What Are Pressure Ulcers and Why Do They Form on the Feet?

Pressure ulcers — also called pressure injuries, bedsores, or decubitus ulcers — develop when sustained pressure impairs blood flow to skin and underlying tissue, causing ischemia and eventual tissue death. While pressure ulcers are classically associated with bony prominences in bedridden patients (sacrum, heels, elbows), the heel is one of the most common and serious locations — accounting for approximately 30% of all pressure ulcers.

The heel is particularly vulnerable: it has limited subcutaneous fat padding, the calcaneal bone creates a prominent pressure point when the foot rests on a surface, and the local blood supply is reduced in elderly and vascular-compromised patients. In hospitalized, nursing home, and home-bound patients, heel pressure ulcers can progress from superficial skin damage to deep wounds exposing bone in a matter of days.

The National Pressure Injury Advisory Panel (NPIAP) Staging System

Stage 1: Non-blanchable erythema (redness) of intact skin. No open wound. Stage 2: Partial-thickness skin loss involving the epidermis and dermis — appears as a shallow open ulcer or intact/ruptured blister. Stage 3: Full-thickness skin loss with visible subcutaneous tissue. Bone, tendon, and muscle are not visible. Stage 4: Full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Unstageable: Depth unknown due to wound base covered by slough or eschar. Deep Tissue Pressure Injury (DTPI): Intact skin with a deep bruise-like area of non-blanchable discoloration — represents deep tissue damage that may evolve rapidly to Stage 3 or 4. DTPI is particularly ominous and can progress from intact skin to Stage 4 within days.

Prevention: The Most Important Intervention

Pressure ulcer prevention is far preferable to treatment. The cornerstone is heel offloading: placing foam wedges or pillows under the calves to float the heels completely off the surface, or using heel protector boots designed for sustained use. Pressure-redistributing mattresses and overlays reduce general body pressure. Regular skin inspection — at least twice daily — identifies early Stage 1 changes before breakdown occurs. Maintaining skin moisture (preventing dry, cracked skin) while avoiding excessive maceration (moisture-related breakdown). Ensuring adequate nutrition — protein, zinc, vitamins A and C — supports skin integrity and healing capacity.

Wound Care for Established Heel Pressure Ulcers

Treatment begins with thorough wound assessment: staging, measurement (length, width, depth), wound bed quality (granulation, slough, eschar, biofilm), periwound skin condition, exudate level, and presence of infection. Debridement removes necrotic tissue that prevents healing — the method (sharp/surgical, autolytic, enzymatic, mechanical) is selected based on wound characteristics and patient status. Appropriate dressing selection based on moisture balance, exudate management, and infection control. For Stage 3-4 ulcers or those with exposed bone, surgical management — debridement, flap coverage, or calcanectomy (partial heel bone removal) — may be necessary. Negative pressure wound therapy (wound VAC) promotes granulation in complex heel wounds.

When Bone Is Involved: Osteomyelitis

Deep Stage 4 heel ulcers with exposed calcaneus are at high risk for osteomyelitis — infection of the bone. This complication dramatically complicates management and is associated with high amputation rates. Diagnosis requires bone culture (ideally from bone biopsy rather than wound swab), MRI for bone marrow signal changes, and sometimes nuclear imaging. Treatment requires 6 weeks of targeted antibiotics, surgical bone debridement, and sometimes partial calcanectomy. Involvement of Balance Foot & Ankle’s podiatric wound care specialists is appropriate for all Stage 3 and 4 heel pressure ulcers. Call (810) 206-1402 for urgent wound care evaluation.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.