The technique of “floating the heels” is a practical intervention designed to protect the highly vulnerable tissue of the heel from damage caused by sustained pressure. This method involves carefully positioning the leg to ensure the heel is suspended completely in the air, thereby transferring the weight-bearing load to the less delicate areas of the calf. For individuals with limited mobility, this simple, at-home solution using common household pillows is an effective way to redistribute localized pressure and maintain skin integrity. The goal is to eliminate all contact between the bony prominence of the heel and the support surface, preventing the tissue compression that can lead to injury.
Why Heel Elevation is Critical
The heel is anatomically predisposed to tissue breakdown, making its protection a high priority in care plans for immobile people. It is the second most common site for pressure injuries, surpassed only by the tailbone or sacrum. The risk is elevated because the heel bone has very little protective tissue, such as muscle or fat, covering it.
When a person lies on their back, the weight of the entire lower leg is concentrated onto the small surface area of the heel, leading to high interface pressures. This compression restricts blood flow to the area, causing cells to suffer from a lack of oxygen and nutrients. Furthermore, the heel is susceptible to friction and shear forces when a person inadvertently shifts or slides in bed, increasing the likelihood of tissue damage. Elevating the heel completely off the bed surface is recognized as an effective strategy to mitigate these combined forces of pressure, friction, and shear.
Step-by-Step Guide to Positioning
The foundational principle of successful heel elevation is ensuring the weight of the limb is borne by the calf and lower leg, not the Achilles tendon or the ankle. Begin by placing a soft, firm pillow or rolled towel underneath the lower leg. The pillow should be positioned so it extends from the mid-calf down toward the ankle.
The top edge of the pillow must rest well below the back of the knee, avoiding the popliteal space where major blood vessels and nerves pass. This careful positioning prevents compression of the popliteal vein, which could increase the risk of deep vein thrombosis. The pillow must be thick enough to lift the entire lower leg, creating a clear space between the bed and the heel.
Check the heel with your hand to confirm it is fully suspended, or “floating,” with no contact with the mattress or any hard surface. The pillow should support the leg just below the knee and continue down to just before the ankle joint. This support effectively disperses the pressure along the broad, muscular surface of the calf.
It is also important to ensure the knee remains in a position of slight flexion, ideally between five and ten degrees. Maintaining this minor bend helps prevent hyperextension of the knee joint and avoids putting undue tension on the leg muscles. If the pillow is not long or wide enough, a second pillow can be placed horizontally beneath the first to create a stable, supportive base.
Monitoring and Common Positioning Mistakes
Proper positioning must be paired with monitoring to ensure the intervention remains safe and effective over time. Before and immediately after placing the legs in the elevated position, the skin over the heels must be inspected for any signs of change, such as non-blanching redness, discoloration, or warmth. Skin assessment should be repeated at regular intervals, as pressure injuries can develop rapidly in high-risk individuals.
Common Positioning Mistakes
A common mistake is using a device or pillow that places pressure directly under the ankle or Achilles tendon. This localized pressure can impair circulation and cause damage to the sensitive tendon structure. Avoid using doughnut-shaped cushions, as they create a counter-pressure ring around the bony prominence, which compromises blood flow to the center of the ring.
Monitoring Circulation and Nerves
To check for adequate circulation, gently press on a toenail or the skin of the toe until it whitens, then release and observe how quickly the color returns (capillary refill time). A slow return to color may indicate compromised blood flow that requires immediate attention and repositioning. Additionally, monitor for signs of nerve compression, such as numbness, tingling, or a noticeable weakness in the foot, sometimes called foot drop.
The effectiveness of heel floating relies on consistency; the position must be maintained and checked frequently. Individuals with limited mobility require regular repositioning of the entire body to shift pressure points and prevent continuous compression on any single area. The pillow setup should be removed entirely at least once per shift to allow for a comprehensive skin and circulation check.