The foot and ankle are a complex of joints that are formed by the joining of the toes, the tarsus, and the metatarsus. The hallux, or great toe, is formed by only two phalanges, while the other toes each have three. The metatarsus consists of five long bones which connect the toes to the tarsus. The tarsus is formed by two bones, the calcaneus and the talus, which is then connected to the tibia to form the true ankle joint. The complexity of the foot and ankle joint is due to the need for mobility and stability in activities such as walking, running, and jumping. This movement can be divided into two main phases: stance and swing. Stance phase occurs when the foot is on the ground and accounts for 60% of the gait cycle. The heel first makes contact with the ground and then a rocker motion around the ball of the foot occurs to lift the toes. This is a period of double leg support and ends as the contralateral limb begins to swing. During the swing phase, the foot is in the air and is a period of single limb support. High forces and stress are placed upon the foot and ankle during these activities, which can lead to excessive load, pain, and injury. Pain associated with the foot and ankle can be a result of many factors such as trauma, overuse, biomechanical abnormalities, and medical conditions. An example of an overuse injury coupled with a biomechanical abnormality is plantar fasciitis, a musculotendinous disorder that affects the fascial insertions on the calcaneus and results in degenerative changes. Plantar fasciitis can occur acutely in a single leg overloading scenario or chronically due to obesity, prolonged standing, or repetitive micro-trauma.
Benefits of Compression Therapy
Swelling can be due to a number of factors, including standing or sitting for long periods, high blood pressure, heat, heart failure, and a number of other medical conditions. Swelling can affect the legs, ankles, or feet and can cause significant discomfort. It can also be a predisposing factor in the development of various leg ulcers due to underlying venous disease. Applying compression can significantly reduce swelling in affected limbs. Pressure applied by compression stockings or bandages helps to increase the tissue pressure in the underlying muscles and helps to reduce the ability of the vessels to distend. This, in turn, helps to reduce the size of the capillaries and the amount of fluids leaking into the surrounding tissue. Compression is more effective than elevation of the legs and taking a rest to reduce swelling, and its effectiveness has been shown to increase with higher pressures of compression.
Compression therapy involves the use of specially designed stockings or bandages to apply pressure to the lower legs. Graduated compression applies a defined amount of pressure, greatest at the ankle, with pressure reducing towards the top of the stocking or bandage. This helps to squeeze the leg tissues and, in turn, helps to move blood and other fluids out of the legs and back to the heart. This, in turn, helps to prevent swelling, maintain a healthy blood flow, and reduce the risk of DVT. Benefits of compression therapy include reduced swelling, improved circulation, and pain relief.
Reduced Swelling
Compression garments are often effective for swelling reduction in an assortment of pathologies. Graduated compression stockings can prevent and treat pathological edema and thrombosis by increasing tissue pressure and slowing the rate of lymph formation and subsequent swelling. The effectiveness of brand new innovations like game-prepared cryotherapy systems (a mixture of pneumatic compression and cryotherapy) are yet to be proven in research, but it’s believed that intermittent pneumatic compression may have a variety of effects on swelling reduction and will well be the longer term of price-effective treatment of swollen tissue.
IManaging material choice leads to increased healing within the acute part by containing tissue and minimizing additional injury. The type of fabric or material elected for the bandages should offer adequate resistance with minimal stretch (adaptive elasticity) to effectively contain the swollen limb. Very elastic bandages offer little resistance and easily conform to changes in limb girth, which frequently lead to applying high resting pressures and inadvertently stronger pressures during active motion. These high pressures aren’t well tolerated and should result in decreased lymph and blood flow, worsening swelling and delaying healing.
Improved Circulation
These studies show promising hope for the reversal of ankle injury-related decreased pressure gradients and fluid stasis for all individuals, with a variety of different cheap and effective compression therapy modalities.
Another study of six volunteers with a saphenectomy on one foot and no surgical intervention on the other foot, with a random allocation of a class II stocking on one limb and a class III stocking on the other for 5 days, demonstrated that the use of a compression stocking increased the lymphatic flow by 22% from baseline, with the greater pressure exerted by the class III stocking. Partsch called for the need of greater standardization for compression therapy in an AIM sponsored consensus meeting in 2009, due to varying forms of compression therapy and lack of data for the current levels of pressure for each therapy.
A study of 22 patients with chronic venous disease who used compression therapy with Unna boots and with a 40mmHg pressure gradient demonstrated a 60% reduction in the deep venous reflux duration from 21 seconds to 8.4 seconds. This proves that increased lower leg compression can increase the effectiveness of the secondary pump.
It has been well documented that compression therapy can reverse the effects of increased fluid stasis and edema pooling by mimicking the secondary pump and aiding in the drainage of the reflex fluid back into the lymphatic system. This is achieved by increasing the interstitial tissue pressure and wicking away the moisture from the affected area into the atmosphere.
However, upon injury of the ankle, sustained for example from an ankle sprain, both the arterial and venous pressures drop. This can lead to increased venous stasis and the potential for the ankle to undergo hypoxia and motor response failure due to an accumulation of edema in the interstitial spaces, which can last several years.
In a healthy ankle, the arterial pressure is higher than the venous pressure. Given that arterial pressure is about 100mmHg and the venous pressure is 10mmHg, the pressure gradient of 90mmHg ensures that there is movement of deoxygenated blood from the foot and ankle. This movement is then aided by the foot and toe musculature acting as a secondary pump with each step that is taken.
Pain Relief
Although many studies have reported pain reduction as an outcome in the treatment of venous and lymphatic disorders, the underlying mechanism of pain relief is not well understood. The pain-relieving effect of compression may be due to the reduction of local edema, which can act as a noxious stimulus on sensory nerve endings. It likely is related to the reduction of inflammation, as reflected by decreased leukocyte migration and reduced fluid filtration. Fibrosis and deposition of connective tissue in the dermis – seen in chronic venous insufficiency – can produce a state of increased skin tightness and a sensation of pain or leg heaviness. By reducing the underlying pathology, compression can prevent further fibrotic change and in some cases reverse it, thus relieving associated pain symptoms.
Compression therapy has been used to address diverse patients with chronic pain conditions. The most persuasive example is the treatment of lymphedema-related conditions. In addition to being documented in numerous venous ulcer studies, compression has been reported to be effective in reducing pain related to acute and chronic edema. For example, patients with a variety of pain symptoms related to chronic venous insufficiency reported a reduction in pain after wearing a compression stocking for 1 week. Pain reduction was also found when patients followed a strict regimen of bandaging for their chronic wounds.
Types of Compression Therapy
Compression therapy involves the delivery of an external force to an injured or painful part of the body to achieve relief and reduce swelling. Compression therapy systems are readily available, and therapy may involve any one or more of the following applications. The direction of the force is most important in the application of the therapy. Usually, the pressure is applied in the upward direction from distal to proximal part of the extremity. This is important in counteracting the hydrostatic forces created by swelling occurring in dependent areas following injury. The magnitude of pressure applied is also important, with a range of 10-50 mmHg having been shown to be effective in various conditions. Increments in pressure can be achieved by use of multi-component bandage systems. Duration and timing of the application of compression therapy are a fundamental part of the prescription and can be used to effect in various conditions. Duration of use of simple bandaging may be for a limited period, whereas more durable solutions such as hosiery can be worn for as long as needed. Periodic change of bandaging materials can also be used when the aim is to intermittently apply compression therapy, for example, to reduce edema. Static modes of compression involving a constant level of pressure are suitable for applications such as splinting of burn scars. Dynamic compression involving graded pressure is employed in prevention of deep vein thrombosis and lymphedema with use of intermittent pneumatic compression pumps. Types of compressive materials vary and include inelastic materials such as neoprene or stiffened bandages for support and control of joint swelling, and elastic materials such as hosiery that exert a controlled amount of pressure to the body part. The use of hosiery and elasticated wraps are most common and are available in a variety of sizes, lengths, and pressure options suitable for prescription to any body part. A recent development has been the use of compression sleeves that are designed into garments for specific body parts. This option to the patient is considered preferable to more traditional forms of bandaging, providing comfort and ease of use with a similar level of pressure application.
Compression Socks
Compression socks are also effective in reducing pain from delayed onset muscle soreness; however, the effects are not long-lasting compared to their efficacy in preventing DVT and ulcer formation.
In diabetics, it has been well documented that there are microcirculatory abnormalities and autonomic dysfunction. The effects of neuropathy, peripheral arterial disease, and infection lead to the development of foot ulcers. It was the largest multi-center RCT that investigated the effectiveness of compression hosiery in the prevention of ulcers in people with diabetes. This study found that there was a 50% reduction in ulcer incidence, though the target population was not specified, nor were the types of ulcers developed by the patients.
A recently published meta-analysis of six articles has evaluated the effectiveness of compression stockings for treatment of venous leg ulceration. The review concluded that use of compression stockings probably reduces time to ulcer healing compared with ‘usual care’ and that use of high compression was more effective at increasing healing rate than lower levels of compression. While this meta-analysis was evaluating the efficacy of compression stockings on leg ulceration, it does support the positive effects on venous blood flow that compression stockings provide.
Compression socks are the most commonly used type of compression therapy. They extend to the mid-thigh and are worn in place of normal socks. They provide the strongest compression at the ankle, with gradually decreasing pressure up the leg. By increasing venous blood flow, they reduce blood pooling and prevent achy and heavy feeling legs.
Compression Bandages
A wide variety of bandages and other dressings can be used in compression therapy. These include short stretch and long stretch bandages, and a range of paddings and other specialized bandaging materials. Many have the advantages of being inexpensive, allowing adjustable levels of compression, and providing additional protection for the wound site. A common shortcoming of bandages relative to other forms of compression therapy is in providing low resting pressure, although short stretch bandages are effective in providing high working pressure. This means that bandages are often useful when compression is indicated during mobility, and are often doubled up with an initial layer of long stretch bandage to provide high sub-bandage pressure and a final layer of cohesive bandage to ensure that the others are kept in place. An inelastic stabilization device known as the Tubigrip can also be used as a multi-layer system to provide low resting and high working pressures. An interesting development in compression bandages is the use of cohesive short stretch bandages, which, like the Tubigrip, allow for adjustable levels of compression by an increase in overlap pressure. However, they do not serve the purpose of other bandages in that they provide little protection and are a temporary solution to the maintenance of the bandage in place before a more suitable compression is determined.
Compression Sleeves
Overall, whether for the ankle, knee, or other areas, the ease of application and proven results in some cases would make a compression sleeve a viable and more patient-compliant option compared with bandages.
Similarly, another article looks at an elastic knee compression sleeve in the treatment of pain and swelling following knee arthroscopy. This showed that with the use of the sleeve compared with bandage and NSAID therapy, there was a significant improvement in treating symptoms of pain and effusion, with patients favoring the sleeve due to better-defined compression and less tightness.
From a clinical view, there are different research articles looking at various sleeves to be used in knee pain. However, it would be fairly logical to say that the findings can be extrapolated and applied with common sense to pain in other areas. An article suggests that the use of a specially designed knee compression sleeve was associated with pain relief, increased pain-free distance, and walking speed compared with the use of simple NSAID therapy. The mechanism here is that the sleeve was reported to have increased proprioception and perceived knee stability. This, in turn, resulted in reduced quadriceps inhibition, increased muscle strength, and motor function.
Compression sleeves – Personally, the writer has a lot of respect for these products. When working in retail pharmacy, it is fairly obvious that a lot of tire kickers and those new to pharmaceutical products find it hard to keep a bandage adhered to an affected area in the correct manner. Bandages do have a tendency to unravel and bunch up if not expertly applied. In these cases, using a low-profile, easier-to-use compression sleeve often yields superior, consistent results compared with a traditional bandage, as adherence tends to be higher due to ease of use.
Compression Wraps
There are many slight variations in the material and style of the compression wrap; however, the general idea stays the same. Materials can be used that allow function through movement such as elasticated or Lycra bandages, and some that are a lot more rigid can be used to completely immobilize an injured area in a plaster cast-like fashion, an example would be an ankle taping technique. This ability to closely customize the form and function of a compression wrap means that it is a highly useful tool that has seen a wide variety of uses in injured patients. In the future of compression wraps, it is possible that more specialized designs may be forthcoming and due to the potentially low production cost, high-grade wraps could see use in some very serious injuries.
Compression wraps have had a variety of uses in medical applications due to the ability to adapt the compression. For ligament sprains and muscle injuries, the application of a slightly looser wrap with a degree of functionality through movement, and increased compression during rest, the RICE model can be effectively combined into the one application. Due to the simplistic nature of a compression wrap, in even its most basic form in which a bandage is applied over a modern dressing and tied off, means the cost effectiveness for the patient can be quite high. This low cost can often be made easier for the patient due to it being a common skill in which many people would feel competent when applying or helping to apply the bandage. This comes in handy in field side situations in sports events where trained professionals may not always be on hand.
Tips for Using Compression Therapy
Proper sizing A too small stocking is the most common mistake when it comes to sizing. With the aim of increasing distal pressure to hasten blood flow velocity and decrease venous stasis, it is essential that gradient compression stockings are correctly sized at the top of the ankle. Stockings that are too large may actually cause more swelling by leading to the stocking acting like a tourniquet sitting on top of the swollen ankle. This will lead to discomfort and patient non-compliance. Accurate measurements should be obtained at the point of most distal swelling because if swelling is already present, it will suggest that the patient has already compromised lymphatic drainage and therefore it is at this level where the main treatment effect is needed. If there is a difference between measurements, always use the larger measurement to determine the size. Custom-made stockings should be considered for patients who have difficulty in fitting the standard sizes and patients who have large ulcerated areas on the lower leg. This is most common in patients with rheumatoid arthritis and lipodermatosclerosis. There is evidence to suggest that these conditions usually require higher levels of compression pressure to heal ulcers and prevent ulcer recurrence. 314 Comparable with wearing splints or strapping in musculoskeletal injuries, a too tight bandage is often thought to provide the most therapeutic benefit, whereas in actual fact, it can sometimes cause more harm than good. In the absence of Doppler or photoplethysmography equipment, finding the correct level of compression with bandaging can often be difficult. An inelastic bandage is usually applied with the calf muscle at maximum stretch, meaning that the bandage is likely to be too tight when the muscle is relaxed. This can lead to worse symptoms when the bandage is removed and can even cause a compartment syndrome in extreme cases. This is more likely to occur with arterial disease where the peripheral blood flow is compromised. An elastic bandage is less likely to cause a pressure injury, but it is still possible if the bandage gives too much pressure. Stockings are therefore a more reliable and controllable means of compression, given that the correct size is chosen.
Proper Sizing
Accurate measurements should always be taken of limb size, and manufacturers’ size guidelines followed in order to ensure a therapeutic and comfortable pressure is achieved.
Open toe stockings are often sized by shoe size rather than a specialty designed length and circumference system. In this case, care should be taken to ensure the length of the stocking is sufficient, as the increased pressure due to sizing issues can cause discomfort and cut off circulation. This is of specific concern in patients with diabetes or arthritis.
If the patient’s limb is too large in circumference in comparison to the stocking, the material may be too stretched and the pressure derived will be lower. If the limb is too small, there will be enough pressure on the part of the limb where the stocking fits well, however, this pressure will be distributed over a smaller area thus applying a higher pressure. Both of these instances are contraindicated. In the former case, the higher pressure is desired on the larger limb, and in the latter case, high pressures on localized areas are often not recommended.
Graduated Compression
The capabilities and limitations of the many presently available bandages or stockings should have a methodical review, but specific description is beyond the scope of this paper. At any rate, the ability to understand and prescribe compression in a manner that is simple, practical, and beneficial to patients is of great importance and encouragement for future research and utilization of this modality.
Alternatively, multi-component compression has manipulation of elastic properties that can enhance mobilization and clearance of edema in conjunction with specific functional tasks. This can be very beneficial in the rehabilitation of musculoskeletal and neurological conditions. An example would be functional wrapping of the ankle to enhance muscle coordination and functional position in gait.
Single-component compression is typically a bandage or stocking that has unchanging elastic properties across the length of the limb. In clinical scenarios, it is usually effective in minor lymphatic/venous edema and in prophylactic use to deter the onset of these conditions. A simple common example would be an elastic bandage on a sprained ankle.
Classification of graduated compression is based upon the familiar description of bandages and stockings, but has not been updated to reflect modern technology, research, and clinical reasoning that can lend incremental credibility to this modality. It is appropriate to make a simple distinction between single-component and multi-component compression, with primary focal points being upon simplicity and efficacy of the former, and the enhancement of those characteristics through functional application of the latter.
Graduated compression is a therapeutic technique that does not have exclusive application in foot and ankle pain management, but is complementary to many therapies that have been advocated. It also has appeal in that it is inexpensive and easy to apply. The basic principles are easy to teach and learn. Therefore, it has potential for both patients and clinicians in that it may enhance patient compliance towards self-management of conditions. If patients and clinicians can appreciate measurable benefits and symptomatic relief through simple cost-effective strategies, it is likely that compliance will be heightened. This would be an important achievement in an era that is being increasingly defined by fiscal accountability in healthcare delivery.
Duration and Frequency of Use
Overall, the more attention patients pay to skin care hygiene, the more comfortable and effective their use of compression therapy will be.
As standard compression therapy can cause a moisture build-up between the bandage and skin, it can lead to softening of the skin and further breakdown. High compression therapy has a risk of causing skin ischaemia and necrosis. Thus, it is important to frequently assess one’s skin condition during the application of compression therapy. Any form of dermatitis should be treated with emollient therapy and the use of corticosteroid if the condition proves to be more severe. If there is an ischaemia-related injury, compression therapy should be stopped and advice should be sought from a dermatologist or vascular specialist. This will help prevent any form of ulceration worsening and further skin damage.
Ultimately, the decision for what length of time to use compression therapy will depend on the nature of the condition. More severe and chronic conditions may require the long-term use of compression therapy. Regarding skin care, it is recommended to perform daily washing with soap. Wearing clean, soft absorbent socks over the bandages is recommended. It is important for patients with chronic wounds to understand the importance of maintaining skin hygiene.
According to Porter et al., initial frequency of use may be as much as 5 times per week and the duration of use 6 months or longer. Initially, it should be worn for 24 hours and then used as a night-time treatment phase. As symptoms subside, compression therapy can be transitioned to solely night-time use.
Skin Care and Hygiene
When wearing compression hosiery, it is important to maintain good skin care and hygiene practices. Fibrosis caused by chronic venous insufficiency and CVI causes skin and subcutaneous tissues to become hardened and discoloured. It can also give the area a woody, tissue-paper like feeling. Mild to moderate forms of edema in the subcutaneous tissues can also cause localized areas of skin and tissue to become softened and macerated. These can cause irritation and itching problems. Therefore, it is important to have a good skin care plan to prevent these from occurring. Mild and transparent silicone dressings can be applied to delicate and dry areas of the skin to protect it and prevent the development of lesions. This can also help to reduce discomfort caused by the skin being stuck on cellulose bandages. Moisturizing the skin can also be very beneficial, but greasy ointments and creams should be avoided. These can cause the compression hosiery to slip and become ineffective. Inelastic zinc paste bandages can also be used to help shape tissues and change the direction of high pressure gradients. However, they are not very effective for maintaining a normal gait and mobility and can cause restriction in knee flexion.
