By Laurie Swezey RN, BSN, CWOCN, FACCWS

Heels are particularly vulnerable to skin breakdown. The posterior heel is only covered by a thin layer of skin and fat, and that makes breakdown a very real risk. When patients lie supine, all of the pressure of their lower legs and feet rest on the heels, which have relatively poor skin perfusion and a paucity of muscle tissue to absorb stress.

Prevalence rates for heel pressure ulcers vary, but have been estimated to be as high as 25% across a mixture of continuing care and acute care settings. Heel ulcers represent approximately one third of pressure ulcers acquired, resulting in increased morbidity and mortality. In some cases, heel pressure ulcers can lead to amputation of the affected limb.

Heel Pressure Ulcer Risk Factors

There are several known factors that increase a patient’s risk of developing a heel pressure ulcer, including:

• Inadequate/malnutrition
• Advancing Age
• Abnormalities of circulation
• Sensory deficiency
• Immobility
• Major surgery
• Multiple health problems (comorbidities)
• Dehydration
• Friction and shear forces
• Diabetes
• Peripheral vascular disease
• Hip fractures
• Low albumin levels/anemia
• Obesity or low body mass index

The above factors can be applied to all pressure ulcers, not just those affecting the heel.

Clinical Presentation of Heel Pressure Ulcers

In the beginning, heel pressure ulcers may present with tenderness, discoloration of the skin and changes in skin temperature over the affected area. Heels that present with nonblachable erythema evidence decrease perfusion to the area, which may be due to friction or shearing forces, or injury related to pressure. Deep tissue injuries may be recognized as areas on the heel that are dark purple or reddish-purple in color, boggy or firm, and warmer or cooler to touch than surrounding tissue. The area will likely be tender and may develop blisters filled with blood or serum. As conditions deteriorate, the blisters may dry and become black in color (eschar); an open wound may develop from the area. (Remember that deep tissue ulcers are a special category of pressure ulcers and cannot be staged).

Preventing Heel Ulcers

The best offense is a good defense, and this saying holds true for preventing heel pressure ulcers. Preventing heel ulcers begins with anticipating that they may occur, generally when patients have one or more of the listed risk factors and are supine for any length of time.

The following can be used to prevent heel pressure ulcers from developing:

• Pillows - pillows can be used for offloading heel pressure in cooperative patients for short periods of time, according to the NPUAP. It is recommended that pillows be placed length-wise under the calf to completely elevate the heel off the supporting surface. It can be difficult to maintain proper positioning when patients move around in bed, which is the reason that the NPUAP recommends this treatment modality only for cooperative patients, and only for short duration.
• Heel offloading devices - devices made of sheepskin, splints and bunny boots are all acceptable offloading devices, and can stay in place around the clock and can be used for all patients, regardless of how much they move in bed. These devices pad the heel and prevent friction and shear. They also remove some pressure from the heel, preventing heel pressure ulcers.

Heel pressure ulcers can cause significant morbidity and mortality. They should be anticipated and prevented in patients at risk for pressure ulcers. Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading device, to protect delicate heels.

Sources
Fowler, E., Scott-Williams, S. & McGuire, J. (2008). Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management, 54(10).
Langemo, D., Thompson, P., Hunter, S., Hanson, D. & Anderson, J. (2008). Heel pressure ulcers: Stand guard. Advances in Skin and Wound Care, 21(6), pg. 282-292.

About The Author
Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care.