Socks: Getting in shape with new technologies

Socks are often an afterthought for patients with diabetes, but they shouldn’t be. Advances in materials science and new twists on old favorites mean that modern socks conform to feet without the bunching, chafing, slipping, and irritation of the past. Some even promote healing.

Socks have come a long way since the days of the long white tube with the colored bands around the top. A visit to any sporting goods store will offer a rock climbing wall’s worth of “performance socks,” tricked out with high-tech properties such as moisture wicking, temperature control, and arch support.

No doubt that these sock manufacturers have taken more than a few cues from diabetic socks, which have always combined fibers to maximize support, cushioning, and comfort. But do diabetic socks offer advantages to patients beyond these performance socks? Yes and no, according to the experts. Proper fit and sizing play a big part in ensuring that diabetic socks do their job.

Materials

One hundred percent cotton or wool socks have been criticized for not maintaining the sock’s shape on the foot, which can be problematic for diabetic patients on two fronts. The increased friction between the skin and the fibers can lead to ulcerations. In addition, 100% cotton or wool socks may start out quite tight, possibly reducing circulation in patients who already have compromised blood flow. As the socks are worn over time, the fibers loosen, resulting in a sock that slides between the foot and the shoe, again leaving diabetic patients vulnerable to shear, blisters, and potential ulcerations.

On the other hand, purely synthetic socks may not allow sweat to evaporate properly; sweaty feet can lead to fungal infections, which in and of itself is more complicated in a patient with diabetes than an otherwise healthy subject and can also be another gateway to ulceration. Synthetics blended with natural fibers would seem to be the best bet, offering support and—most importantly—breathing room, according to Marybeth Crane, MS, DPM, FACFAS, CWS, managing partner of Foot and Ankle Associates of North Texas in Grapevine.

“I’m not one that really likes totally cotton socks,” she said. “I find that socks with a little bit of Lycra in them are better. They also offer some compression to address swelling.”

Crane also advocates seamless socks because seams, constantly rubbing against the skin, may cause blisters, calluses, or ulcerations. For a patient with neuropathy, a skin irritation caused by the seam will not be felt immediately, increasing the risk of calluses and other pre-ulcerative conditions.

Moisture wicking can be achieved with a variety of materials: Wool, synthetics, cotton, silk, and renewable materials. Each has its pros and cons.

The biggest advantage of wool, and merino wool in particular, is that it is thermostatic so that feet stay comfortable in a range of temperatures. Wool also can absorb 30% of its own weight in water so feet are more likely to stay dry. Cushioning is another benefit, because diabetic patients have an increased risk for pressure ulcers and because focused areas of high plantar pressure are most likely to become sites of ulceration. On the downside, wool dries out slowly, and wool socks generally carry a higher price-tag than other materials. Both factors could prove problematic for a diabetic patient who cannot afford multiple pairs of socks.

Synthetics, such as nylon and Lycra spandex, help socks retain their shape. Some synthetics may provide arch support, which can help lateralize plantar pressures and provide a bit of extra stability for diabetic patients who have problems with balance. Socks with polypropylene, polyester, or acrylic fibers will offer moisture wicking. Synthetic socks are durable but may be unsuitable for warmer climates. In addition, the socks’ insulation properties may be reduced if the socks get too wet.

Silk is a natural insulator that is often blended with wool for extra softness. The lightweight material offers reliable wicking and a smooth texture; however, it is less durable than other materials. This is important not only with regard to the cost and inconvenience of replacing socks, but also because areas of wear in a sock’s fabric fail to protect the diabetic foot and leave skin vulnerable. In addition, the very “silkiness” of a silk-based material could cause the foot to slip within the shoe, leading to abnormal skin shear and friction-induced skin issues.

A full cotton sock is not advisable for the diabetic foot. The material is easily saturated with sweat and dries slowly, both of which leave the foot vulnerable to blisters. Cotton is less expensive than other materials and, when blended in small quantities with synthetics, it can offer softness.

Eco-friendly materials, such as bamboo, corn-based polylactic acid (PLA), hemp, and charcoal, offer moisture wicking and odor control properties. Combining these materials with synthetic fabrics ups their durability.

Finally, socks made of fabrics embedded with copper, silver, or charcoal fibers offer protection against bacteria. Patients with diabetes are less resistant than healthy individuals to infection, which can lead to complications such as cellulitis (diffuse inflammation of the connective tissue) or osteomyelitis (bone infection, which almost always occurs in the presence of an ulcer). However, a sock billed as resisting bacterial growth does not automatically reduce the chance of infections on the surface of the foot, nor will this type of fabric necessarily protect an open wound from becoming infected. Visual inspection of the feet, along with daily washing, is still needed to avoid infection.

Socks come in sizes

While it’s obvious to patients with diabetes that their shoes come in sizes, the same cannot always be said for socks.

“A lot of patients don’t realize that their socks need to be the correct size,” Crane said. “If the sock is too tight, it can cause ingrown toenails, it can cause problem with compression in between the toes, it can cause ulceration between the toes.”

Crane said she advices her patients with diabetes to “size up” when it comes to socks.

“For instance, I wear a size 6-6.5 (in shoes) and most size small socks go to 6. I’ll go to a medium sock instead of a small because they will shrink once they are washed,” she said.

Socks that are too tight can reduce flow, which is particularly problematic in patients whose diabetes is complicated by vascular disorders. Poor blood flow impairs healing of existing ulcers and other wounds; it can exacerbate loss of sensation in neuropathic patients, increasing the risk of neuropathic ulcers; and it can also increase the risk of ischemic ulcers, which are even more difficult to heal. However, socks that are too big can wrinkle or bunch inside the shoe, putting excess pressure on the feet. For patients with neuropathy, a bunched sock can easily lead to blisters or ulcerations.

But as with shoes, neuropathic patients often need a sock to feel snug against their leg. A sock with binding elastic at the top may feel right to these patients, but can negatively impact blood flow.

If possible, socks and shoes should be fit simultaneously, Crane added.

“One of my pet peeves is that the socks and shoes are not fit at the same time,” she said. “I have a patient who has a beautiful pair of diabetic shoes, but she wears them with pantyhose that she buys at the drug store. The hose have a seam in them and that causes an ulceration on the tip of her toe.”

Another argument for fitting shoes and socks simultaneously is that once a sock size has been determined, the shoe size may change. For instance, a neuropathic patient who is prescribed a therapeutic sock with silicone padding to reduce plantar pressure may have to go with a shoe that is a half-size larger or convert to extra-depth shoes.

OTS socks

Crane pointed out that socks are not covered under the Therapeutic Shoe Bill (see HEADLINE, PAGE XX) so they are an out-of-pocket expense for the patient.

“Good socks are expensive,” she said. “You can’t buy a good pair of socks for $4. You are looking at as much as $20.”

As a result, off-the-shelf (OTS) socks are not always out of the question.

“In terms of the OTS, performance socks, I like the ones that have a bit of Lycra and a bit of either DryWeave or CoolMax to wick the sweat away from the foot. That’s necessary whether the person is a diabetic or not,” she said.

But these performance socks don’t necessarily offer the kind of support that a diabetic foot requires, pointed out Roy H. Lidtke DPM, CPed, FACFAOM, associate professor of podiatric medicine and surgery at Des Moines University and director of the Center for Clinical Biomechanics at

St. Luke’s Hospital, Cedar Rapids, IA. Socks made especially for patients with diabetes provide that support, along with added benefits.

“They offer extra padding and compression that can produce a form of neuromuscular feedback,” Lidtke said. “An example would be when you wear a pair of padded socks with areas of elastic compression and you feel a tightness around your arch. This provides greater proprioceptive feedback on the position and neuromuscular control of the foot.”

Diabetes is often complicated by a loss of postural control, which research suggests is a product of more than just the loss of sensation that accompanies neuropathy. Any intervention that can improve proprioception could potentially also help to improve postural control and, in turn, reduce patients’ risk of falling.

Most diabetes amputations 'preventable'

An estimated 80% of lower limb amputations in people with diabetes are preventable, a charity has revealed.

In Northern Ireland, there were 199 diabetes-related amputations last year.

A campaign has been launched aimed at putting a stop to preventable amputations.

'Putting Feet First' by Diabetes UK Northern Ireland wants to reduce diabetes-related amputations by 50% within five years.

Diabetes is a serious condition where the amount of glucose in your blood is too high.

People with Type 1 diabetes do not produce any insulin which is needed in order to control the levels of glucose in the blood. Those with Type 2 diabetes produce an insufficient amount of insulin - or can be insulin resistant.

If blood glucose levels are not maintained at normal levels, it can lead to long-term complications such as heart disease, stroke and amputation.

There are currently 73,500 people diagnosed with diabetes in the region.

Iain Foster, the charity's National Director, said: "A single preventable amputation is one too many so the fact that hundreds of people in Northern Ireland have endured unnecessary foot amputations is nothing short of shameful."

Amputations have a devastating effect on quality of life and so every amputation that results from poor healthcare is a tragedy.

Iain Foster
He explained that diabetic foot problems arise from reduced circulation and damaged nerve endings.

He said a big part of bringing this to an end is giving people with diabetes information about how to look after their feet.

The charity wants everyone with diabetes to get a thorough annual foot check and for a specialist diabetes foot care teams for foot ulcers to deal with referrals within 24 hours.

"Many people with diabetes aren't even aware that amputation is a potential complication. We also need to make sure that people with diabetes understand what healthcare they should be getting."

Mr Foster said there are opportunities within the current healthcare system for problems to be detected early - and treatment obtained - before complications set in.

The campaign will include working with healthcare professionals in GP practices and areas, such as A&E departments, to increase awareness of the signs of early complications and the need for a quick referral to specialist staff.

He added: "Quality of care makes a big difference to amputation rates. Foot ulcers can deteriorate in a matter of hours so failing to refer someone quickly enough can literally be the difference between losing a foot and keeping it."

"It is a scandal that needs to be brought to an end."

WWE Legend Kamala Loses Foot To Diabetes

WWE legend Kamala is at risk of losing another foot due to his diabetes-related medical problems -- this according to his son.

As TMZ previously reported ... Kamala’s left leg was amputated last year due to ongoing complications with diabetes and high blood pressure. Unfortunately the problems aren’t over.

Kamala Jr. went on "The Roman Show" today and revealed, “[My father] is havingcomplications with his other foot now ... Friday we’ll know if they have to take his other foot off.”

Seinfeld Actor Survives After Shooting Self in Head

Seinfeld actor Daniel von Bargen, who's best known for playing George Costanza's boss Mr. Kruger in the sitcom, is in critical condition after a failed suicide attempt earlier this week, TMZ reports.

The 61-year-old was in his Cincinnati apartment Monday morning when he shot himself in the head and then called for help. According to audio of the 911 tape posted on the gossip site, he told the operator, "I've shot myself in the head and I need help."

Check out the rest of today's news

The gunshot to the temple was not an accident. Von Bargen, who is a diabetic, recently learned some bad news. "I was supposed to go to the hospital and I didn't want to. So I shot myself... They were supposed to amputate at least a few toes."

Von Bargen was transported to a nearby hospital.

The veteran actor also recurred as Commandant Edwin Spangler on Malcolm in the Middle. On the big screen, he's appeared in O Brother, Where Art Thou?, The Faculty and Super Troopers.

CDC: Big Drop in Diabetes Amputations

65% Lower Rate of Foot, Leg Amputations in Just Over a Decade

Jan. 24, 2012 -- There has been a dramatic drop in the rate of diabetes-related amputations in the U.S., and experts attribute the improvement to better management of risk factors that lead to the loss of feet and legs.

The amputation rate declined by 65% among adults with diabetes in a little over a decade, the CDC reports.

Foot and leg amputations occurred in 4 out of every 1,000 adults with diabetes in 2008, compared to 11 out of every 1,00 in 1996, the CDC reports.

Non-injury-related amputation rates were still eight times higher among those with diabetes than adults without the disease.

Nevertheless, the decline shows that efforts to reduce the complications of diabetes are having a major impact, says American Diabetes Association President of Medicine and Science Vivian Fonseca, MD.

“This is very encouraging and important news for people with diabetes,” he says. “The decline confirms the tremendous progress we have made in translating research into practice."

What Your Feet Say About Your Health

Diabetes-Related Amputations Down

Nerve damage or neuropathy is a common complication of diabetes, especially among people who have had the disease for many years.

Poor control of diabetes, such as prolonged high blood sugar, low insulin levels, and high blood pressure, are believed to be major contributors to diabetes-related nerve damage.

According to this new study, foot and leg amputation rates serve as an important gauge of the effectiveness of efforts to reduce diabetes complications by controlling these risk factors.

Researchers analyzed data from two national surveys to determine the prevalence of diabetes-related leg and foot amputations in adults aged 40 and over.

Among the major findings:

· Between 1996 and 2008, the rate of leg and foot amputations among adults with diabetes declined by 65%, with men having three times the rate of amputations as women (6 per 1,000 vs. 2 per 1,000).

· Amputation rates were higher among blacks than whites (5 per 1,000 vs. 3 per 1,000).

· Those over the age of 75 had the highest rate of amputations.

The study will appear in the February issue of the journal Diabetes Care.

Keep a Close Eye on Your Feet

While the decline is encouraging, CDC epidemiologist Nilka Rios Burrows, MPH, says much more could be done to reduce amputation rates among diabetic people.

“The message to patients and their doctors is that addressing the modifiable risk factors for diabetes complications can have a huge impact,” she says.

That means aggressive medical management of blood pressure, blood sugar, and cholesterol, maintaining a healthy lifestyle, and keeping a close eye on your feet.

“A foot exam should be part of every medical visit,” Burrows says. “If the doctor doesn’t mention it, the patient should. And people with diabetes should check their own feet every day to look for sores or injury.”

Other recommendations for diabetic people from the CDC’s National Diabetes Education Program include:

· Wash your feet every day, keep feet soft with lotion or petroleum jelly, smooth corns and calluses gently, and trim toenails frequently.

· Wear shoes and socks at all times to minimize the risk of injury.

· Protect feet from extreme heat and cold.

· Remain active and do other things to promote blood flow to feet.

· Discuss foot care with your doctor.

Study Cites Eleven Risk Factors That Could Predict Amputation

Given that lower extremity amputation is a devastating consequence of diabetic foot infection, physicians must be vigilant for the signs that could presage amputation. In a new study in Diabetes Care, authors have developed a risk score of 11 factors that could predict amputation.

Researchers identified 3,018 patients who were hospitalized for culture-documented diabetic foot infection at 97 hospitals in the U.S. between 2003 and 2007. Among those patients, 21.4 percent underwent a lower extremity amputation.

The 11 risk factors for amputation, in ascending order of point value, are: chronic renal disease or creatinine >3 mg/dL; male sex; temperature <96°F or >100.5°F; age 50 or older; ulcer with cellulitis; history of amputation; albumin <2.8 g/dL; history of peripheral vascular disease; white blood cell count >11,000 per mm3); surgical site infection; and transfer from another acute care facility.

Authors note that treatment of a patient with a low score may require fewer medical resources than a patient with a high risk score. The study also says in an attempt to avoid amputation, healthcare providers should concentrate efforts on a patient with a risk score of more than 21 as they have a 50 percent chance of amputation.

Lead study author Benjamin A. Lipsky, MD, notes researchers developed the risk score specifically to use information that is present at (or soon after) the time of hospitalization. As he notes, this info includes findings from the history, physical examination or simple laboratory tests. He foresees “relatively minimal” organizational challenges for healthcare facilities implementing this scoring system. Dr. Lipsky says facilities would just need to educate providers about the score and perhaps provide a score sheet with explanations on how to use it.

Although the study used a database of patients who were hospitalized for their diabetic foot infection, this risk score would likely apply to the majority of patients who do not require hospitalization, according to Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the Primary Care Clinic at the VA Puget Sound Health Care System. He and his co-authors would like to see the score validated in such a population.

David G. Armstrong, DPM, MD, PhD, cites the importance of the risk score system, saying it will be helpful to have a predictable system as another tool to predict outcomes. He compares this to a wound classification system, which is “highly predictive of good and bad outcomes” when a patient presents with a wound.

Dr. Armstrong has found the most critical predictors of amputation to be infection, ischemia and renal disease. He expresses surprise that renal disease was not more of a factor in the study.

“We believe that people on dialysis, people with end-stage renal disease and people with kidney disease are going to become increasingly important targets for aggressive intervention or hospice,” says Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance (SALSA).

Dr. Lipsky would like to see if the score can be further simplified and refined so clinicians can remember it more easily. He would also like to see the risk score applied to patients in other countries and healthcare systems.

By Brian McCurdy, Senior Editor

Understanding the 2010 Consensus Recommendations for Diabetic Foot Ulcer Care

Note to the Reader: These articles summarize the "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes," authored by Robert J. Snyder et al., published as a supplement to Ostomy Wound Management in April 2010.

Published as a supplement to the April 2010 issue of Ostomy Wound Management was a pivotal reference paper titled, "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes."1 The authors are a recognized group of leading experts in the field who convened the consensus panel.

The world's population with diabetes will increase from 171 million to 366 million by 2025.2 In the U.S., there are an estimated 24 million people with diabetes. Up to 25% of those with diabetes will develop a foot ulcer in their lifetimes.3 That translates roughly to 1-2% of the diabetic patients per year.

Diabetic foot ulcers (DFU) and lower extremity amputations (LEA) are a costly problem. In 2007, it was estimated that $30 billion was spent for the care of those two conditions.4

The recommendations from the consensus panel are important because they help to update the standard of care based on a review of 111 studies. The recommendations are divided into three categories: Assessment, Treatment, Advanced Therapies.

In this issue we will look at recommendations on assessment of the diabetic foot ulcer.

Recommendations on Assessment of the Diabetic Foot Ulcer

The team approach to assessment and management of the DFU is recognized as the standard of care. No physician "is an island", and the co-morbidities within the diabetic foot cross multiple physician disciplines. A thorough history should be performed. Since wound healing delays can occur with anemia, renal insufficiency, and uncontrolled blood sugar, a CBC and HbA1c should be performed at baseline. If osteomyelitis is suspected, erythrocyte sedimentation rate (ESR) and (CRP) should be ordered.

The patient's nutritional status should be assessed by history and serum pre-albumin. Historical concerns are unintentional weight loss, chronic alcohol use, and problems chewing or swallowing. Smoking is a risk factor for peripheral arterial disease (PAD) and delays wound healing. One should remember the four A's of smoking cessation: Ask about smoking, Advise to quit, offer Assistance, Arrange follow-up.

Neurologic screening should consist of 10 gram monofilament and 128-Hz tuning fork tests. Vascular evaluation is more complicated. There is no single test that can completely evaluate vascular health. Palpation of pulses or ante brachial index (ABI) cannot be relied upon in this population. The absence of pulses is a good indicator of poor flow, but the presence of pulses cannot rule out arterial insufficiency. The toe brachial index (TBI) is less susceptible to false readings due to diabetic arterial calcification. Skin perfusion pressure (SPP) measures capillary pressure in the skin and is very sensitive at uncovering vascular disease in diabetics as well as predicting wound healing. Transcutaneous oximetry (TCPO2) can validate referral for hyperbaric oxygen. Vascular imaging tests should be performed by an appropriate specialist if there is reasonable suspicion of underlying vascular disease.

The foot examination should include assessment of dermatologic changes, musculoskeletal deformities, and ulcer evaluation. Dermatologic changes can show inflammation by thermometry or thermography. Also, it can reveal ischemia by the presence of purpura, fat atrophy, loss of hair growth, or taut skin. The podiatrist is a key member of the team for understanding the biomechanical abnormalities that lead to ulceration. Range of motion of the ankle and first metatarsophalangeal joints should be assessed for restriction in dorsi-flexion. Inspect for deformities associated with Charcot joint disease.

Radiography is useful to help uncover osteomyelitis or deformities. The foot should be x-rayed at baseline and it is appropriate to perform bilateral x-rays for comparison.

The wound assessment and documentation includes size, depth, shape, probing, undermining, condition of the wound bed, and condition of the periwound area. One should use a standard wound classification scheme. The consensus panel recommends use of the University of Texas Classification.5

Infection is devastating to the diabetic foot and its evaluation is primarily clinical. Heat, redness, pain, and swelling are the classic symptoms. The diabetic neuropathic patient does not always exhibit all those signs, so one should be aware of secondary signs like exudate, delayed healing, discolored granulation tissue, and malodor. Culture should only be taken if the clinician suspects infection.