What do compression stockings do, and what do they not do?

Compression stockings are one of the first things a person with varicose veins asks about. The short answer is that they are good for some situations and not enough for others. The full answer depends on the condition of the leg.

How do stockings work?

The UK’s National Health Service (NHS) says compression stockings put pressure on the lower leg, improve blood flow and can reduce swelling and pain. They are worn during the day and taken off at night. A doctor or pharmacist helps in choosing the type.

What does the evidence say for varicose veins?

A Cochrane review (2021) examined thirteen trials with 1021 participants. The certainty of the evidence was low to very low, and the conclusion is cautious:

• All four studies that compared stockings with no stockings or placebo stockings and reported a change in symptoms found an improvement that patients themselves felt, but the change was not always compared between the study groups.
• Of the two studies that measured swelling, one found no clear difference in ankle circumference and the other, using ultrasound, found less swelling in the stockings group.
• Side effects were mainly itching and skin irritation, and no serious side effect was reported.
• One study reported a high rate of stopping use, because of discomfort, difficulty putting them on and the look of the stockings.
• The authors conclude that the evidence is not strong enough, with high certainty, to say whether stockings as the sole and first treatment for varicose veins are effective or not, and it cannot be said what length or what pressure is better.

So symptoms may improve, but the claim that stockings get rid of the varicose vein itself has no source.

What do specialist guidelines say?

The American Vascular Surgery and American Venous Forum guideline (2011) says stockings can be suggested for symptomatic varicose veins (a weak recommendation). But if the patient is a candidate for closing the main (saphenous) vein, stockings should not be the first treatment. The NHS also describes stockings as mostly for when a procedure or surgery is not suitable or not needed.

For a venous ulcer the picture is different. The 2011 guideline names stockings or compression dressings as the first treatment to help the ulcer heal and says that to reduce recurrence of the ulcer, the failing superficial vein should also be treated. The NHS says most venous ulcers heal within six months with the right care and compression, and that an ulcer may return months or years later in the same leg. That is why stockings and other preventive steps are needed.

After treatment of varicose veins

The NHS gives about a week in compression stockings after closing a vein with heat or sclerotherapy. A review and meta-analysis in the Annals of Vascular Surgery (2021) also showed that after closing a vein with heat, stockings reduced pain in the first ten days and shortened the time to return to activity, but found no difference in how well the vein closed or in quality of life. The authors themselves say larger studies are needed. The treating doctor tells you how long stockings are needed and whether they are needed at all.

Who should not wear stockings?

The NHS says that if you have a problem with arterial blood flow in the leg, stockings are not suitable, and a specialist checks for this. If you do not know, ask before buying. If you develop new pain or discomfort after putting stockings on, tell a doctor.

Stockings and clots

Compression stockings have also been studied for preventing clots on journeys. A Cochrane review (2021) on flights of at least four hours says compression stockings substantially reduced symptomless clots and also reduced swelling. But in these trials no symptomatic clots, lung clots or deaths were seen, so the effect of stockings on those cannot be assessed. Details are in the article on long journeys.

If your leg suddenly swells and hurts, do not wait. This can be a sign of a clot and should be checked the same day.

A few practical points

• Choose stockings after an examination and ask a doctor or pharmacist about the size and pressure.
• If stockings bother you, tell a doctor; in the studies, discomfort was one of the reasons people stopped using them.
• Stockings are one stage of treatment and do not replace an examination and a Doppler.