We like to think of our heels as among the toughest areas of our bodies. After all, we walk, run, and jump on them regularly - sometimes exerting as much as 1600psi. That’s more than 50 times the pressure of a car tyre!
Despite this toughness, heels are actually particularly vulnerable to skin breakdown. The heel is only covered by a thin layer of skin and fat, so when patients spend a good deal of time lying down, all the pressure of their legs ends up resting on the heels. And there’s not much muscle tissue or fascia available to absorb this stress.
Prevalence rates for heel pressure sores vary, but they’re estimated to be as high as 25% across healthcare settings. They also account for approximately one third of all pressure ulcers, coming second only to the sacrum as the most common site for pressure sore development.
Not only are heel ulcers painful and take a long time to heal, they can cause other problems such as infections and permanent bone loss. It’s perhaps not surprising then, that heel ulcers result in increased morbidity and even mortality, especially in older patients. In some cases, heel pressure sores can lead to amputation of the affected limb.
Heel pressure ulcers are a critical challenge for nurses and the wider healthcare team.
Risk factors for heel pressure sores
Various conditions put patients at a higher risk of developing a pressure ulcer on one or both heels. Age, immobility, inadequate nutrition, sensory deficiency, incontinence, diabetes, circulatory problems, obesity, and dehydration are all key factors that can contribute to the development of heel ulcers.
Signs of pressure ulcer development on the heel
A heel pressure injury usually first presents with discolouration, tenderness, and changes to skin temperature compared with the surrounding skin. If the tissue injury is deep, the skin might look purple or maroon, and feel boggy to the touch. It may also be accompanied by painful blood or serum-filled blisters.
As the damage to the heel evolves, the blister roof dries and dead tissue (eschar) appears around the injury, which may turn into an open wound. This progression can happen rapidly, even if the area is undergoing treatment.
Early intervention and proper treatment are crucial for managing these wounds. Left untreated, they can potentially lead to infection that spreads to the bloodstream.
Prevention of heel pressure injuries
Heel pressure injuries are an enormous concern for healthcare staff and facilities as a whole. As the saying goes, ‘prevention is the best medicine’.
Preventative strategies involve end-to-end vigilance from staff, including recognising risk, decreasing pressure on common injury areas, assessing patient nutritional status, avoiding excessive bed rest, and preserving the integrity of the skin.
The following healthcare equipment is also essential for preventing heel pressure ulcers from developing:
- Support pillows - These are useful for offloading heel pressure for short periods of time. It’s recommended that pillows are placed lengthwise underneath the calf to completely elevate the heel off the bed.
- Alternating pressure mattresses - These can be filled with foam, gel, or air to provide a softer surface for patients at risk of pressure injuries. These devices are classified as either static or dynamic, meaning some have programmable cycles that automatically alternate a patient’s position. Some of the static options have a built-in pressure-reducing feature specifically to minimise heel injury risk.
- Pressure redistributing heel pads – These types of heel pads are designed to reduce pressure on the vulnerable heel area. Heels are rested on independent gel sacs that are filled with a special gel. The pads control the volume of gel in the sacs, which alternates at specific time intervals. This allows pressure displacement and even weight distribution, resulting in significant pressure reduction and patient comfort.
