Management of Heel Pressure Injuries
The cornerstone of heel pressure injury management is complete offloading of the heel combined with frequent wound inspection, sharp debridement, and appropriate dressing selection to maintain a moist wound environment. 1
Immediate Priority: Complete Pressure Offloading
The single most critical intervention for heel pressure injuries is eliminating all pressure from the affected area:
- Use heel suspension devices that completely float the heel off any surface, ensuring the Achilles tendon remains free of pressure 1
- For non-plantar heel ulcers, consider shoe modifications, temporary footwear, or orthoses 2
- Instruct patients to strictly limit standing and walking; provide crutches if necessary 2
- During bed rest, ensure heels are elevated and "floating" to prevent contralateral heel injury 3
Common pitfall: Removable offloading devices are often removed by patients or staff. Ensure compliance through education and frequent monitoring.
Vascular Assessment - Critical Early Step
Heel ulcers have high risk for vascular compromise due to the heel's relatively poor blood supply 4. Immediately assess perfusion status:
- Measure ankle-brachial index (ABI) and toe pressures
- If ankle pressure <50 mmHg, ABI <0.5, toe pressure <30 mmHg, or TcPO2 <25 mmHg, obtain urgent vascular imaging and consider revascularization 2
- Even with normal initial vascular studies, if the wound shows no healing progress within 6 weeks despite optimal management, pursue revascularization evaluation 2
Note: ABI may be falsely elevated in diabetic patients due to arterial calcification; toe pressures and TcPO2 are more reliable 3, 1.
Local Wound Management
Debridement
- Perform sharp debridement with a scalpel to remove all necrotic tissue and surrounding callus 2
- Repeat debridement as frequently as needed 2
- Exception: Do not debride ischemic heel ulcers without signs of infection until perfusion is restored 3
Wound Cleansing and Dressing Selection
- Inspect the ulcer at every dressing change 2
- Select dressings that control excess exudate while maintaining a moist wound environment 2
- Avoid antimicrobial or silver-containing dressings - these are not well-supported for routine management 2, 3
- Never use footbaths as they cause skin maceration 2
Advanced Therapies
- Consider negative pressure wound therapy for post-operative wounds 2
- Consider hyperbaric oxygen therapy for poorly healing wounds 2
- Biologically active products (collagen, growth factors) are not recommended for routine use 2, 3
Infection Management
Assess for infection by looking for ≥2 signs of inflammation (redness, warmth, induration, pain/tenderness) or purulent drainage 2. Note that neuropathy or ischemia may blunt these signs.
Mild Superficial Infection:
- Cleanse and debride necrotic tissue
- Start oral antibiotics targeting S. aureus and streptococci 2
Deep/Limb-Threatening Infection:
- Urgently evaluate for surgical debridement to remove necrotic tissue and drain abscesses 2
- Assess for osteomyelitis if wound is longstanding, deep, overlies bone, or probe-to-bone test is positive 2
- Initiate parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 2
- Reassess vascular status and consider urgent revascularization 2
Systemic Optimization
- Optimize glycemic control (target blood glucose <140 mg/dL or <8 mmol/L) 3
- Address malnutrition and edema 3
- Implement cardiovascular risk reduction: smoking cessation, control hypertension and dyslipidemia, use antiplatelet therapy 2
When to Escalate Care
Patients with heel ulcers extending deeper than subcutaneous tissue require intensive multidisciplinary management and may need hospitalization 2. The evidence strongly supports that multidisciplinary foot care teams reduce amputation rates 3.
Key principle: Even optimal wound care cannot compensate for continued pressure on the wound bed, untreated ischemia, or uncontrolled infection 2. Address all three factors simultaneously for successful healing.