tolerated
at first, but discussions should include
the fact that as tolerance builds over time,
compression levels may also be increased.
Practitioners and patients alike should
understand that compression is an on-
going treatment that needs to be worn
long-term, just as long-term medication
regimens should be adhered to.
e focus of compression treatment is to
slow disease progression, but it can be dif-
ficult for the patient to imagine what will
happen if they do not wear compression.
A way of promoting concordance with
compression therapy is to ask the patient
to consider the future with regard to their
lower limbs and to discuss the possible
consequences of not wearing compres-
sion therapy, i.e. What might occur if they
choose not to wear it? What could life be
like in a few years’ time?
During appointments, explore with the
patient other avenues that will aid treat-
ment and make compression more toler-
able, such as skin care, elevation, activity,
weight loss, access to support groups. Ask
questions that might not be directly relat-
ed to compression therapy itself, but might
help to identify areas where the patient
could be supported. Box 2 includes areas
of discussion for clinician and patient to
help inform compression selection.
‘Best’ garment for the patient
e ‘best’ garment for the patient is the
garment that they will use and wear cor-
rectly. To identify the best garment for the
patient:
1. Listen and explore: Explore the pa-
tient’s understanding, concerns and
hopes related to medical compression
hosiery (Box 2).
2. Asse ss: Assess the limb and patient to
determine the most appropriate medi-
cal compression hosiery clinically (see
Chapter 2).
3. Consider patient ability: Consider the
patient’s ability to apply compression ho-
siery, for example their manual dexterity
and their body size and shape.
4. Check fit: Check how the medical com-
pression hosiery fits on the leg(s).
5. Patient preference: Ask the patient if
they are happy with the appearance and
fit of the medical compression hosiery.
CHAPTER 4: ENCOURAGING SHARED DECISION
MAKING
e clinician should
be confident in their
own knowledge of
medical compression to
confidently explain the
impact of compression
hosiery. During
consultations, explore the
patient’s individual ideas,
concerns and expectations
of compression therapy.
Best Practice
Statement
You should expect to be
involved in making joint
decisions about your care,
feel able to voice your
concerns and be reassured
that changes can be made
to your care if required.
Your clinician may ask
whether you have family/
carers who would like to
take part in the care plan if
you need extra support.
Patient
expectation
MYTH
Some conditions such as lymphoedema
require compression therapy for life, others,
such as varicose veins, may be surgically
treated and may not require life-long
therapy. For patients with chronic oedema
and venous insufficiency where intervention
is not suitable, medical compression therapy
is a life-long therapy.
Wearing compression is always for life.
TRUTH
TRUTH
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
14
Box 2. Questions to ask the patient during medical compression hosiery selection:
gathering information and encouraging adherence
Supporting patients at home
To successfully support your patient to care at
home, they need to have understanding of:
■ e reasons why hosiery has been pre-
scribed
■ A well-fitting garment, skin care and how
to apply and remove the garment
■ e expectations of care
■ When they should contact the clinician
and the ‘red flags’
■ e emergency contact details of who to
contact if issues arise
■ When and how to re-order hosiery
Patients may also benefit from keeping a self-
care journal and being provided with where to
access online patient resources (e.g. Legs Mat-
ter campaign: www.legsmatter.org/help-infor-
mation/resources) or advice leaflets designed
for patients (e.g. www.lymphoedema.org).
4. SHARED DECISION-MAKING
MYTH
If the patient refuses to wear medical
compression hosiery, listen to the patient’s
concerns and why they feel they cannot
wear compression hosiery. Consider with
the patient whether the expectations of care
need to be modified. e expectations of
care should be agreed between the clinician
and patient before treatment begins and
revisited during treatment.
If the patient refuses to wear medical
compression hosiery, there is nothing more
that can be done for the patient.
TRUTH
TRUTH
MYTH
Patients with venous and lymphatic
disorders should always feel more
comfortable when wearing medical
compression hosiery than when they are not.
Wearing medical compression hosiery is
uncomfortable.
TRUTH
TRUTH
■ What do you understand about the condition in your leg(s)?
■ Have you used medical compression garments before?
■ If yes, how did they affect your day-to-day lifestyle?
■ What are your priorities for treatment?
■ Do you feel confident in applying and removing your hosiery?
■ Is there someone who can help you apply/remove your medical compression garments?
■ Are you happy with the medical compression hosiery’s colour? Pattern? Texture? Softness? (is is
especially important to ask as summer approaches, so patients have medical compression they are
comfortable with when wearing lighter/shorter clothing).
■ Would you prefer open- or closed-toe medical compression hosiery?
■ Do you have at least two pairs of medical compression hosiery? (Patients must wash and wear pairs
alternately, and not keep one pair ‘in good shape’ for later).
15
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
Medical compression hosiery is only effective
if the patient’s limbs are measured accurately
and the garment is applied correctly. Medical
compression measured and prescribed inac-
curately can lead to tissue trauma/pressure
damage particularly if the fabric rolls during
wear or is too tight and digs into the skin
(Robertson et al, 2014). ese experiences
may stop the patients wanting – or being able
– to continue with treatment.
Limbs should be measured and hosiery pre-
scribed according to each manufacturer’s own
measuring guide, as sizes vary according to
manufacturer. Every effort should be made to
reduce oedema before hosiery is measured. In
some cases, bandaging may be required dur-
ing the intensive management phase to help
reshape the limb, reduce limb volume and/
or treat the ulcer. Once oedema has reduced,
patients can be measured for medical com-
pression hosiery that will deliver sufficient
pressure to control their limb on an ongoing
basis. After measurement, it is important to
continue with compression bandaging until
the patient’s compression hosiery garment
is available. Box 3 includes tips for hosiery
measurement.
If a patient does not fit the measurements on
the manufacturer’s sizing chart for standard,
off-the-shelf sizes, ‘made-to-measure’ medical
compression hosiery should be prescribed.
Made-to-measure can be considered first line
for chronic oedema and larger limbs with a
uniform shape, i.e smaller at the ankle, in-
creasing in size up the leg. Where skins folds
are present compression bandaging will be re-
quired first to achieve reduction and reshap-
ing. If fitting is not accurate, hosiery will fail
to prevent oedema, maximise ulcer healing or
prevent recurrence, and will increase the risk
of skin damage complications (Wounds UK,
2015).
CHAPTER 5: MEASURING AND SIZING
Limbs should be
measured and medical
compression hosiery
prescribed according
to the manufacturer’s
own measuring guide, as
sizes vary according to
manufacturer. ere are
tools available to support
clinicians to measure
and identify the correct
compression garment for
the patient.
Best Practice
Statement
You should expect your
clinician to measure both
of your legs so that you can
be prescribed appropriately
sized medical compression
hosiery.
Patient
expectation
Box 3. Tips for hosiery measurement (Wounds UK, 2015)
■ Use the correct measuring guide for the brand of medical compression hosiery to be pre-
scribed, as each manufacturer will vary
■ Take measurements as early in the morning as possible, when oedema is at a minimum
(see below for common measurement points for A] off-the-shelf; and B] made-to-measure
compression hosiery)
Images used with permission of medi UK©.
■ Take measurements directly against the skin to ensure accuracy (use a skin marker to ensure
accuracy and reproducability)
■ Take measurements for both leg, as they may differ in size
■ Take measurements when the patient is sitting down, with feet flat on the floor
■ If the patient has skin folds due to oedema or the limb is particularly misshapen, a specialist
flat-knit garment may be required. is will require specialist assessment.
■ Ask the patient to wear their medical compression hosiery to the next appointment so that the
fit can be re-evaluated.
A.
B.
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
16
e practitioner should prescribe a minimum
of two, but preferably three pairs of medi-
cal compression hosiery (one to wash, one
air drying and one to wear) every 6 months
(3 months for British Standard compres-
sion hosiery), to ensure the effectiveness of
compression. is is regardless of the type of
compression or class. Prescriptions should
be clearly and thoroughly specified to ensure
accurate dispensing.
When a new prescription is required, the pa-
tient must be re-measured. If the patient has
a current medical compression prescription,
it should be continued until the new prescrip-
tion is ready. If the weight of the patient re-
duces or increases, this is likely to change the
size of the limb. Old, worn hosiery should be
handed back to the clinician when the patient
receives a new prescription to prevent the
patient wearing old ‘comfy’ medical hosiery.
Some hosiery manufacturers a wide range of
colour and options on prescription, which
may support concordance. Patients may be
given details of websites where they can re-
search the hosiery products further online.
FAQs
5. MEASUREMENT AND SIZING
MYTH
It would be beneficial to the patient if
clinicians prescribed a minimum of two
pairs of medical compression hosiery every
6 months (3 months for British Standard).
Some patients may be able to purchase more
pairs privately if they are given the full details
of the garment.
e patient only ever needs two pairs of
medical compression hosiery.
TRUTH
TRUTH
Fitting
The patient has previously found compression uncomfortable
and doesn’t want to try again – what do I do?
If the patient did not tolerate compression in the past, it does
not mean that they will not be able to tolerate compression
ever again. If the hosiery is not comfortable, it is not the right
choice for this patient right now. Talk to the patient again and
listen to their concerns.
What if the hosiery digs in at the top around the knee?
Check that the garment is not overstretched and that place-
ment is correct (the top band should sit two fingers’ width
from the crease of the knee). If the size and the placement are
correct, it may be beneficial to change the fabric. Contact your
local TVN/lymphoedema specialist if unsure.
What if the compression hosiery is too tight?
Ensure patients understand that a larger garment size will not
make the garment feel less tight, and that this will reduce the
effectiveness of the treatment. Less elastic garments may be
useful if this feeling persists.
What if the top of the compression hosiery is rolling?
Check that the garment is the correct size/measurement
and ensure placement is correct (with the top band sitting
two fingers’ width from the crease of the knee). If the size
and placement are correct, it may be beneficial to suggest
using a garment with a different style or a stiffer fabric. If the
hosiery are thigh-length garments and the hosiery fit has
been checked, consider using an adhesive designed to adhere
compression garments to the limb.
How will I know that the compression garment is working?
Compression therapy will help with limb volume reduction
and leg comfort. If the leg was initially swollen and the medi-
cal compression hosiery starts to loosen and fall down after
a few weeks, this could be a positive sign that treatment is
working. You might have to order a smaller-sized stocking
initially, depending on the condition you are treating and until
the limb is stable. The patient should know who to contact if
the garment is getting loose quickly, and that this is not a sign
that the compression therapy has worked and is no longer
required.
What if the garment starts to fall down?
Garments that continue to fall down cannot provide thera-
peutic compression. If the garment fits and the fabric is the
correct type for the condition being treated, the use of a body
glue, or addition of a top band, may help to keep the garment
in place.
Hosiery application (donning) and
removal (doffing)
Even if the patient is experienced with
compression hosiery, they should not
independently apply compression hosiery
for the first time or if the prescription has
changed. e practitioner should demon-
strate donning and doffing, then help the
patient practise until they are competent at
applying and taking off compression hosiery
on their own. Showing how to apply and
remove the hosiery and what constitutes a
good fit when a carer is present is beneficial
(Box 4).
It is important to explain that compression
hosiery application is a new skill, which
may require patience and practice in the
early phase of treatment. Patients should
ensure they set aside time in their daily
routine and their environment is suit-
able to apply/don and remove/doff their
hosiery. Instructions to apply thigh-length
hosiery without a fabric or rigid aid are
shown in Figure 3, page 18.
If a patient finds it difficult to don their
hosiery, a hosiery application aid can help.
Application and removal aids are typically
either fabric or rigid. A fabric compres-
sion stocking aid is usually made from a
slippery fabric, which is designed to make
it easier to slide compression hosiery over
the foot and leg. Patients will still need
to be able to bend to reach their feet with
fabric aids. Rigid aids typically provide a
frame that lets the patient step into hosiery
or pull up garments without bending to
reach the floor (Dilks and Green, 2005).
ere are many different aids available,
which should be chosen according to each
patient’s physical needs (Table 4, page 19).
Other aid options include non-slip mats,
roll-on adhesives and roll-on membranes.
Wearing rubber gloves with soft interior
linings can aid grip during application
and removal of all types of compression
stockings.
17
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
CHAPTER 6: KEY ELEMENTS TO SUPPORTED SELF
MANAGEMENT: HOSIERY APPLICATION, REMOVAL
AND CARE, AND SKIN CARE
e practitioner who
measured, selected and
prescribed the medical
compression hosiery
should guide the patient
through first application,
and discuss how to apply
and remove the hosiery,
how to manage skin
care under compression
and how to take care of
compression hosiery.
If this is not possible,
another qualified, skilled
practitioner should guide
the patient.
Best Practice
Statement
e clinician who
measured and prescribed
your medical compression
hosiery should show you
how to apply (don) and
remove (doff) the hosiery,
and provide you with
advice on how to care
for your limb, skin and
garments. If you do not
understand any part of
what has been said, you
should ask for further
explanation.
Patient
expectation
Box 4. Quick guide for good medical
compression hosiery fit
■ Hosiery should fit well and not feel loose
■ Hosiery should not be twisted, rolled or
folded down
■ Hosiery should sit two fingers’ width below
the knee crease, or four fingers’ width
below the gluteal fold in thigh-length gar-
ments
■ e fabric should be evenly distributed
over the length of the garment
■ Hosiery should not pinch the skin or cause
pain
■ If numbness or pain occurs while wear-
ing medical compression, it should be
removed and reported to the clinician who
prescribed the compression hosiery
■ Hosiery should not cause shortness of
breath.
Clinicians who prescribe compression
hosiery should ensure that they are familiar
with the aids that are available on FP10
locally and advise patients accordingly.
MYTH
Hosiery application and removal aids are not
available on the NHS.
TRUTH
Can the patient wear compression while
they sleep at night?
It is preferable that the patient wears medi-
cal compression hosiery throughout the day
and removes them at night, allowing for the
skin to be routinely checked for compression
damage and to be moisturised. However,
if the patient sleeps in a chair, they should
wear medical hosiery throughout the night
to prevent the legs from swelling. Patients
with complex lymphoedema may be advised
to wear a garment overnight.
FAQs
Application & removal
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
18
1. Reach into the compression
stocking and grasp the heel
6. HOSIERY APPLICATION,
REMOVAL AND CARE
Figure 3. Instructions to apply thigh-length medical compression hosiery without a fabric or rigid aid. Images used
with permission of medi UK©.
2. Turn the compression stocking
inside out at the heel
3. Pull the compression stocking
over the foot to the heel
4. Hold the fabric of the outer
layer at the middle of the foot
7. Distribute the fabric evenly over
the calf and in stages up to the
knee
5. Lift the fabric up over the heel
8. Lift the fabric up over the knee
6. Use both hands to grasp the
material that is hanging down
9. Check the complete compres-
sion stocking for the correct fit
and even distribution of material
over the limb
Applying compression hosiery
19
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
Hosiery care
Patients will largely be responsible for
keeping their compression hosiery in good
condition, so it is critical that they receive
advice to maximise the life and effective-
ness of the garment until the next pre-
scription. Providing written information
that patients can refer to on an ongoing
basis is essential.
Table 4. Main examples of hosiery application and removal aids
Fabric applicators Rigid applicators
Fabric applicators work similarly to slide
sheets. ey are made of slippery material
to assist with application of hosiery. ey
can be used for open-toe and closed-
toe hosiery, and are compactable and
transportable.
Rigid applicators often comprise of a frame
with a semi-circular tube to assist with
opening the medical compression stocking
to allow for easier application. ese types
of frames often have long handle options
and may assist those who have difficulty
bending forward to and reaching their foot.
Miscellaneous:
Anti-slip mats: Anti-slip mat to aid application and removal of hosiery
Gloves: Rubber gloves with soft interior linings to aid grip during application and removal of
all types of compression stockings
Roll-on adhesive: Helps hosiery ‘stick’ to the limb and can be washed off with water
Rolling compression aids: e hosiery is folded down over the flexible, donut-shaped aid,
which is then slid up or down the leg to apply or remove the hosiery.
6. HOSIERY APPLICATION,
REMOVAL AND CARE
FAQs
Hosiery care
How does the patient clean their medical
compression hosiery?
Compression garments can generally be
worn for a maximum of 3 days before
washing. Most compression hosiery can
be laundered daily in a washing machine at
40
o
C; fabric softener should not be used.
Check with the manufacturer’s information
for specific hosiery care.
If the compression is laddered, should it still
be worn?
No, if the compression hosiery is damaged
in any way it loses its structural integrity and
must be replaced.
Can the patient exercise or swim in medical
compression hosiery?
Wearing compression garments encourages
good muscle pump action, and therefore is
very beneficial to wear during activity. If the
patient wants to swim wearing hosiery, after
swimming, the hosiery should be taken off,
rinsed to remove chlorine or saltwater, and
cleaned and dried as soon as possible.
Should hosiery be worn in the hot summer
months?
When it is hot, the body may swell more
readily; therefore, wearing compression
hosiery is required in warmer months and
climates. Some compression technologies
have incorporated breathability and climate
control into their designs, making the limb
feel cool in the summer and warm in the
winter. Other techniques, such as spraying
cold water onto the garment to cool the limb
can be effective (the ‘wicking’ ability of some
fabrics will ensure this dries off quickly).
Check with the manufacturers if you have
questions.
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
20
Skin care under compression
CVI, oedema and lymphoedema affect
the skin integrity, so patients with these
conditions have an increased risk of skin
infection (Harding et al, 2015). Skin care
is therefore a priority for these patients,
so providing the patient with simple-to-
follow instructions on how to care for their
skin at home is integral to supported self-
management:
■ Ensure legs are dry before putting on
medical compression hosiery.
■ Avoid applying emollients (e.g. lotions
or creams) just before application of
hosiery, as they can make the garment
harder to put on. Applying emollients
20 minutes before medical compression
application can reduce the difficulty.
■ Apply skin care products (e.g. emollients,
topical corticosteroids) in the evening,
after removing hosiery for bed.
■ Check daily for skin changes, including
on the legs, toes/nails and space between
the toes.
■ Hosiery should be applied first thing in
the morning, when oedema is at its low-
est levels, to help avoid skin damage and
limb expansion.
■ Gently elevate legs when resting to
reduce pooling of oedema that can result
in skin damage (high elevation is not
necessary).
■ Keep physically active to the fullest
extent possible, depending on each pa-
tient’s specific situation. Follow guidance
for ankle exercises for CVI, oedema and
lymphoedema if possible.
6. HOSIERY APPLICATION,
REMOVAL AND CARE
When should the patient remove their
medical compression garments?
If possible, the patient can remove their
hosiery daily to inspect the skin for any
breaks, signs of infection (e.g. increased
temperature or tenderness) and rashes or
fungal infections (e.g. tinea pedis), or the
early signs of pressure damage. Particu-
lar attention should be given to areas of
reduced sensation, such as under skin folds
and between the toes.
FAQs
Skin care
21
BEST PRACTICE STATEMENT: COMPRESSION HOSIERY
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