What is the recommended treatment for a deep tissue injury on the heel?

Treatment of Deep Tissue Injury on the Heel

Immediately assess vascular status and initiate complete pressure offloading while performing sharp debridement of any necrotic tissue, as deep tissue injuries to the heel require aggressive early intervention to prevent progression to full-thickness wounds and amputation. 1

Immediate Vascular Assessment

• Measure ankle-brachial index (ABI) or ankle pressure urgently upon presentation 1
• If ankle pressure is <50 mmHg or ABI <0.5, obtain urgent vascular imaging and consider revascularization 1
• Vascular compromise is a critical factor in heel deep tissue injury outcomes and must be addressed before definitive wound management 1

Infection Evaluation

• Examine for local swelling, erythema >0.5 cm around the wound, tenderness, warmth, or purulent discharge 1
• Document wound size, depth, presence of necrotic tissue, and surrounding tissue condition 1
• For superficial infection, initiate empiric oral antibiotics targeting Staphylococcus aureus and streptococci immediately 1
• For deep infection with signs of abscess, compartment syndrome, or extensive gangrene, obtain urgent surgical consultation and initiate parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1, 2

Debridement Strategy

• Perform sharp scalpel debridement at the bedside or clinic to remove all necrotic tissue, slough, eschar, and surrounding callus 1
• Sharp debridement is the preferred method and should not be delayed 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 1
• For large and deep heel ulcers with deep space infection, frequent debridement and drainage of deep heel spaces may be necessary 3
• In non-ischemic feet with extensive tissue loss, elevation of the heel pad as a flap with broad pedicle can facilitate adequate debridement and subsequent reconstruction 3

Pressure Offloading (Critical Component)

• Institute complete pressure relief from the heel using pillows, foam wedges, or specialized heel suspension devices 1
• Instruct the patient to avoid bearing weight on the affected heel entirely 1
• Provide crutches or wheelchair for mobility 1
• Educate caregivers on maintaining strict pressure offloading, as this is essential to prevent progression 1
• Most deep tissue injuries occur at the heel and sacrum, making offloading particularly critical at these sites 4

Antibiotic Therapy Duration

• Administer antibiotics for 1-2 weeks for skin or soft tissue infection 2
• Consider continuing treatment for up to 3-4 weeks if the infection is extensive, improving but resolving slower than expected, or if severe peripheral artery disease is present 2
• If evidence of infection has not resolved after 4 weeks of appropriate therapy, re-evaluate the patient and reconsider the need for further diagnostic studies or alternative treatments 2

Advanced Therapies

• Consider hyperbaric oxygen therapy for poorly healing wounds, though evidence is moderate 1
• Negative pressure wound therapy can be safely applied after acute debridement of deep diabetic foot infections 5
• Evaluate for adjunctive therapies including bioengineered skin equivalents, growth factors, or granulocyte colony-stimulating factors, though evidence supporting these is weak to moderate 1

Monitoring and Follow-Up

• Between 9.3% and 27% of deep tissue injuries deteriorate to full-thickness tissue loss 6
• Factors associated with deterioration include cooler skin on infrared thermography and negative capillary refill 6
• Positive capillary refill is associated with resolution without tissue loss and may be an effective prognostic indicator 6
• C-reactive protein (CRP) is the most adequate parameter for both diagnosis and monitoring treatment response 5
• Healing of large and deep heel ulcers typically requires 4-7 months (median 6 months) with appropriate multidisciplinary management 3

Critical Pitfalls to Avoid

• Never underestimate the severity of deep tissue injury - these injuries have a hallmark of rapid deterioration despite appropriate preventive interventions 1, 4
• Do not delay debridement of necrotic tissue - early intervention is essential to prevent progression 1
• Avoid inadequate pressure offloading - this is the most common cause of treatment failure 1
• Do not miss vascular compromise - critically ischemic limbs require revascularization before or concurrent with definitive reconstruction 1
• Never use footbaths or soaking - this induces skin maceration and should be avoided 1
• Avoid delaying surgical consultation - obtain urgent surgical evaluation for moderate or severe infection, extensive gangrene, necrotizing infection, signs of deep abscess, compartment syndrome, or severe lower limb ischemia 2

When to Consider Amputation

• Life-threatening sepsis persisting despite aggressive surgical debridement and antibiotics 7
• Critical limb ischemia not amenable to revascularization 7
• Extensive soft tissue loss precluding coverage of a reconstruction 7
• With appropriate multidisciplinary management including revascularization when needed, 89.2% of large and deep heel ulcers can be salvaged 3