Wound Healing: Reasons Wounds Will Not Heal

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hand wound

by Bruce E. Ruben MD

A non-healing wound is generally defined as a wound that will not heal within four weeks. If a wound does not heal within this usual time period, the cause is usually found in underlying conditions that have either gone unnoticed or untreated. In general, there are five reasons why wounds will not heal and more than one of these conditions can be operating at the same time.

They are:

  1. Poor Circulation
  2. Infection
  3. Edema
  4. Inadequate Nutrition
  5. Repetitive Trauma to the Wound

Poor Circulation

Wounds heal most efficiently when there is easy access to and from the wound site through the body's circulatory system. Here, the two issues impeding the healing process are arterial insufficiency, where there is compromised blood flow to a wound site through the arteries; and venous insufficiency, where spent blood and fluids cannot return up through the veins.

With arterial insufficiency, the most common cause is Peripheral Atherosclerosis Disease (PASD). This occurs when plaque forms on the inside of arteries and impedes blood flow. Treatments may include artery bypass or angioplasty to open the artery that is obstructed.

With venous insufficiency, the valves inside the veins that prevent the backflow of fluids are not functioning properly. Thus, blood and fluids leak out and pool in the lower extremities. The challenges presented involve forcing blood and fluids back into the tissues and veins and then manually or mechanically pumping them back up toward the heart. This can be accomplished through various kinds of compression therapy including compression stockings and bands, manual lymphatic drainage and electronic sequential venopneumatic pumps. In extreme cases, a vein specialist can employ venous ablation where a tiny laser is passed into an insufficient vein. That vein closes down completely, allowing the body to re-route blood and fluids up through more viable veins.


Infection is the proliferation of bacteria, virus or fungus in or under a wound site that inhibits the natural and timely healing of the wound. Normally, when these invaders enter a wound site they are quickly overtaken and destroyed by the millions of fresh white blood cells the body makes every day.

But when the wound is compromised by any of the other four conditions described in this article, infections can be difficult to resolve. That's particularly true when the infection originates on or around a bone (osteomyelitis). With no other place to go, the infection "tunnels" up to the skin surface and forms a lesion or sore. Here, diagnosing the type of bacteria is the key to resolving the infection through excellent wound care and competent administration of IV antibiotics.

Infections may also be surgically excised as with abscesses and cysts. Once the infection is treated and eradicated, the body is then able to resume its normal course of organic wound healing.


Edema is fluid that accumulates in the skin, dermis or fatty tissue and usually occurs in the lower extremities. This fluid build up is typically due to venous insufficiency (poor venous return) and is a risk for developing sores (venous ulcers). Once those sores form, edema is also a major barrier to healing by blocking the flow of nutrients to and from the area.

As with poor circulation, various forms of compression therapy are employed to transport or force the fluids back into the circulatory system including manual lymphatic drainage, compression therapies and specific medications like Lasix. Once the edema has been resolved, proper wound healing can occur.

Protein Malnutrition

Just as you cannot build a house without the building blocks, bricks or foundation, the body cannot build new tissues without an adequate supply of protein. In fact, insufficient nutrition is, by far, the most overlooked reason why wounds will not heal.

Treating the outside of wounds with grafts, flaps, special compression wraps and debriding agents can only heal wounds to the degree that there is adequate nutrition inside the body. So with malnutrition and insufficient protein intake, the wound-healing process is fundamentally halted until these insufficiencies are corrected.

This means a very substantial intake increase is needed to heal wounds in addition to the amounts needed to carry on normal daily body functions. In fact, the amount of protein alone needed can be up to three times the recommended daily requirement. At Encompass HealthCare, we use blood work along with an indirect calorimeter to determine a patient's nutritional needs during healing.

Repetitive Trauma to the Wound

When a wound undergoes repetitive pressure due to bumping or rubbing against a surface, it is said to be undergoing repetitive trauma. This can lengthen the healing process or stop it completely. This problem is magnified in paraplegic patients since they cannot feel if one or both of their feet are continuously bumping on their wheelchair, for example.

Similarly, in spinal cord injury patients, pressure ulcers can develop due to lack of body movement such as when they are sleeping in the same position night after night without the ability to shift, or even when watching a two-hour movie without repositioning.

In these cases, diligent offloading and repositioning are keys to resolving repetitive trauma to the wound. Then, normal blood circulation can resume and wound healing can occur.

As you can see, it's important to understand the five reasons why a wound won't heal: poor circulation, infection, edema, insufficient nutrition, and repetitive trauma to the wound. The challenge to wound care providers is to recognize these conditions when they are occurring and also to understand that more than one condition can be operating at the same time.

Editor's Note: This article was originally published on December 3, 2013 and has been updated for accuracy and comprehension.

About the Author
Dr. Bruce Ruben is the Founder and Medical Director of Encompass HealthCare, an outpatient facility featuring advanced wound care, IV antibiotic therapies, hyperbaric oxygen treatment, nutritional assessment, and other treatment modalities. Dr. Ruben is board certified in Internal Medicine, Infectious Disease, and in Undersea and Hyperbaric Medicine. He is a member of the Medical and Scientific Advisory Committee and National Spinal Cord Injury Association (NSCIA) board.

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.

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I heard a comment about wound healing from a WOCN member to the effect of "when we encounter recalcitrant wounds, and use advanced products to heal the wound without result, we use matrix powder and pig tissue and it works every time.
Why didn't they use the matrix powder/pig tissue in the beginning??

This is a very good article - thank you. Inflammation is problematic for most chronic wounds, so measures to help decrease inflammation (such as compression for a venous ulcer and offloading for a diabetic foot ulcer or pressure ulcer) can often speed the healing process.

It is important to recognize that 4 weeks may not be a reasonable time frame in which to expect closure for a large wound, a debilitated patient, or a diabetic foot ulcer. Ince and Jeffcoate (2007) found that 60% of neuropathic wounds with adequate circulation closed in 12 weeks (a far cry from 4) and 71% were closed at 20 weeks. At one year, most of the remaining ulcers were closed, with only 3.9% requiring major or minor amputations. In addition to thorough initial wound cleansing, excellent offloading, improved circulation and nutrition, and an ideal wound dressing, we may sometimes need to instill hope and patience in our patients.

Ince P, Game FL, Jeffcoate WJ. Rate of Healing of Neuropathic Ulcers of the Foot in Diabetes and Its Relationship to Ulcer Duration and Ulcer Area. Dia Care. 2007 Mar 1;30(3):660–3.

Thank you for your comments. The 3-4 weeks for wound healing mentioned was specific for a normal host without the five variably treatable systemic conditions that impair local wound healing. I am not purporting that once all the five host factors are addressed and maximally improved, wound healing would take place within 4 weeks. Certainly, a wound not healing within 4 weeks would simply select a person with one or more host factors to address based on guidelines that arbitrarily determine a difference by time between a healing and a non-healing wound.

Undoubtedly neuropathic wounds are of the most troublesome to treat because there is little available in Western Medicine to explain or reverse neuropathy. I have had a number of spinal cord injured patients with stasis ulcers, arterial ulcers, and even harvest sites on affected limbs that have significantly longer times to healing despite restoration of circulation, relief of pressure, and beneficial lymphadema management. Sensory and motor nerve impairment has a clear role in delayed healing and this observation is well substantiated in the literature you cited.

Great summary - I agree with this list of 5 problems. I would add dessication as a cause of repeated wound trauma. It is my belief that we would experts tend to be so afraid of maceration that most wounds are kept too dry for optimal healing. Addressing the cause of the wound with compression or offloading (or vascular surgery) is extremely beneficial, but in real life sometimes not much can be done, and the wounds will often heal well despite these problems.

My tried and true topical wound management methods address four of the five problems listed here directly (protein deficit being the obvious exception). I do as thorough an initial wound cleaning as possible, but after that, I use continuously cleansing polymeric membrane dressings (PMDs) so that I do not damage the fragile new granulation tissue. These dressings also increase circulation by limiting edema (they moderate the inflammation caused by the nociceptor response), and they keep the wound warm and well cushioned. My patients have had such good results using PMDs that I am dedicated to spreading the word about these novel dressings. I work for the small family-owned company that makes them and would be happy to answer questions. - LindaBenskin@utexas.edu

You mentioned blood work as one of your tools that you use to determine the nutritional status of a patient with chronic wounds. Would you be kind enough to share what you measure and how you have determined nutritional status from those particular labs? I work with RD all the time and they insist that there is no lab available to identify malnutrition. What about our bariatric population? Many with non-healing wounds. Thank you in advance.

Thanks for sharing information.

wound didnt heal:
D - diabetes
I - infection
D - drugs (hormons, cytostatics)
N - nutrition (pour nutrition)
T - tumor (not chronic wound)
H - hypocirculation
E - edge (wound debridment)
L - low temperature (pour arterial supplay)

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