How should a boggy heel (deep‑tissue pressure injury) be managed?

Management of Boggy Heels (Deep-Tissue Pressure Injury)

Immediately offload the heel completely by elevating it off the support surface using a pressure-redistribution device, combined with aggressive surgical debridement if infection is present, and initiate broad-spectrum antibiotics if there are systemic signs of infection. 1

Initial Assessment and Risk Stratification

Examine the heel for:

• Depth of tissue involvement: Use a sterile probe to assess depth and determine if bone is palpable (characteristic stony feel indicates possible osteomyelitis) 1
• Signs of infection: Erythema extending >1.5 cm from wound edge, purulent discharge, elevated temperature (>38°C), tachycardia, elevated white blood cell count (>15 × 10⁹/L), and elevated C-reactive protein (>100 mg/L) 1
• Vascular status: Palpate dorsalis pedis and posterior tibial pulses; if absent or diminished, obtain ankle-brachial index (ABI) and toe pressures. ABI <0.50 or toe pressure <30 mmHg indicates critical ischemia that will impair healing 1
• Neuropathy: Test with 10-g monofilament at plantar heel, metatarsal heads, and toe tips—inability to detect at 2 of 3 sites confirms loss of protective sensation 1

Immediate Pressure Offloading (Priority #1)

Complete heel elevation is non-negotiable for healing. 1, 2

• Use non-removable offloading devices (total-contact cast or fixed walker boot) rather than removable devices, as they provide superior pressure relief and ensure compliance 1
• The heel must be suspended completely off the support surface while preventing foot-drop and leg rotation 3, 2
• Standard foam pillows are insufficient—use wedge-shaped viscoelastic foam cushions or specialized heel protection devices that elevate the entire lower leg 3, 2
• Avoid complete immobilization of the patient to prevent muscular atrophy and deconditioning 1

Surgical Debridement

Sharp debridement is the gold standard and should be performed immediately if necrotic tissue, slough, or eschar is present. 1

• Remove all nonviable tissue, hyperkeratosis, and wound debris using scalpel, scissors, or tissue nippers 1
• Debride until bleeding tissue is encountered—this removes colonizing bacteria, facilitates granulation, and allows proper wound assessment 1
• Repeat debridement as often as needed if nonviable tissue continues to form 1
• For deep stage IV ulcers involving muscle, tendon, or bone, surgical debridement in an operative suite may be required, potentially including partial or total calcanectomy 4

Infection Management

If systemic signs of infection are present (fever, elevated WBC, elevated CRP), initiate empiric broad-spectrum antibiotics immediately after obtaining cultures. 1

• Pressure ulcer infections are typically polymicrobial with both aerobes (S. aureus, Enterococcus, Proteus, E. coli, Pseudomonas) and anaerobes (Peptococcus, Bacteroides fragilis, Clostridium) 1
• Start empiric coverage with intravenous amoxicillin-clavulanic acid or a combination covering Gram-positive, Gram-negative, and anaerobic organisms 1
• Obtain tissue specimens (not superficial swabs) for culture before starting antibiotics—tissue samples provide more accurate results 1
• If MRSA is suspected based on local epidemiology (>20% prevalence) or risk factors, add vancomycin or linezolid 1
• Continue IV antibiotics until clinical improvement (normalization of temperature, WBC, CRP), then transition to oral therapy for 2 weeks total 1

Vascular Assessment and Revascularization

If ABI <0.50, toe pressure <30 mmHg, or TcpO₂ <30 mmHg, the wound will not heal without revascularization. 1

• Obtain arterial duplex ultrasound to identify stenotic lesions 1
• Refer immediately for vascular surgery or interventional radiology consultation for endovascular or open revascularization 1
• For deep-tissue injury with tissue loss, both inflow and outflow lesions typically require treatment in the same procedure to optimize healing 1

Wound Care After Debridement and Offloading

Maintain a moist wound environment while controlling exudate and avoiding maceration. 1

• For dry/necrotic wounds: Use hydrogels or continuously moistened saline gauze 1
• For exudative wounds: Use alginates or foam dressings 1
• Avoid topical antimicrobials for clinically uninfected wounds 1
• Consider negative pressure wound therapy (NPWT) for deep wounds after adequate debridement and revascularization 1

Adjunctive Therapies (After Primary Interventions)

If the wound fails to heal despite adequate offloading, debridement, and revascularization:

• Hyperbaric oxygen therapy may be considered for diabetic foot ulcers after revascularization 1
• Bioengineered skin equivalents or growth factors may be considered for slow-healing wounds 1

Critical Pitfalls to Avoid

• Never inject corticosteroids near the heel—this is contraindicated and can cause tissue necrosis 1
• Do not rely on removable offloading devices—patients remove them, leading to treatment failure 1
• Do not use superficial wound swabs for culture—they yield contaminants and miss deep pathogens 1
• Do not delay vascular assessment—ischemic wounds will not heal regardless of other interventions 1
• Do not use antibiotics without systemic signs of infection—colonization does not require treatment 1

Follow-Up and Monitoring

• Measure and document wound size, depth, surrounding erythema, and drainage quality at each visit 1
• Obtain plain radiographs to assess for osteomyelitis if bone is palpable or wound fails to improve 1
• If no improvement after 6-8 weeks of appropriate treatment, obtain MRI to evaluate for osteomyelitis or deep abscess 1
• Refer to podiatric foot and ankle surgeon if no improvement after 6-8 weeks despite optimal conservative management 1