Heel Ulcers and How To Reduce Risks Surrounding Them

Although not widely used among the medical community, hearing the term “bed sore” conjures up images and concerns often associated with incapacitation.   To the public, bed sores or pressure ulcers may represent what can happen when excessive pressure near a bony prominence and the inability of an individual to move or shift in bed, results in an open wound.

Pressure ulcers, often referred to as decubitus ulcers, can result in further debilitating issues, such as infection, amputation, and death.  Among the more common pressure ulcers are wounds that occur on the heels.  So serious is the issue of heel ulcers, that the government has declared them a “never event”.  Originally developed in 2002, the “never event” list, referring to serious adverse medical events or errors, is now comprised of 29 “serious reportable events” that are grouped into seven categories.1,2 Within the care management event category is the description of “any Stage 3 (full thickness of the skin that may extend deep into the subcutaneous layer) to Stage 4 (extends down to bone), orunstageable pressure ulcers (tissue injury is apparent, but actual depth is not obvious due to presence of dead or bruised appearing tissue) acquired after admission/presentation to a health care facility.”1,2

Heel ulcers are not solely limited to an underlying cause of pressure. Even when pressure and subsequent reduced blood flow to the skin have resulted in a tissue injury and ulcer, conditions such as diabetes, peripheral arterial disease, lymphedema, peripheral neuropathy, immobility (from any cause), connective tissue disorders, malignancies, lower extremity contracture, and other conditions may exacerbate the situation.   Shifting in a chair after being seated for several minutes or tossing and turning in bed are ways our body ensures pressure is relieved to skin overlying a bony prominence.  If we were unable to move, blood flow and subsequently oxygen to the skin will be diminished to the point of causing injury (hypoxia) and tissue death (ischemia and necrosis).  That being stated, in an immobile individual, injury to the skin that can lead to formation of a wound, can occur in as little as 30 minutes.

As such, the treatment plan must reflect consideration of all factors, including the overall skin integrity and nutritional status of the patient. I will discuss the assessment of nutritional status as it pertains to wound healing later in this article. Addressing and attempting to reverse the underlying contributing factors of heel ulcers is the first step in the healing process. The body was designed to heal itself but when its ability has been compromised, knowing how to enhance reparative processes is essential.

At this time, the active treatment of heel ulcers may include but is not limited to: debridement (sharp, enzymatic, mechanical, biological, hydrosurgical (use of a water jet) removal of dead (necrotic) tissue, offloading (removing pressure from the area by “floating” the heel with pillows or other assistive devices), revascularization, hyperbaric oxygen, negative pressure wound therapy (“Wound VAC”) and topical dressings. Deciding when to implement any of these cited modalities should be based on reversing the issues that led to the formation of the ulcer. Additionally, knowing how and when to use modalities efficaciously and safely requires an appreciation of what the patient can tolerate.

That being stated, it is always best to be proactive and prevent ulcer formation.  “It is easier to prevent, than it is to treat”.  Daily inspection of skin, adequate hydration and nutrition, and keeping pressure off an area with an underlying bony prominence are essential in reducing the risk of ulcer formation.  Hydration of the skin is especially important as adequate moisture helps maintain integrity of the skin as well as providing an additional mechanism of protection.  The act of applying an emollient or skin moisturizer twice a day, not only provides additional hydration to the skin, but ensures that active monitoring of the skin is ongoing, and with it a reduced chance of developing a limb threatening wound.

  1. Agency for Healthcare Research and Quality. Never events. Available at: https://psnet.ahrq.gov/primers/primer/3/Never-Events . Updated January 2019. Accessed July 16, 2019.

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