The real risk to deep tissue injury on heels


There is very little padding on our heels which makes it a very high risk area of developing pressure ulcers.

With a number of extra risk factors compromising the heel, are diabetes, vascular disease, lymphoedema, conditions causing muscle loss, reduced mobility, friction, poor nutrition and hydration.

Healing rates for ulcers on the heal can be long, this may be due to the above underlying co-mobrbidities, or I have increasingly observed as potential part of skin failure at life end. Further research is needed in this field to properly inform the patients and their relatives of the risks.

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Amputation risks for ulcers on the heel where there is recurrent infection, osteomyelitis, gangrenous, or becoming repeatedly systemically infected is high.

Morbidity, that is to say amputation, for heel ulcers with osteomyelitis or critical limb ischaemia is common.

Han P, Ezquerro R. Surgical treatment of pressure ulcers of the heel in skilled nursing facilities: a 12 year retrospective study of 57 patients. J Am Podiatry 2011; 101(2): 167–75.

For your diabetic resident it is vital that as part of the SSKIN care plan there is extra emphasis on foot care as part of the plan. For the resident with capacity explaining to them how they can self care for their feet and explain the risks all part of informed design making on the residents part.

Heres some facts you may not know about ulcers on heels of diabetics:

  • Estimated more than 5 million people by 2025 will have Diabetes.

  • Peripheral arterial disease effects 1:3 people with diabetes over the age of 50.

  • 10% of people with diabetes will have a foot ulcer.

  • Foot ulcers precede 80% of amputations in people with diabetes. 

  • Up to 70% of those who have amputations die within 5 years.

  • Approx. £1 for every £150 spent in the NHS annual is related to foot ulcers or amputations. (£650 million) NHS Diabetes 2012.

So what can you do to prevent?

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  • Individual care planning is essential using SSKIN principles.

  • While the SSKIN care plan principles prompt us to ensure the principles of prevention are in play. There is no ‘one size fits all’ offloading heel boot.

  • The risks sometimes may out weight the use, for example falls if the boot is not for ambulatory patients. They may have reduced capacity and attempt to walk with the boot on.

  • For those in bed 25/7 the boots can get in the way and in some case raising the foot off the end of the bed at an angle placing further pressure on the sacral/coccyx area.

See below taken from our current guidelines from EPUAP/NPUAP/PPPIA: International Pressure Ulcer Prevention Guidelines NPUAP/EPUAP/PPPIA 2014

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  • Ensure that the heels are free of the surface of the bed.

  • Use heel suspension devices that offload the heel completely.

  • The knee should be in flexion 5-10 degrees, to avid popliteal vein compression and increased risk of DVT.

  • Avoid pressure to the Achilles.

  • If using a foam pillow ensure that it extends the full length of the calf, and the heel can be maintained free from the surface.

  • Decrease friction and shear. Use slide sheets to reposition and lateral transfer sheets.

  • Remove anti-embolic stockings regularly in high risk patients to check the heels. Use a large mirror if necessary.

  • Feet should be washed daily and an emollient applied to any dry skin.

  • Apply heel suspension devices according to the manufacturers instructions.

Ask OSKA™ about the very high risk Series2-V2 and Series4-V3 mattresses which have an inbuilt heel OFFLOADER™ feature, ideal for creating a zone of zero pressure.


For any other queries contact me.