Preventing Heel Pressure Ulcers: Simple Methods and Identifying Risk Factors Protection Status
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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.

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, and advocate of incorporating digital and computer technology into the field of wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

WoundSource ENEWS


I appreciate your comments about pillows- most places don't realize the new PU guidelines say "only for cooperative patients' and 'only for a short time'. Just a comment to add about the boots. Boots and wedges for off-loading heels are great. However- caution should be observed when using a brace (AFO- ankle-foot orthotic) because that actually increases their chance of a pressure ulcer. They should be used carefully exclusively for footdrop issues and by using one AFO and trading foot to foot when the person is repositioned you can lessen the chance of a PU related to the brace. Thank you for your blog- an important topic!!

I don't agree that bunny boots and sheepskin devices (among a few others) are acceptable offloading devices for heels....

With all due respect... you (and anyone else) who believe lamb's wool "bunny boots" can prevent heel pressure ulcers (as you state) are living in Neverland. Sadly, this myth is rampant throughout the profession and points out the woeful lack of basic understanding of many nurses and physicians as to the pathogenesis of P/Us. It matters not how comfy-cozy you make the patient (and his heels); if your device simply reduces the pressure BUT DOES NOT REDUCE IT BELOW THE CRITICAL CAPILLARY REFILL PRESSURE OF approx. 20 mm Hg THEN YOU HAVE NOT---REPEAT NOT---PREVNTED PRESSURE ULCERS FROM OCCURRING. The same can be said for pressure-reducing vs pressure-relieving mattresses and ischial/sacral pressure ulcers.
To anyone who takes exception to this position; show me real (not anecodotal) published evidence in the form of a blinded study. It’s amazing how many measures are taken by doctors and nurses in the name of preventing pressure ulcers which are performed ONLY because “that’s what my professor did”; when in reality no trace of proof can ever be cited.
It’s time this country gets serious about pressure ulcer prevention.

-- John Baeke, M.D.

Unfortunately, there is no 1 magic answer for heel protection. Medical device related pressure ulcers develop when we rely upon equipment. Always remind caretakers to remove equipment to evaluate the skin and to have a secondary plan if early damage is detected.

Milsport Medical is a new company in Buffalo, New York that has developed an offloading, open wound cavity heel rest for the prevention and healing of pressure ulcers. Please check out our website for further product information at or we are on Facebook at Milsport Medical.
You can also call our office at 877 341 6494
Thank you!
This was a great Article and I agree also with Dr. Baeke's comment on sheepskin.

I agree with Lori and Dr. Baeke. Bunny Boots are an inappropriate product to use as a treatment or a preventative for heel pressure ulcers. Cost may be a factor although the money spent on Bunny Boots vs an acceptable product is minimal, especially when considering the cost to treat a heel PU.

Is it detrimental to a patients heels to tuck in the bed covers or should they be folded over?

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