What is the treatment for deep tissue injury to the heel?

Treatment of Deep Tissue Injury to the Heel

Deep tissue injury to the heel requires immediate pressure offloading, thorough assessment for infection and vascular compromise, sharp debridement of any necrotic tissue, appropriate moisture-retentive dressings, and close monitoring for rapid deterioration. 1

Initial Assessment and Classification

Deep tissue injuries (DTIs) are serious pressure injuries that begin in muscle closest to bone and may not be visible initially, with a hallmark of rapid deterioration despite appropriate interventions. 2 The heel is one of the most common sites for DTPI development, along with the sacrum and buttocks. 2

Key assessment priorities include:

• Inspect thoroughly for the extent of tissue damage, looking for purple or maroon discoloration, blood-filled blisters, or intact skin that may be concealing deeper injury 1, 2
• Evaluate vascular status immediately by measuring ankle-brachial index (ABI) or ankle pressure; if ankle pressure is <50 mmHg or ABI <0.5, urgent vascular imaging and revascularization should be considered 3, 1
• Assess for infection by examining for local swelling, erythema >0.5 cm around the wound, tenderness, warmth, or purulent discharge 3, 1
• Document wound characteristics including size, depth (once visible), presence of necrotic tissue, and surrounding tissue condition 3, 1

Debridement Strategy

Sharp debridement is the preferred method for removing necrotic tissue and should be performed as soon as necrotic tissue is identified. 3, 1

• Perform scalpel debridement to remove all necrotic tissue, slough, eschar, and surrounding callus at the bedside or clinic when possible 3
• Repeat debridement as often as needed if nonviable tissue continues to form 3, 1
• Consider operative debridement if the wound requires deeper or more extensive tissue removal, the patient has intact sensation requiring anesthesia, or clinic time is limited 3
• Avoid debridement temporarily if the wound is primarily ischemic until vascular status is restored 3

Alternative methods include hydrogels for autolytic debridement of dry or necrotic wounds, though these are less definitive than sharp debridement. 3

Pressure Offloading (Critical Priority)

Complete pressure relief from the heel is mandatory and represents a cornerstone of treatment. 3, 1

• Elevate the heel off all surfaces using pillows, foam wedges, or specialized heel suspension devices 1
• Instruct the patient to avoid bearing weight on the affected heel and use crutches or wheelchair for mobility 3, 1
• Consider temporary footwear modifications or orthoses once ambulation resumes 3
• Never allow the heel to return to the same footwear that contributed to the injury 3

Wound Dressing Selection

Select dressings based on wound moisture level and stage of healing:

• For dry or necrotic wounds: Use continuously moistened saline gauze or hydrogels to facilitate autolysis 3, 1
• For moderately exudative wounds: Apply alginates or foam dressings to absorb exudate 3, 1
• For wounds requiring moisture balance: Consider hydrocolloids or films 3
• Avoid silver or antimicrobial-containing dressings unless infection is documented, as they are not well-supported for routine wound management 3, 1

For post-operative wounds following surgical debridement, negative pressure wound therapy may be considered to facilitate healing. 3

Infection Management

If infection is present, initiate treatment immediately based on severity:

Superficial Infection (Mild)

• Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 3, 1
• Cleanse and debride all necrotic tissue 3

Deep Infection (Moderate to Severe)

• Urgently evaluate for surgical intervention to remove necrotic tissue, drain abscesses, and debride infected bone 3, 1
• Initiate parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 3, 1
• Reassess vascular status and consider urgent revascularization if PAD is present 3
• Adjust antibiotics based on culture results and clinical response 3

Advanced Therapies for Non-Healing Wounds

If the wound fails to show improvement within 6 weeks despite optimal management:

• Reevaluate vascular status with urgent imaging and consider revascularization 3, 1
• Consider hyperbaric oxygen therapy for poorly healing wounds, though evidence is moderate 3
• Evaluate for adjunctive therapies including bioengineered skin equivalents, growth factors, or granulocyte colony-stimulating factors, though evidence supporting these is weak to moderate 3

Monitoring and Follow-Up

DTIs characteristically deteriorate rapidly, requiring vigilant monitoring:

• Inspect the wound frequently (at least daily initially) as DTIs may remain invisible for up to 48 hours before progressing rapidly to full-thickness tissue loss 2, 4
• Consider open-to-air wound care in the immediate post-debridement period to permit frequent re-evaluation for disease progression while reducing pain associated with dressing changes 5
• Monitor for signs of worsening infection including fever, increasing erythema, or worsening hyperglycemia 3, 1

Patient Education

Instruct patients and caregivers on:

• Recognizing signs of infection including fever, increased wound drainage, worsening pain, or changes in wound appearance 3, 1
• Maintaining strict pressure offloading and avoiding weight-bearing on the affected heel 1
• Preventing ulcers on the contralateral foot during periods of enforced bed rest or altered mobility 3

Common Pitfalls to Avoid

• Underestimating the severity of DTI based on initial appearance, as extensive deep tissue damage may be present beneath intact or minimally damaged skin 2, 4
• Delaying debridement of necrotic tissue, which serves as a reservoir for infection and impedes healing 3, 1
• Inadequate pressure offloading, which is the most common reason for treatment failure in heel pressure injuries 3, 1
• Missing vascular compromise, particularly in diabetic or elderly patients who may have asymptomatic peripheral arterial disease 3, 1
• Using footbaths or soaking, which induces skin maceration and should be avoided 3