1. Delmore, Barbara PhD, RN, CWCN, MAPWCA, IIWCC-NYU, FAAN
  2. Ayello, Elizabeth A. PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

Article Content

Heels are the second most common anatomic site for pressure injuries1,2 and are particularly vulnerable because the skin that covers the posterior calcaneus (heel) bone is only about 3.8 mm thick, with the epidermis accounting for 0.46 mm.3 The usually angular shape of the calcaneus impacts tissue strain, so the part of the heel that rests on the bed or foot device experiences high pressure over a small area.1 The subcutaneous tissue is thin, highly vascularized, firm, and fibrous; it lacks muscle/fat tissue for cushioning/protection rendering it vulnerable to pressure and shear forces.4 Heel blood supply is equally compromised because it relies largely on collateral circulation from the posterior tibial artery.3,5,6 Diseases, conditions, medications, or prolonged heel positioning without relief can cause ischemic changes to the heel's skin surface.1,4


Risk Factors

A retrospective case-control study (n = 337)4 found four factors significantly and independently associated with a heel pressure injury (HPI): diabetes mellitus, vascular disease, immobility, and Braden Scale score <=18 on admission. When repeated in a larger, more diverse population (n = 1,697), seven variables were significantly and independently associated with an HPI: diabetes mellitus, vascular disease, perfusion issues, impaired nutrition, age >=65 years, mechanical ventilation, and surgery.7 The second study yielded a mnemonic-based enabler to assist clinicians in translating this evidence into practice (Figure 1).7

Figure 1 - Click to enlarge in new windowFigure 1. HEEL PRESSURE INJURY PREVENTION ENABLERThe enabler is based on validated risk factors

Some handy tips for practitioners from the 2019 International Guideline on the prevention and treatment of pressure injuries1 and other literature8,9 include:



Providers should evaluate heel vascular/perfusion status (including foot pulses, ankle brachial index, smoking status, edema), check patient heel sensation (eg, assess for peripheral neuropathy using monofilament testing assessment), and assess risk for HPI (physical assessment of heel skin condition,1 previous HPI, and if available newer devices to identify nonvisual signs of tissue deformation/edema as well as clinical condition, medical history, comorbidities, etc).1 The need for consults from other members of the interprofessional team should be determined.8,9



The position of the heel is critical. Providers should be careful when transferring, turning, and repositioning patients to avoid damage to the heels and avoid both dorsiflexion and plantar flexion.8 Further, there should be no external or internal rotation of the foot because it increases tissue deformation (Figure 2).10 Heel suspension devices maintain feet in a neutral (90[degrees]) position (Figure 3) but proper leg and foot alignment (slight knee flexion, even pressure distribution under the calves, and proper foot alignment) must be ensured.1 The heel suspension device must be removed periodically (at least twice a day).1 Pillows are also sometimes used to offload or "float" the heels8 and should be placed vertically, creating even pressure distribution under the calf muscle as well as avoiding pressure to the vulnerable popliteal space and Achilles tendon (Figure 3).1 Providers may want to consider the use of a prophylactic dressing as an adjunct to offloading.1,11,12 The patient's clinical condition, tolerance for these interventions, and manufacturer guidelines should be considered when evaluating offloading methods. The National Pressure Injury Advisory Panel offers a free tip sheet on proper heel offloading.13

Figure 2 - Click to enlarge in new windowFigure 2. POSITION THE FOOT AND HEELSFigure (C)2021 Delmore and Ayello, reprinted with permission. Left, Photo (C)2021 Delmore and Ayello. Middle, Reprinted from American College of Sports Medicine.
Figure 3 - Click to enlarge in new windowFigure 3. PRESSURE REDISTRIBUTION FOR THE HEELProper offloading and redistribution of the heel help to avoid a heel pressure injury or any damage to the Achilles area.Figure (C) 2021 Ayello, Goodman, and Delmore, reprinted with permission. Left, Modified image by unknown author licensed under CC-BY-ND. Middle and right, Photos (C) 2021 Goodman, used with permission.


The principles of treating HPIs include pressure redistribution via care measures/offloading devices, skin protection, and local wound care based on the Wound Bed Preparation paradigm.1,9,12-14 Stable heel eschar should not be debrided in the presence of untreated peripheral vascular disease unless there is a high suspicion of infection.1




1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Chapter 9: heel pressure injuries. In: Prevention and Treatment of Pressure Ulcers/Pressure Injuries: Clinical Practice Guideline. Haesler E, ed. EPUAP/NPIAP/PPPIA; 2019. [Context Link]


2. VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009. Adv Skin Wound Care 2010;23(6):254-61. [Context Link]


3. Salcido R, Lee A, Ahn C. Heel pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care 2011;24(8):374-80. [Context Link]


4. Delmore B, Lebovits S, Suggs B, Rolnitzky L, Ayello EA. Risk factors associated with heel pressure ulcers in hospitalized patients. J Wound Ostomy Continence Nurs 2015;42(3):242-8. [Context Link]


5. Faglia E, Caminiti M, Vincenzo C, Cetta F, Clerici G. Heel ulcer and blood flow. Int J Low Extrem Wounds 2013;12(3):226-30. [Context Link]


6. Bosanquet DC, Wright AM, White RD, Williams IM. A review of the surgical management of heel pressure ulcers in the 21st century. Int Wound J 2016;13(1):9-16. [Context Link]


7. Delmore B, Ayello EA, Smith D, Chu AS, Rolnitzky L. Refining heel pressure injury risk factors in the hospitalized patient. Adv Skin Wound Care 2019;32(11):512-9. [Context Link]


8. Cuddigan JE, Ayello EA, Black J. Saving heels in critically ill patients. World Counc Enteros Ther J 2008;28(2):16-24. [Context Link]


9. Brienza DM, Tescher AN, Call E. Chapter 11: pressure redistribution: seating, positioning, and support surface. In: Baranoski S, Ayello EA, eds. Wound Care Essentials: Practice Principles. 5th edPhiladelphia, PA: Wolters Kluwer; 2020. [Context Link]


10. Tenenbaum S, Shabshin N, Levy A, Herman A, Gefen A. Effects of foot posture and heel padding devices on soft tissue deformations under the heel in supine position in males: MRI studies. J Rehabil Res Dev 2013;50(8):1149-56. [Context Link]


11. Ramundo J, Pike C, Pittman J. Do prophylactic foam dressings reduce heel pressure injuries?J Wound, Ostomy Continence Nurs 2018;45(1):75-82. [Context Link]


12. Reid K, Ayello E, Alavi A. Pressure ulcer prevention and treatment: use of prophylactic dressings. Chronic Wound Care Manag Res 2016;3(10):117-21. [Context Link]


13. National Pressure Injury Advisory Panel. Offloading heels effectively in adults to prevent pressure injuries. 2020. Last accessed March 4, 2021. [Context Link]


14. Sibbald RG, Elliott JA, Persaud-Jaimangal R, et al. Wound bed preparation 2021. Adv Skin Wound Care 2021;34(4):183-95. [Context Link]