What is the treatment for a deep tissue injury (DTI) on the heel that is not open?

Treatment of Non-Open Deep Tissue Injury (DTI) on the Heel

For a non-open deep tissue injury on the heel, immediate aggressive pressure offloading is the cornerstone of treatment, combined with close monitoring for progression to full-thickness injury, as most DTIs will either resolve or stabilize without surgical intervention if managed appropriately. 1

Initial Assessment

When evaluating a heel DTI, you must determine several critical factors that will guide your treatment approach:

• Assess vascular status by checking pedal pulses; if diminished, obtain ankle-brachial index (ABI) and transcutaneous oxygen pressure (TcPO2) measurements to determine if revascularization is needed 1
• Evaluate for peripheral neuropathy using a 10-g monofilament test, as this affects both wound healing trajectory and treatment approach 1
• Rule out underlying infection through clinical examination—look for warmth, erythema, purulence, or systemic signs of infection 2
• Document wound characteristics including size, depth (using sterile blunt probe), and surrounding tissue condition 1

A critical pitfall is assuming all heel DTIs will progress to full-thickness injury—research shows that 73-91% of DTIs actually resolve or remain stable without deteriorating to full-thickness tissue loss 3, 4.

Primary Treatment: Aggressive Offloading

The single most important intervention is complete pressure relief from the affected heel 1:

• Implement heel-relief shoes or boots that completely suspend the heel off any surface 1
• For severe cases or non-compliant patients, consider total contact casting or non-removable walkers to ensure adherence 1
• Reposition patients every 2 hours if bedridden, ensuring heels remain elevated 5

The heel is particularly vulnerable to DTI because of its anatomical structure—the calcaneus has minimal soft tissue padding and is subjected to high interface pressures 5, 3.

Wound Care for Intact Skin DTI

Since the DTI is not open, your wound care approach differs from open ulcers:

• Do not debride intact skin over a suspected DTI—this can introduce infection and worsen outcomes 1
• Apply protective dressings such as thin hydrocolloids or foam dressings to protect the area from shear and friction 2
• Monitor skin temperature using infrared thermography if available—cooler skin temperatures are associated with progression to full-thickness injury 3
• Assess capillary refill—positive capillary refill is strongly associated with resolution (100% resolution rate in one study, p=0.02), while negative capillary refill predicts deterioration 3

Monitoring for Progression

Reassess the DTI at least weekly to evaluate for signs of progression 1:

• Purple or maroon discoloration darkening suggests worsening ischemia 5
• Development of fluctuance or drainage indicates evolution to open wound requiring different management 4
• Increasing warmth and erythema beyond 2 cm suggests infection requiring urgent intervention 2
• Eschar formation may indicate full-thickness tissue loss 5

Research indicates that 9.3-27% of DTIs will deteriorate to full-thickness tissue loss, with most progression occurring within the first 2-4 weeks 3, 4.

Risk Factor Modification

Address modifiable factors that predict DTI progression 4:

• Correct anemia if present—anemia is uniquely associated with DTI development and poor outcomes 3, 4
• Minimize vasopressor use when clinically feasible, as vasopressors are linked to DTI progression 3, 4
• Optimize nutrition—consider albumin levels and provide adequate protein intake 4
• Manage moisture—address incontinence and excessive perspiration 4

Patients on mechanical ventilation, those with feeding tubes, and those with history of cerebrovascular accident have significantly worse DTI outcomes 4.

When to Escalate Care

Obtain urgent surgical consultation if 2, 1:

• The DTI evolves to an open wound with signs of deep infection (abscess, exposed bone)
• Necrotizing soft tissue infection develops
• Compartment syndrome is suspected
• Severe ischemia is present (ABI <0.4, TcPO2 <30 mmHg) requiring revascularization

For moderate to severe infections that develop, consider early surgical intervention within 24-48 hours to remove infected and necrotic tissue 2.

Vascular Intervention

If vascular assessment reveals significant ischemia 1:

• Obtain urgent vascular surgery consultation for consideration of revascularization 2, 1
• Revascularization options include endovascular procedures or open bypass, and should be performed before or concurrent with any definitive wound management 1
• Critical limb ischemia (ABI <0.4) will prevent healing regardless of other interventions 1

Special Considerations for Diabetic Patients

If the patient has diabetes, additional considerations apply 2:

• Obtain plain radiographs to rule out underlying osteomyelitis, especially if the DTI overlies a bony prominence 2
• Consider MRI if osteomyelitis is suspected and plain films are inconclusive 2
• Ensure glycemic control as hyperglycemia impairs wound healing 2

Common Pitfalls to Avoid

• Delaying offloading while waiting for other interventions—pressure relief must be immediate 1
• Premature debridement of intact skin over DTI, which can introduce infection 1
• Failing to assess vascular status—ischemic DTIs will not heal without revascularization 1, 3
• Assuming all DTIs will progress—most actually resolve with appropriate conservative management 3, 4
• Using negative pressure wound therapy on closed DTI—this is not indicated and provides no benefit 2