Systematic Review on Socks and Stability: A Global Analysis of the Impact of Socks on Balance and Gait

INTRODUCTION

Balance is defined as the ability to maintain the body’s centre of mass within the base of support during both movement and rest.^[1] Effective postural control is essential to maintain balance, which can be enhanced through the perception of environmental stimuli and the use of adaptive compensatory muscle activity.^[2] These adaptive mechanisms enable the body to adjust continuously to changes in posture and motion.^[2] This is a key mechanism for performing activities of daily living, such as sitting, standing, walking, and others.

“Gait” refers to the specific movement patterns of the limbs during locomotion over a solid surface.^[3] The neuromusculoskeletal system plays a critical role in coordinating these movements by integrating internal and external forces. A normal gait is characterised by its adaptability and stability, which facilitate energy-efficient navigation across various terrains and adjustments in walking speed.^[4]

Gait impairments are closely associated with balance dysfunction. Improving balance is a key determinant in regaining functional ambulation, as observed in functional ambulation categories. Numerous exercise-based therapies, such as computer game-based training,^[5] Tai Chi,^[6] and balance-board training,^[7] have been shown to enhance balance. However, the effectiveness of these interventions often relies significantly on participant compliance, posing challenges in implementation.^[8]

Sensory feedback from cutaneous and muscle receptors plays a pivotal role in movement regulation. Compression garments, such as leggings or socks, have been studied for their potential to enhance performance across various sports disciplines. These enhancements include improved anaerobic thresholds during running,^[9] greater power output in jump tests following exhaustion,^[10] and faster recovery post-exercise.^[11-14]

Sensory input from cutaneous receptors is critical for regulating muscle activation during locomotor, particularly for adapting to environmental changes and preventing falls or tripping, a phenomenon termed the “stumble corrective response.”^[15-20] Previous studies have extensively investigated the leg cutaneous reflexes, revealing task- and phase-dependent reflex modulation.^[15-20] Reflex responses are influenced by stimulation of distinct regions in the dorsum and plantar side of the foot.^[17,18] These responses are topographically organised and result in distinct kinematic and kinetic adaptations depending on the site and phase of stimulation.^[17,18] Such findings suggest that sensory input from the skin of the foot plays a crucial role in controlling both the stance and swing phases of gait.^[17,18] The sensorimotor system may be further enhanced by compressive and textured materials that stimulate skin receptors through compression, deformation, and contortion.^[17,18]

The impact of socks on foot mechanics, balance, posture, and gait varies significantly depending on their type. Understanding these variations is crucial for their potential applications in injury prevention and gait training in healthy individuals. Therefore, this systematic review aims to analyse the global influence of different sock types on gait and balance. The research question addressed in this systematic review is “How do different types of socks impact gait and balance in healthy individuals?”

METHODOLOGY

A systematic review of randomised controlled trials was reported following the PRISMA-P guidelines^[21], as shown in Figure 1. The review included full-text original articles that addressed and explored the effects of various socks on gait and balance in healthy individuals. The search strategy involved databases Google Scholar, PubMed, Research Gate, and Cochrane Library, including all published articles between January 2013 and December 2023. All databases were searched with the combination of three keyword sets such as Socks “AND” Balance “AND” Gait “AND” Healthy Adults “AND” Compression socks “OR” Textured socks “OR” Five toed socks “OR” anti-slip socks “AND” Biomechanics “OR” Static Balance “OR” Dynamic Balance “AND” Gait parameters “AND” Fall risk “AND” Postural Sway “AND” Velocity “AND” Stride Length,” with Boolean operators such as “AND” and “OR.”

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Figure 1:

Screening procedure using PRISMA-P flow diagram. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

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The first set of keywords aimed to describe outcome variables, such as gait or balance. The second set of keywords was focused on sock features (e.g., anti-slip, textured), while the third set of keywords aimed to describe outcome measures such as biomechanics and posture instability. Following the screening process, titles and abstracts of all identified articles were examined based on inclusion criteria and exclusion criteria, as shown in Figure 1.

The inclusion criteria of the study included only randomised controlled trials (RCTs), different types of socks worn by the participants and their influence on balance and gait analysed in the studies, and healthy individuals > 18 years old without having any disease. English-written articles and full text were included for analysis.

Studies without a control or comparison group, non-RCTs, observational studies, case reports, review articles, and oral communications were excluded from this study. Studies including any other form of footwear or combining socks with other types of footwear were also excluded.

RESULTS

An extensive literature search was conducted using electronic and manual methods and obtained 1632 articles, of which 121 studies potentially evaluated the influence of socks on gait and balance. After excluding 69 studies due to insufficient data or the inclusion of participants with comorbidities, 10 articles that met all inclusion criteria were selected for final qualitative analysis. These studies, published in English between January 2013 and December 2023, underwent a rigorous evaluation.

Characteristics of included studies

The selected studies exhibited a greater heterogeneity in participant demographics, sample sizes, and types of socks. Participants’ ages ranged from 18 to 85 years, and sample sizes varied from small groups of 10 participants to 61 participants, as shown in Figure 2. Duration and frequency differed significantly, spanning from short-term tests, such as 15-second trials repeated three times, to extended protocols like 8-week programmes where participants wore socks two to three times for one-hour walking sessions per week.

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Figure 2:

Comparison of study sizes and their relative impact on outcome measures.

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6. Agility and movement performance:

Impact of training programmes: In studies assessing agility, it was found that training interventions yielded significant improvements in agility regardless of the sock type, emphasising that physical conditioning played a more prominent role than the type of sock worn. Jaakkola et al. noted that while all participants improved, no significant differential benefits were found with compression socks compared to regular socks (p >0.05).^[30]

Static and dynamic balance tasks: Compression socks show significant differences in physical performance and dynamic balance in the elderly population.^[31] Training effects on static and dynamic balance were observed across the board, but no additional benefits from compression or textured socks were noted in comparison to regular socks (p >0.05).^[31]

The findings indicate that compassion and non-slip socks offer significant benefits in improving postural control and proprioception (p <0.001 to p <0.05), while textured socks can enhance sensory feedback, but no significant changes in stride length or walking speed (p <0.05; p >0.05) as shown in Figure 3. The importance of sock type is evident, especially in specific tasks involving balance, stability, and sensory input. However, physical training influences overall movement performance and agility more than the type of sock worn. Meta-analysis is not conducted in this study due to heterogeneity in the included studies.

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Figure 3:

P-values for studies showing the impact of socks on gait and balance. Green: Statistically significant (p <0.05), Red: Not statistically significant (p <0.05), Blue dashed line represents the significance threshold (p = 0.05).

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DISCUSSION

This study explored the impact of specialised socks, including compression, nonslip, textured, and sensory-enhancing designs, on balance, proprioception, and gait stability in healthy adults. These socks are emerging as accessible and cost-effective tools to enhance mobility and mitigate fall risks, particularly among vulnerable populations such as older adults and individuals with sensory impairments. The findings from this research highlight both the immediate and long-term benefits of these interventions, with variations observed across sock types and populations.

Compression socks demonstrated consistent improvements in postural control, proprioception, and lower-limb reflexes, emphasising their role in rehabilitation and fall prevention strategies. For instance, Sun et al. observed that healthy individuals aged 19-45 years experienced reduced postural sway and enhanced reflex control during walking due to improved proprioceptive feedback, showcasing the potential of compression socks for balance rehabilitation.^[22] Similarly, Woo et al. reported significant enhancements in ankle joint position sense among older adults (aged 60-85 years), underscoring their importance in reducing fall risks in elderly populations.^[25] Long-term investigations, such as Kiikka et al., further revealed motor leaning and balance improvements following an eight-week intervention, suggesting sustained benefits for older adults and individuals with stability challenges.^[31] These findings collectively emphasise the utility of compression socks in enhancing sensory feedback and maintaining stability under various conditions.

Textured socks, designed to stimulate mechanoreceptors in the foot, exhibited promising effects in improving balance and sensory perception. Pinvanichkul et al. demonstrated improvements in balance among older adults, using texture socks during walking training over four weeks, although gait parameters such as stride length remained unaffected.^[27] Similarly, Wheat et al. showed moderate balance improvements in young adults during tasks requiring increased sensory input, such as single-leg standing.^[26] These results highlight the ability of texture socks to enhance somatosensory feedback, making them viable interventions for populations with sensory deficits or reduced postural stability.

Nonslip socks were particularly effective in mitigating fall risks on slippery surfaces by providing enhanced traction. Hatton et al. found significant improvements in gait stability, stride length, and balance among older adults wearing nonslip socks in environments prone to sleeping hazards.^[24] This practical intervention holds significant potential in real-world settings, where fall risks are elevated due to uneven or wet surfaces. The findings suggest that non-sleep socks can serve as an immediate and practical solution for enhancing mobility and preventing accidents in at-risk populations.

Sensory-enhancing socks were also evaluated for their ability to preserve food sensation while providing adequate protection. A study demonstrated that an elderly lady, navigating obstacle courses, experienced significant improvement in walking speed and stride length when using sensory-enhancing socks or walking barefoot compared to conventional socks.^[28] This suggests that sensory-enhancing socks can maintain critical sensory input for effective gait mechanics, particularly for elderly individuals at risk of falls.

Interestingly, some studies indicated that the benefits of specialised socks might depend on the specific design, population, and task being assessed. For example, Jaakkola et al. found that improvements in postural control and agility following an eight-week training programme were primarily attributed to the training itself rather than differences in stock compression levels.^[30] Similarly, Shinohara et al. found no miserable differences in balance between five-toed socks, regular socks, and barefoot conditions, emphasising the need for targeted designs tailored to specific populations and functional goals.^[29]

Despite the promising findings, several limitations should be acknowledged. Many studies, such as those by Shinohara et al. and Tomita, involved small sample sizes, limiting the generalisability of their conclusions.^[28,29] Additionally, most investigations were short-term, focusing on immediate effects rather than sustained impacts of specialised socks. This highlights the need for longitudinal studies to evaluate the durability of these interventions in daily life. Furthermore, the variability in study designs and assessment methods complicates comparisons between findings, underscoring the need for standardised protocols in future research.

Real-world applicability was another limitation, as most studies were conducted in controlled environments rather than in daily settings characterised by external variables such as uneven terrain or distractions. Comparative studies assessing specialised socks alongside alternative interventions, such as orthotics or balance training programmes could further establish their relative efficacy.

The collective findings indicate that specialised socks, particularly compression and nonslip designs, offer significant benefits in improving balance, proprioception, and gait stability across diverse populations. Compression socks appear especially valuable for enhancing sensory feedback and motor learning, while textured and sensory-enhancing socks stimulate mechanoreceptors to preserve foot sensation. Nonslip socks provide immediate benefits by improving traction on hazardous surfaces and reducing fall risks in daily environments.

Future research should address existing limitations by conducting larger-scale, long-term studies involving diverse populations, including individuals with chronic conditions or disabilities. Investigating the combined effects of specialised socks with other interventions, such as balance training or advanced footwear technologies, could provide insights into synergistic benefits. Moreover, innovations in sock design, such as the integration of smart sensors for real-time feedback, hold promise for expanding the applications of these interventions. By addressing these gaps, specialised socks could emerge as a practical, cost-effective tool for improving balance, mobility, and fall prevention strategies in clinical and community settings.

CONCLUSION

This systematic review synthesised evidence from ten studies investigating the effects of various socks on gait and balance. The findings highlight that sock-based interventions represent an affordable, accessible, and non-invasive approach to improving balance, proprioception, and mobility, particularly among populations at risk of falls. Compression socks, textured socks, nonslip socks, and sensory-enhancing socks all provide unique benefits, from enhancing sensory feedback to preventing slips and falls, thus making them valuable tools in promoting independence and safety. However, further research is needed to optimise these interventions, better understand their long-term effects, and identify the most effective applications for different populations. With growing evidence, sock-based interventions could play a significant role in fall prevention and rehabilitation, ultimately improving the quality of life for individuals experiencing balance or mobility challenges.