Heel ulcers and pressure injuries: protecting and healing the heel

What a heel pressure injury is

A pressure injury (also called a pressure ulcer or bedsore) is damage to the skin and soft tissue from prolonged pressure and shear, usually over a bony prominence or under a medical device.⁠^[1,6] When your heel rests on a mattress for hours, the tissue over the bone is squeezed and its tiny blood vessels close. Damage can start deep down, before anything shows on the skin.⁠^[1]

Not every heel ulcer starts in bed: with diabetes, a blister on a numb heel can go unnoticed and become a sore.⁠^[7] See also diabetic foot ulcers and, on our parent practice’s site, cracked heels (external site).

Who is at risk

Your risk is higher with:

• Long hours in bed, as in a hospital stay, long-term care or a long illness.⁠^[1]
• A cast, splint or brace pressing on the heel.⁠^[1]
• Numb feet.⁠^[7] The Lower Extremity Nerve Institute explains peripheral neuropathy (external site).
• Poor circulation, older age, poor nutrition, anemia, or memory and thinking problems.⁠^[1]

How pressure injuries are staged

Stages describe how much tissue has been lost, and an injury doesn’t necessarily move step by step from 1 to 4.⁠^[6]

• Stage 1. The skin is unbroken but has a red area that doesn’t fade when you press it (it can look different on darker skin).⁠^[6]
• Deep tissue injury. A deep red, maroon or purple area, or a dark blood-filled blister, that doesn’t fade when pressed; the skin may be intact or broken. It may open quickly to show deeper damage, or settle without tissue loss.⁠^[1,6]
• Stage 2. A shallow, moist pink or red wound, or a blister filled with clear fluid, intact or broken.⁠^[6]
• Stages 3 and 4. Loss through the skin into the fat (stage 3), or down to fascia, muscle, tendon, ligament or bone (stage 4).⁠^[1,6]
• Unstageable. The base is covered by slough (soft, yellowish material) or eschar (dry, dark, leathery dead tissue), so its depth can’t be seen.⁠^[6]

The heel has its own rule: a stable eschar there (dry, firmly attached and unbroken, with no redness or softness around it) should not be softened or removed.⁠^[6] We protect it and check circulation rather than trim it.

Why heel ulcers are slow to heal

In 1,000 people with diabetic foot ulcers from the European Eurodiale study, median healing took 147 days for toe ulcers, 188 for midfoot and 237 for heel ulcers. Peripheral artery disease and heart failure also slowed healing.⁠^[2]

An Italian team treated 254 people with diabetes, poor circulation and a foot ulcer, including opening narrowed arteries. Within a year, 60% of heel ulcers healed, against 78% of other ulcers; shallow, uninfected heel ulcers did better.⁠^[8] So come in early.

How a heel wound is evaluated

Heel wound care at all three of our offices is led by Dr. Efe Ozturk, a Foot and Ankle Surgeon who is board certified in wound care (FAPWH). We measure the wound each visit and check its depth, whether bone can be felt, infection, sensation and pulses. X-ray and ultrasound are available at our practice; MRI is arranged at an outside imaging center. See how a foot wound is evaluated.

In a US series of 157 people who had part of the heel bone removed, nearly half had peripheral artery disease, which raised the odds of a major amputation; the authors advise circulation testing before every such operation.⁠^[4] We do noninvasive circulation testing at our practice and, when artery disease reduces blood flow, arrange imaging and treatment to restore it with a vascular specialist.

Healing a heel ulcer without surgery

Non-surgical care is the foundation for every heel wound:

• Taking the pressure off. Offloading is arguably the most important step in healing a diabetic foot ulcer; without it, a pressure ulcer tends to widen and deepen.⁠^[3,1] For an ulcer on the sole of the heel in someone with diabetes and numb feet, an international guideline suggests a non-removable knee-high device over a removable one, on very limited evidence.⁠^[3] For one on the back or side of the heel, it advises a removable offloading device or footwear changes, and notes that an ankle-foot brace may ease pressure in bed.⁠^[3] We fit a total contact cast or similar device when needed and show you how to get around safely; see also offloading boots and footwear.
• Wound care every week or two. We clear callus and dead tissue that block healing (debridement), apart from a stable heel eschar, and adjust the dressings.
• Treating infection. A deep pressure injury can spread into the bone or the bloodstream.⁠^[1] We choose antibiotics from culture results; see bone infection of the foot.

When surgery is considered

Surgery is the step that saves the foot when wound care alone can’t. If a heel wound hides a pocket of infection, Dr. Ozturk drains it and removes dead tissue in the operating room, with cultures to guide antibiotics.

Below-knee amputation has been regarded as the definitive treatment for heel bone infection, but it may be less desirable when the rest of the foot is healthy.⁠^[9] A partial calcanectomy instead removes the infected part of the heel bone and keeps the foot.⁠^[9,5] Dr. Ozturk performs it for the heel wounds that need it; a below-knee amputation, if ever needed, is done by a vascular or orthopedic surgeon.

• In a 20-study review of 295 people with diabetes, most with a partial calcanectomy, the bone infection healed in about 80%. About 17% later needed a below-knee amputation. The authors called calcanectomy a good alternative to amputation above the ankle.⁠^[5]
• In an earlier review of 100 people who walked before surgery, 85% kept or improved their walking; about 10% needed a major amputation.⁠^[9]

After surgery, you keep weight off the heel while it heals (see surgery for bone infection). If the wound needs help to close, we use negative-pressure wound therapy, skin substitutes or skin grafts and local flaps, and refer you for hyperbaric oxygen therapy when it fits.

Risks and limits

People who need heel bone surgery often have several other health conditions and limited mobility. Walking may decline: in the 157-person series, independent walking fell from 40% before surgery to 18% at last follow-up.⁠^[4] In the 20-study review, removing the whole heel bone was linked with more deaths than removing part of it.⁠^[5]

That is why, when needed, we arrange treatment with a vascular specialist to restore blood flow first, treat infection, work with your diabetes doctor on blood sugar, and remove only as much bone as necessary. If you’ve been told a heel wound means amputation, a second opinion can help you weigh the options.

Preventing heel pressure injuries

A review of 15 randomized trials found low-quality evidence that heel offloading devices may reduce new heel pressure ulcers, and too little evidence on dressings.⁠^[10]

• Float your heels in bed, and ask your care team how often to change position.
• If you have diabetes, check your feet every day, heels included, with a mirror or a helper.⁠^[7]
• In a cast or splint, report any new pain, rubbing or drainage.
• After an ulcer heals, ask about the therapeutic shoes and custom inserts we fit.

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. On a heel, that includes a red area that doesn’t fade when pressed, a purple or maroon patch, or a blister. New black tissue on the heel, even a dry crust, is an emergency sign (see below). If you have diabetes or poor circulation, call us the same day for new redness, warmth, swelling or drainage around a heel wound (see a red, hot, swollen foot) or for new foot pain at rest or at night.