Compression stockings: how to choose, wear and care for them

If I had to name the item I recommend most often in clinic, it would be the graduated compression stocking. It is also, I suspect, the item most often bought, worn twice and retired to a drawer — usually because the class was wrong, the fit was wrong, or nobody explained how to get the thing on.

That is a shame, because properly chosen compression stockings are genuinely effective at relieving the heaviness, aching and ankle swelling of vein disease. Here is what I actually tell patients: how compression works, how to choose, and how to wear and care for the stockings so they keep doing their job.

What graduated compression actually does

“Graduated” is the key word. A medical compression stocking is tightest at the ankle and becomes progressively looser up the leg. That gradient gently squeezes blood in the direction the veins are trying to move it — upward — and narrows the superficial veins so their valves sit closer together and leak less. It also supports the calf muscle pump, the squeezing action of the calf that does most of the work of returning blood to the heart.

Compression does not cure vein disease. If the valves in a vein have failed — the underlying problem in varicose veins and chronic venous insufficiency — the stocking controls the consequences while it is on, rather as spectacles correct vision only while they are worn. That is still worthwhile: less pooling means less aching, less swelling, and less strain on the skin at the ankle.

Compression classes: what the numbers mean

Compression strength is measured in millimetres of mercury (mmHg) — the same unit as blood pressure — at the ankle. Classification systems vary slightly between countries and brands, but broadly:

• Class 1 (roughly 15–20 mmHg) — light compression. Suits tired, achy legs after long days of standing, long flights, pregnancy-related heaviness and mild spider veins.
• Class 2 (roughly 20–30 mmHg) — firmer, and the class I prescribe most often. Suits established varicose veins, chronic venous insufficiency, swelling that leaves a dent when pressed, and the recovery period after vein procedures.

Higher classes exist for severe swelling and for legs that have had ulcers, but those should be worn on specialist advice only. More pressure is not automatically better: a Class 2 stocking that is too uncomfortable to wear does less good than a Class 1 worn every day.

Knee-high or thigh-high — and getting the measurement right

For most people, knee-high. The pooling that causes symptoms happens mainly in the lower leg, so a well-fitted knee-high stocking captures most of the benefit — and it is far easier to put on, stays up better, and is more likely to be worn. Thigh-high versions earn their keep when varicose veins run up the inner thigh, and in the weeks after certain procedures.

Fit begins with measurement, and measurement should happen in the morning, before the day’s swelling arrives. The circumference of the narrowest point of the ankle matters most, followed by the widest part of the calf. Off-the-shelf sizes fit most legs; unusually slim ankles with wide calves, or significant swelling, sometimes need made-to-measure. A stocking that rolls down, digs in a tight band behind the knee, or leaves deep ridges in the skin is the wrong size — not a fact of life to be endured.

Putting them on — the part everyone finds difficult

A Class 2 stocking is meant to be firm, so it will never glide on like a sock. A few things make the job much easier:

• Put them on first thing in the morning, before you have been upright long enough for the leg to swell.
• Keep the skin dry — apply moisturiser at night rather than just before dressing, as damp or creamed skin grips the fabric.
• Wear rubber gloves — ordinary washing-up gloves. They grip the fabric far better than fingertips, spread the effort evenly, and protect the stocking from nails.
• Turn the stocking inside out down to the heel, fit the foot and heel first, then unroll it up the leg in stages, smoothing as you go rather than hauling from the top.
• Never fold the top down — a doubled band acts as a tourniquet.

For anyone with arthritic hands or a stiff back, donning frames and slide aids exist and work well; it is a request worth making rather than a reason to give up.

Washing and replacement

Wash the stockings regularly — ideally after each day’s wear — in cool water with a mild detergent, and air-dry them away from direct heat and sunlight. Washing does not wear them out; it actually helps the elastic fibres recover their shape. Owning two pairs and rotating them makes this practical.

The elastic does fatigue, however quietly. With daily wear, a stocking has typically lost a meaningful amount of its pressure by about three to six months, even if it looks intact. A stocking that has become easy to put on is telling you something: it is no longer doing much.

When stockings are the wrong answer

Compression squeezes the leg — which is exactly what you do not want if the arteries, rather than the veins, are the problem. In peripheral arterial disease, the arteries are already struggling to push blood into the leg, and compression can make that worse. Anyone with calf pain on walking that eases with rest, cold or pale feet, wounds that will not heal, long-standing diabetes or a heavy smoking history should have the arterial circulation checked — a pulse examination and a simple Doppler pressure measurement — before wearing compression. The same caution applies to severely numb legs, where a too-tight stocking may not be felt.

The other limitation is the one I mentioned at the start: stockings manage symptoms, they do not repair valves. If you find you cannot get through a day without them, if the veins are becoming steadily more prominent, or if the skin at the ankle is itching, drying or darkening, the leg deserves a proper assessment rather than a stronger stocking. A duplex ultrasound scan shows exactly which valves are leaking, and modern treatment for most superficial vein problems is minimally invasive, performed under local anaesthesia — most patients walk out the same day. Compression is an excellent servant; it should not have to be a life sentence.