Outpatient Treatment of Deep Tissue Injury (DTI) Heel
For a DTI heel in the outpatient setting, implement aggressive pressure offloading as the cornerstone of treatment, using a total contact cast or removable cast walker if available, combined with regular wound assessment and debridement as needed. 1
Primary Treatment: Pressure Offloading
The most critical intervention for DTI heel is complete pressure relief from the affected area:
Total contact cast (TCC) is the gold standard offloading device, showing superior healing rates and faster time to healing compared to other modalities in diabetic foot ulcers (which share similar pathophysiology with pressure-related DTI) 1
Removable cast walker (RCW) is an acceptable alternative when TCC is unavailable or contraindicated, though patient adherence is crucial for effectiveness 1
Custom pressure-offloading footwear should be considered for patients who cannot tolerate casting, with evidence showing effectiveness when worn as prescribed 1
Felted foam in combination with appropriate footwear (post-operative shoe or healing shoe) can be used when other offloading options are unavailable, though this requires frequent replacement 1
Wound Care Management
Active wound management must accompany offloading:
Regular debridement of necrotic tissue is essential, as DTI often evolves to reveal deeper tissue damage with eschar formation 2
Maintain moist wound environment using appropriate dressings that control drainage while avoiding maceration 1
Weekly wound assessment to monitor for signs of infection, biofilm formation, or progression of tissue damage 1
Clinicians without adequate debridement training should seek consultation from wound care specialists 1
Critical Diagnostic Considerations
DTI heel requires careful differential diagnosis:
Distinguish DTI from other purple-hued lesions including bruising, hematoma, venous engorgement, arterial insufficiency, or necrotizing fasciitis 2
Assess vascular status immediately - check pedal pulses and consider ankle-brachial index (ABI) measurement, as peripheral arterial disease is present in 20-30% of at-risk patients and significantly impacts healing 1
Document "time down" history - DTI results from sustained pressure exposure, so establishing timeline of pressure exposure is diagnostically important 2
Medical Optimization
Systemic factors must be addressed concurrently:
Smoking cessation is mandatory for wound healing 1
Glycemic control if diabetic 1
Nutritional optimization to support tissue repair 1
Cardiovascular risk factor modification 1
Infection Surveillance
Monitor closely for infection development:
Do NOT use prophylactic antibiotics for clinically uninfected wounds 1
Obtain urgent surgical consultation if signs of deep infection, abscess, or necrotizing infection develop 1
If infection develops, obtain cultures (preferably tissue or bone samples rather than swab) and initiate appropriate antibiotic therapy for 1-2 weeks for soft tissue infection 1
Follow-up Protocol
Structured monitoring is essential:
Weekly assessment initially to evaluate healing progression and adjust treatment 1
Re-evaluate at 4 weeks if no improvement is seen, considering alternative diagnoses or need for advanced interventions 1
Continue offloading until complete healing - premature discontinuation leads to recurrence 1
When to Escalate Care
Certain situations require specialist involvement:
Severe ischemia (ABI <0.40) requires urgent vascular surgery consultation 1
Non-healing wounds after 4 weeks of appropriate treatment warrant reassessment and possible advanced therapies 1
Development of osteomyelitis (positive probe-to-bone test, elevated inflammatory markers) requires infectious disease consultation 1
Common Pitfalls to Avoid
Inadequate offloading is the most common cause of treatment failure - partial weight-bearing is insufficient 1
Premature return to regular footwear before complete epithelialization leads to recurrence 1
Missing concurrent arterial insufficiency - always assess vascular status as this fundamentally changes prognosis and may require revascularization 1
Inappropriate antibiotic use in uninfected wounds does not promote healing and contributes to resistance 1