Sore heels developing in bed are often the first sign of a pressure injury (bedsore or pressure ulcer). These injuries occur when sustained pressure compresses blood vessels, restricting oxygen and nutrient flow to underlying tissues. This lack of blood flow (ischemia) causes tissue damage, especially over the heel bone where cushioning is minimal. Prevention focuses on relieving constant pressure and maintaining skin integrity.
Proper Positioning to Relieve Heel Pressure
The primary technique for preventing heel pressure injury is achieving “floating heels,” ensuring they are entirely suspended and do not touch the mattress. This is done by elevating the lower leg along the calf, distributing weight over a larger, fleshy area. The ankle and heel must hang freely, completely offloaded from the bed.
A standard pillow, foam wedge, or rolled blanket can support the calf, but position it carefully to avoid pressure on the Achilles tendon or the back of the knee (popliteal space). The knee should remain slightly bent (5 to 10 degrees) to prevent compression of the popliteal vein and reduce the risk of deep vein thrombosis. Repositioning the entire body on a schedule, typically every two hours for immobile individuals, is also foundational to prevention.
Avoiding friction and shear forces is equally important when moving. Shear occurs when the skin remains stationary while underlying tissue shifts, stretching and tearing blood vessels beneath the surface. To prevent this, avoid dragging feet or sliding down. Use a lift sheet or assistance to move the entire body as a unit during repositioning. If the head of the bed is elevated, raising the knee gatch slightly helps prevent sliding down, reducing shear on the tailbone and heels.
Choosing and Utilizing Specialized Equipment
While standard pillows are useful for temporary elevation, specialized equipment is often necessary for high-risk individuals or those with existing skin damage. Heel suspension boots are specialized devices designed to completely offload the heel, cradling the foot and lower leg to maintain the “floating heel” position consistently. These boots distribute weight across the calf and lower leg, unlike pillow setups that can shift.
For full-body pressure management, specialized support surfaces like pressure-reducing mattresses are highly beneficial. These include low air loss mattresses (using continuous airflow to wick away moisture and regulate skin temperature) or alternating pressure mattresses (cyclically inflating and deflating air cells). This changing pressure pattern regularly redistributes the body’s weight, preventing prolonged pressure. However, even with advanced mattresses, heels must still be actively elevated or suspended, as the bony prominence requires a dedicated offloading strategy.
Heel protectors and cushions (often foam or gel) are available, but choose devices that achieve complete offloading rather than just padding. Padding alone does not remove pressure and can worsen the situation by increasing heat and moisture. For individuals with existing stage III or stage IV pressure injuries, use only specifically designed heel suspension devices that guarantee zero contact with the support surface.
Daily Skin Inspection and Care Routines
Routine inspection of the heels is a necessary component of skin care, as tissue damage progresses rapidly over bony areas. Check the skin at least once daily, and ideally during every position change, for signs of early injury. A primary indicator of potential damage is localized, persistent redness that does not turn white when light pressure is applied (non-blanching erythema).
The skin should be kept clean and at an appropriate moisture level. Skin that is too dry can crack, while excessive dampness can lead to maceration and weaken the skin barrier. Use a pH-neutral cleanser and apply a barrier cream or moisturizer to maintain skin resilience, especially on dry heels. Avoid excessive moisture from perspiration or incontinence by using absorbent pads and changing linens frequently to manage the skin microclimate.
Gentle massage around the heel area can help promote circulation to the surrounding tissue, but never massage directly on reddened or discolored skin. Massaging a damaged area, such as one with persistent redness, could cause further trauma to compressed blood vessels. The goal is to maintain the health and elasticity of the skin and underlying soft tissues, making them more resistant to pressure.
When to Consult a Medical Professional
While home care is effective for prevention, certain signs indicate severe tissue damage requiring immediate medical attention. Any open sore, blister, or area of skin breakdown on the heel should prompt a consultation. The appearance of black, hardened tissue (eschar) suggests underlying tissue death and needs professional assessment and treatment.
Signs of infection, such as fever, increased pain, a foul odor, or warmth and swelling extending beyond the injured area, require urgent medical care. Individuals with conditions affecting circulation and sensation (e.g., diabetes, peripheral vascular disease, or severe immobility) are at a significantly higher risk for rapid pressure injury development. If current preventative methods fail to stop new damage, a comprehensive evaluation by a medical professional or wound care specialist is necessary to adjust the plan.
use a lift sheet or another person’s assistance to lift and move the entire body as a unit during repositioning. When the head of the bed is elevated, raising the knee gatch slightly can help prevent sliding down toward the foot of the bed, reducing shear on the tailbone and heels.
Choosing and Utilizing Specialized Equipment
While standard pillows are useful for temporary elevation, specialized equipment is often necessary for high-risk individuals or those with existing skin damage. Heel suspension boots are a type of specialized device designed to completely offload the heel, cradling the foot and lower leg to maintain the “floating heel” position consistently. These boots distribute the weight across the calf and lower leg without relying on a perfect pillow setup that can shift over time.
For full-body pressure management, specialized support surfaces like pressure-reducing mattresses are highly beneficial. These may include low air loss mattresses, which use continuous airflow to wick away moisture and regulate skin temperature, or alternating pressure mattresses, which cyclically inflate and deflate air cells. This changing pressure pattern helps to regularly redistribute the body’s weight, preventing prolonged pressure on any single spot. However, even when using these advanced mattresses, the heels must still be actively elevated or suspended, as the bony prominence of the heel often requires a dedicated offloading strategy.
Heel protectors and cushions, often made of foam or gel, are also available, but it is important to choose devices that achieve complete offloading rather than merely padding the area. Padding alone does not remove the pressure and can sometimes worsen the situation by increasing heat and moisture. For individuals with existing stage III or stage IV pressure injuries, it is generally recommended to use only specifically designed heel suspension devices that guarantee zero contact with the support surface.
Daily Skin Inspection and Care Routines
Routine inspection of the heels is a necessary component of skin care, as tissue damage can progress rapidly over bony areas. The skin should be checked at least once daily, and ideally during every position change, for signs of early injury. A primary indicator of potential damage is localized, persistent redness that does not turn white when light pressure is applied, a phenomenon known as non-blanching erythema.
The skin should be kept clean and at an appropriate moisture level; skin that is too dry can crack, while excessive dampness can lead to maceration and weaken the skin barrier. Using a pH-neutral cleanser and applying a barrier cream or moisturizer can help maintain skin resilience, particularly on dry heels. However, avoid excessive moisture, especially from perspiration or incontinence, by using absorbent pads and changing linens frequently to manage the skin microclimate.
Gentle massage around the heel area, but never directly on any reddened or discolored skin, can help promote circulation to the surrounding tissue. If a specific area is already showing signs of damage, such as persistent redness, massaging that spot could cause further trauma to the compressed blood vessels. The goal is to maintain the health and elasticity of the skin and underlying soft tissues, which makes them more resistant to the effects of pressure.
When to Consult a Medical Professional
While home care is effective for prevention, certain signs indicate that the tissue damage is severe and requires immediate medical attention. Any open sore, blister, or area of skin breakdown on the heel should prompt a consultation with a healthcare provider. The appearance of black, hardened tissue, known as eschar, suggests that the underlying tissue has died and needs professional assessment and treatment.
Signs of infection, such as fever, an increase in pain, a foul odor emanating from the site, or warmth and swelling extending beyond the injured area, are also reasons to seek urgent medical care. Individuals with conditions that affect circulation and sensation, such as diabetes, peripheral vascular disease, or severe immobility, are at a significantly higher risk for rapid pressure injury development. For these high-risk populations, or if current preventative methods are not stopping new damage from occurring, a comprehensive evaluation by a medical professional or wound care specialist is necessary to adjust the prevention plan.