hear this question all the time -- "Why
do you knit socks?" It's a question that
instantly betrays the asker as a non-knitter.
Any knitter knows we don't need a reason to
knit anything! We know perfectly well that
we can buy socks. We just like to knit.
With diabetes on the rise, we find ourselves
with another reason to knit socks. Most every
new diabetic comes out of the clinic looking
baffled by all the emphasis on their feet and
particularly puzzled by the admonition to toss
their cotton tube socks and wear special socks.
Special socks are our specialty! But in order
to knit the best socks, we must first understand
two things: 1) The diabetic foot, and 2) the
effects of different fibres on the diabetic
Diabetic feet are usually
cold, don't sweat as much as normal feet, heal
slowly, infect easily, and aren't as sensitive
to touch or pain. The effects may be more or less, depending
on the progress of the disease. The root cause
of nearly all of these effects is diabetes'
destruction of nerves and blood circulation.
Loss of blood circulation is the cause of nearly
all of diabetes' end effects, from sepsis and
amputation to heart attack and stroke.
The decrease of blood circulation to the
feet means that not enough white corpuscles
are brought to injured areas; thus the risk
of infection is substantially increased for
the diabetic. Healing is also slower, again
because of the impaired blood supply.
Like the palms of the hands, the soles of
the feet do not have sebaceous glands and rely
on perspiration to maintain their suppleness.
The cold feet of diabetics don't sweat as easily
or as much as normal feet, so the skin may
dry out and be prone to cracking. Cracks allow
bacteria to enter the body, leading to possible
Diabetes also damages the nerves and decreases
sensitivity. This means that diabetics
quite often don't feel small wounds and abrasions
on their feet that people with normal feet
would feel right away. Small wounds go unnoticed
and untreated, heal slowly, and thus provide
fertile ground for bacteria. Because of this,
diabetics are usually advised to examine their
feet daily, treat and bandage small wounds
even if they aren't painful, and moisturize
their feet. They're also cautioned to wear
socks and shoes that are properly fitted and
don't rub or abrade the feet.
Now we're into our territory: The socks! Now
that we understand the characteristics of the
feet we're knitting for, we need to understand
what makes a sock good or bad for diabetes,
plus we need to understand how different fibre
contents affect diabetic feet. Diabetes journals
and diabetes educators offer a lot of conflicting
advice about this topic, because, quite frankly,
there hadn't been much research into socks.
That's changed now and there are several studies
that we can learn from. Alas, the studies only
investigated commercial socks, but we can use
their results to improve our handknitting.
For diabetic feet,
a "good sock" is
defined as one that fits snugly without impairing
circulation, that stays in place and doesn't
bunch or twist in the shoe, which keeps the
foot comfortably warm and dry, and which doesn't
cause abrasions. The heel is particularly vulnerable
because it's the most insensitive (even in
a normal foot), it's exposed to considerable
abrasion from shoes and impact, and it's difficult
to inspect by oneself. Tube socks tend to bunch
at the instep and stretch over the heel, reducing
cushioning of this vulnerable spot. They frequently
twist around during wearing and the seams may
abrade the toes. Shaped, fitted socks are preferable
to tube socks because they stay in place better
and provide more uniform cushioning over the
Natural fibers are best,
right? Surprisingly, Doctors Kirk M. Herring
and Douglas H. Richie found that this wasn't
necessarily the case. These researchers ranked
sock fibers in terms of moisture wicking, moisture
retention, shape retention, and abrasiveness.
Their findings were quite surprising: The
best fibers were Coolmax and acrylic, while
the absolute worst was cotton! Cotton
absorbs moisture, but then hangs onto it like
a towel, keeping the moisture against the skin
instead of wicking it away (which is why cotton
socks start to feel slimy after wearing for
a while.) This can lead to chapping. Cotton
socks were found to get more abrasive with
continued wash-wear cycles, leading to blisters
and abrasion rashes. Lastly, cotton socks were
found to stretch and lose their shape with
wearing, causing them to shift and bunch in
the shoe. These effects were not mitigated
by blending with other fibers.
Wool fared better than cotton. Wool
absorbs some moisture, but also wicks it
away from the skin. However, wool will compress during
wearing and reduce its wicking ability. Although
wool is still more abrasive than synthetics,
superwash merinos are less abrasive than untreated
wools and overall wool was found to be less
abrasive than cotton. The abrasive qualities
of wool were found to be mitigated by blending
with synthetics, which also enhanced wool's
wicking qualities. There are still many good
reasons to dress diabetic feet in wool or a
wool blend, though: Wool is the only fiber,
natural or synthetic, that retains its thermal
qualities when wet. That's particularly important
for people who work outdoors or in cold climates.
Being a natural fiber, wool breathes and deters
fungal growth like athlete's foot. As knitting
fingers know, wool is more elastic than cotton
and retains its shape better, so wool socks
are less prone to bunching and twisting.
Acrylic fared well. It has decent wicking qualities,
doesn't compress, doesn't lose its shape, and
is less abrasive than cotton or wool. Comparing
cotton socks to acrylic socks, the acrylic
socks were found to cause fewer blisters.
What does this mean
for us handknitters? I haven't found any
Coolmax yarns yet and a search of the Coolmax
site reveals no such thing. It does mean
that we should probably pass
over any sock yarn with cotton when knitting
for a diabetic.
Instead, we should look
for baby acrylics and soft wool blends with
a higher percentage of synthetic.
The best wool blend would include some acrylic
or polypropylene along with soft superwash
merino, perhaps with some nylon or polyamide
for strength, such as Lang's "Jawoll
Superwash" sock yarn.
Otherwise, a traditional wool/nylon sock yarn
will be good, especially if the percentage
of nylon is a little higher, such as Regia's
75/25 blend. Some wool blends are treated,
such as Austerman's "Step", which
is a wool/nylon blend treated with aloe vera
and jojoba oil. These help soften the feet
and reduce abrasion.
Another yarn to consider
is Knit One Crochet Too's "Wick." This
is a blend of soy protein fibre and polypropylene.
Polypropylene has been shown to have excellent
wicking properties and elasticity; it has
long been used in mesh thermal underwear
for sports. Although to my knowledge, soy
protein fibre has not been investigated specifically
as a sock, its smooth fibre staple, strength,
wicking and anti-bacterial properties make
it promising, especially for vegan diabetics. "Wick's" downside
is that it is currently available only as a
worsted-weight yarn. It makes a bit thicker
of a sock and the purl-side bumps could prove
irritating to the feet. To combat this, knit
the sock in reverse stockinette, or wear a
the diabetic to give feedback on your handknit
to continue doing so. This is very important:
Diabetes has a tendency to "jump" in
severity every five years or so, so socks
that were giving no trouble one year may
give rashing or blisters the year after.
Diabetes may progress slowly or quickly,
but it never stops.
With our awareness of abrasion, should we
choose a traditional heel-stitch heel? This
will depend on the individual's needs and feet.
My diabetic husband wears steel-toed safety
boots at work and these are quite hard on the
heels. Socks with a short-row heel seem to
wear down quickly, so I knit his socks with
a heel-stitch heel flap for the extra cushioning
it provides, bearing in mind the roughness
of the inner surface. (So far so good, he hasn't
shown any signs of irritation.) If a heel-stitch
heel proves to be irritating, the knitter can
choose another sort, such as short-row or peasant
heels. We're lucky that way!
Knitters are lucky another
way as well: We can shape the sock to fit the
foot exactly, even if part of the foot is missing.
No joke - my diabetic brother-in-law just lost
two toes due to septic infection of the foot.
After amputation, the need for protective socks
is even more urgent. Commercial socks can't
deliver a perfect fit, but we can.
Because of abrasion, we might want to think
twice about using those lovely lacy or pebbled
pattern stitches for a diabetic's sock and
stick with simple stockinette
Again, get feedback: Some will have no problems,
while others will show irritated skin or rashing.
If the sock bags a little at the heel or ankle,
it's too loose and will abrade; if the stitches
look stretched when on the foot, it's too tight
and may hamper circulation at the skin surface.
The sock must fit like a glove, without stretched-looking
stitches. If your favorite sock pattern doesn't
fit quite perfectly, adjust it. Or, as I do,
use a formula based on measurements and gauge
that gives a perfect fit every time. If you're
knitting a pattern and wish to keep it intact
on the instep, do your adjusting on the sole
If the foot has lost much of its feeling,
or if it has already suffered serious injury,
such as septic wounds or amputation, it's best
to take no chances with
abrasion - these are
high-risk feet. According to Dr. Richie, a
study done by the United States military discovered
that wearing a CoolMax or polypropylene liner
sock beneath the outer sock will reduce abrasions
considerably. The friction of the shoe is dispersed
between the outer sock and inner sock, instead
of a single sock and the skin. CoolMax and
polypropylene have been found to have excellent
wicking qualities, so moisture is transported
away from the skin and into the outer sock.
For the high-risk foot, the best combination
would be a thin CoolMax or polypropylene liner
sock, under a wool sock. The wool will retain
what little heat the high-risk foot creates,
and will wick away moisture, while the liner
protects the skin.
A diabetes diagnosis can be scary: Strokes,
organ failure, infection, and amputation are
potential threats if blood sugar levels are
not properly maintained, while a restricted
diet and daily poking are immediate, permanent
changes. A handknit sock is a gesture of love;
a knitter who does research, gets feedback,
and knits the best possible sock is saying "I'm
with you all the way." Why knit socks?
It's not because we can -- it's because we
"Socks and Your Feet," Douglas
H. Richie Jr
Recommendations for People with Diabetes," Carol B. Feldman & Ellen
Faddis, University of Missouri-Columbia
published research portal, with links
to PDFs, Institute for Preventative Foot
of Soybean Fibre," SwicoFil
AG Textile Services, Switzerland