Why heels and feet break down under pressure
The back of the heel is a small, rounded bone covered by thin skin and a little fat. When someone lies on their back, the weight of the leg rests on that one spot. Hours of steady pressure squeeze the small blood vessels and starve the tissue of oxygen.
Heel pressure ulcer care is needed most often by people who cannot easily move their legs, such as those recovering from a hip fracture, surgery or a stroke. Nerve damage, poor circulation and swollen legs add to the risk.
Other parts of the foot are vulnerable too. The ankle bones take pressure when a person lies on their side, and toes can be injured by tight shoes, braces, splints or a footboard.
Gateway arranges care for this kind of wound across the region. See wound care in St. Louis for how visits at home and in facilities are set up.
What a heel or foot pressure injury can look like
These injuries do not always start as an open sore, and on darker skin early redness may not show.
- A patch that stays red, purple or darker than nearby skin after pressure is removed
- Skin that feels warmer, cooler, firmer or softer than the area around it
- A blister, either clear or filled with blood
- A deep purple or maroon area, like a bruise that does not fade
- A dry, dark, hard scab covering the heel
- An open wound
The guide on pressure injury stages explains how clinicians describe depth, and the page on pressure injuries and bed sores covers other body sites.
Why circulation is reviewed early
A foot wound heals only as well as blood can reach it. The treating clinician checks pulses, skin color and temperature, and may order a noninvasive circulation test. Our page on circulation and vascular health has more on this.
The result changes the plan, including whether dead tissue is removed or left alone. If blood flow looks limited, the clinician may order a vascular referral, and Gateway can help with vascular referral coordination.
Offloading the heel
Offloading means taking pressure off the injured area so blood can return to the tissue. For a heel, the aim is that it rests on nothing, which clinicians call floating the heels.
Two common approaches are a pillow placed under the calf so the heel hangs free, and a heel protection boot that suspends the heel. Each has limits. Pillows shift during the night, and boots must fit, stay on and come off for regular skin checks.
The treating clinician chooses the method and shows caregivers how to use it. Our guide on what offloading is and the page on offloading for foot wounds explain more.
Bed and chair positioning
Raising the head of the bed can make a person slide down, which drags and presses the heels into the mattress. Tightly tucked sheets push on the toes. A pressure-relieving mattress lowers pressure in general, but it does not replace floating the heels. The guide to a repositioning schedule at home shows how families organize turning.
Chairs cause heel injuries too. Check that:
- Feet rest flat, not on the back edge of the heels
- A recliner footrest does not press on the heels or the back of the ankles
- Wheelchair footplates and heel straps are at the right height and are not rubbing
- Skin is checked each time a brace, boot or splint comes off
Changes to report and when to call 911
Tell the treating clinician or facility nurse about:
- A new discolored spot, blister or sore on a heel, ankle or toe
- A dry scab that becomes soft, wet or loose, or starts to drain
- Redness, warmth or swelling spreading up the foot, or a fever
- A new odor, or drainage that increases or changes color
- New pain in the foot, especially at rest or at night
Call 911 if a foot or leg suddenly becomes cold, pale or blue with severe pain, or if the person is confused, faint, breathing fast or has a racing heartbeat.
How Gateway coordinates heel pressure ulcer care
Gateway arranges wound care with partner clinicians in private homes, skilled nursing facilities, assisted living, memory care and rehabilitation centers across Greater St. Louis and the Metro East. We coordinate scheduling, records, clinician orders, supplies and equipment requests such as heel protection, and we keep facility staff and family informed. The treating clinician makes every clinical decision.
Families can call 314-325-0126 or send a care request without a referral. Tell us the care setting, and we will confirm visit availability there.
Common questions
Should a dark, dry scab on the heel be removed?
The treating clinician decides, and it depends heavily on circulation. When blood flow to the foot is limited, a dry, firmly attached scab is often left in place and protected, because it acts as a natural cover. Do not pick at it, soak it or trim it, and report any softening, wetness or redness at the edges.
Is a blister on the heel a pressure injury?
It can be. A blister on the back of the heel in someone who spends long hours in bed is often an early pressure injury, even when the fluid is clear. Leave it intact, keep pressure off it and have the clinician or nurse look at it.
Can someone walk with a heel pressure ulcer?
It depends on the depth of the wound and the person’s circulation and balance. Walking on an injured heel adds pressure, but staying in bed has risks of its own. Ask for specific guidance on weight bearing and footwear, and whether heel boots made for bed should come off before standing.
How is a heel pressure ulcer different from a diabetic foot ulcer?
The difference is the cause. A heel pressure ulcer comes from resting on the heel for too long. A diabetic foot ulcer usually forms on a weight-bearing or rubbing spot in a foot that has lost feeling. A person with diabetes can have either. The clinician identifies which it is, because the plan for relieving pressure differs.
Related pages
General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.