Heel pressure injuries: causes, prevention and clinical solutions
Heel pressure injuries are among the most common and preventable complications in hospitalized and immobile patients. According to international pressure injury guidelines from the National Pressure Injury Advisory Panel (NPIAP) and the European Pressure Ulcer Advisory Panel (EPUAP), the heel is the second most common location for pressure injuries, after the sacrum.
Because the heel contains minimal soft tissue and is often exposed to prolonged pressure when patients lie in bed, it is particularly vulnerable to tissue damage. In hospitals, intensive care units (ICUs), rehabilitation centers, and long-term care facilities, heel pressure injuries can lead to:
- delayed recovery
- increased infection risk
- higher treatment costs
- longer hospital stays
- reduced patient mobility and quality of life
The good news: most heel pressure injuries are preventable with early risk assessment and effective heel offloading strategies.
This page explains the causes, risk factors, prevention strategies, and clinical solutions for heel pressure injury prevention, helping clinicians and healthcare organizations implement evidence-based care.
On this page
- What are heel pressure injuries?
- Why the heel is highly vulnerable to pressure injuries
- Main causes and risk factors
- How to prevent heel pressure injuries
- Clinical solutions for heel offloading
- Best practices for hospitals and long-term care facilities
- Frequently asked questions
What are heel pressure injuries?
A heel pressure injury is localized damage to the skin and underlying tissue at the heel, caused by sustained pressure, shear, and/or reduced blood flow. Pressure injuries usually develop over bony areas of the body, such as the sacrum, hips or heels.
The NPIAP/EPUAP international pressure injury guidelines define pressure injuries as:
Localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from pressure or pressure in combination with shear.
The heel is especially vulnerable because it is a bony prominence with limited cushioning tissue.
Clinical classification
Heel pressure injuries are classified in stages using the standard NPIAP staging system:
Stage 1 – Non-blanchable erythema of intact skin
- Intact skin with persistent redness
- Early warning sign of pressure damage
Stage 2 – Partial-thickness skin loss with exposed dermis
- Loss of epidermis and part of dermis
- May appear as a blister or shallow open injury
Stage 3 – Full-thickness skin loss
- Damage extends into subcutaneous tissue
- Fat tissue may be visible
Stage 4 – Full-thickness tissue loss with exposed structures
- Damage reaches muscle, tendon, or bone
Additional stages:
Unstageable pressure injury
- Tissue damage obscured by necrotic tissue
Deep tissue pressure injury
- Persistent discoloration or blood-filled blister caused by underlying tissue damage
Early recognition and prevention is critical, as advanced heel pressure injuries can be difficult and costly to treat.
Why the heel is highly vulnerable to pressure injuries
The heel is one of the most at-risk anatomical areas for pressure injury development. The calcaneus is a prominent bone with minimal protective tissue.
Several physiological factors contribute to this vulnerability.
Limited soft tissue
Unlike areas such as the buttocks, the heel has very little fat or muscle between the skin and bone. This makes it highly susceptible to pressure.
Small contact surface
When a patient is lying in bed, body weight is concentrated directly on the heel which is a small area. When pressure remains on the heel for prolonged periods, tissue perfusion decreases and ischemic damage may occur.
Reduced blood supply
The heel has relatively limited vascularization, increasing the risk of:
- ischemia
- delayed tissue recovery
- tissue necrosis
Patients with vascular disease or diabetes face an even higher risk.
Immobility
Patients who can’t reposition themselves may experience continuous pressure on the heels for prolonged periods, which is one of the main causes of pressure injury development.
Main causes and risk factors
Several clinical conditions significantly increase the risk of pressure injury development in the heel.
Immobility
Patients who are unable to move independently are at the highest risk.
Examples include:
- post-surgical patients
- ICU patients
- patients with spinal cord injury
- frail elderly individuals
- patients with neurological disorders
Without regular repositioning or clinical heel offloading, sustained pressure can rapidly damage tissue.
Poor Perfusion
Reduced blood circulation limits oxygen delivery to tissues.
Conditions associated with poor perfusion include:
- peripheral vascular disease
- heart failure
- hypotension
These patients require aggressive heel injury prevention strategies.
Diabetes
Diabetes contributes to pressure injury risk through:
- impaired circulation
- neuropathy
- delayed wound healing
Diabetic patients often have reduced sensation in the feet, meaning early pressure damage may go unnoticed.
Advanced age
Older adults experience:
- thinner, more fragile skin
- reduced tissue tolerance
These factors significantly increase susceptibility to heel pressure injuries.
Surgery and anesthesia
During surgical procedures, patients may remain immobile for several hours. The heels often remain in contact with the operating table, increasing the risk of perioperative heel pressure injuries.
Intensive care patients
ICU patients are among the highest-risk populations due to:
- prolonged immobility
- sedation
- hemodynamic instability
Research shows that heel pressure injuries are particularly prevalent in critical care settings.
How to prevent heel pressure injuries
Evidence-based guidelines from NPIAP, EPUAP, and international wound care organizations emphasize that prevention should focus on pressure redistribution and heel offloading.
1. Heel offloading
The most effective way to prevent heel pressure injuries is to completely offload the heel. Heel offloading means lifting the heel so it no longer bears weight against the bed surface.
Clinical methods include:
- heel suspension boots
- specialized heel offloading devices
- positioning aids
Dedicated hospital heel protectors are widely used to maintain consistent offloading.
Specialized devices are designed to suspend the heel while distributing pressure across the calf and lower leg, such as the Maxxcare Heel Pro Evolution.
2. Regular repositioning
Patients at risk should be repositioned regularly to relieve pressure.
Guidelines typically recommend:
- repositioning at least every 2 hours
- adjusting positioning based on patient condition
However, repositioning alone may not fully relieve heel pressure, which is why heel suspension devices are often recommended.
3. Daily skin inspection
Regular skin assessment allows clinicians to identify early warning signs.
Healthcare providers should inspect:
- heel skin color
- temperature changes
- swelling
- blistering
- non-blanchable redness
Early intervention can prevent progression to deeper tissue damage.
4. Pressure redistribution surfaces
Advanced support surfaces such as pressure redistribution mattresses can reduce interface pressure, though they often do not fully eliminate heel pressure.
Additional heel offloading devices are typically required.
5. Use of heel protection devices
Specialized heel protection devices can provide:
- consistent heel offloading
- reduced shear and friction forces
- improved patient comfort
Clinically designed devices help healthcare teams implement reliable heel injury prevention protocols.
Clinical solutions for heel offloading
Several types of clinical devices are used to prevent heel pressure injuries. Each solution offers different levels of protection and stability.
Pillows
Pillows placed under the calf can lift the heel off the mattress. However, pillows often:
- shift position
- collapse under weight
- require frequent repositioning
Integrated mattress systems
Some specialized mattresses incorporate heel relief zones, but these often require additional offloading devices to fully prevent pressure injury at the heel.
Heel offloading devices
Heel suspension boots are commonly used in hospitals and long-term care facilities. These devices are designed to:
- fully lift the heel off the mattress
- distribute pressure along the lower leg
- stabilize foot positioning
- reduce shear and friction
They provide more reliable clinical heel offloading compared with improvised positioning methods.
For example, the Maxxcare Heel Pro Evolution device is developed to provide consistent heel suspension while maintaining patient comfort and ease of use for caregivers.
Why Maxxcare is an effective solution for heel offloading
Effective heel pressure injury prevention requires consistent heel offloading, pressure redistribution, and protection against shear forces. Specialized medical devices are often needed to achieve this reliably in clinical practice.
The Maxxcare HeelPro Evolution is specifically developed to support clinical heel offloading protocols in hospitals, rehabilitation centers and long-term care facilities.
Designed for complete heel offloading
One of the most important requirements in heel pressure injury prevention is complete heel suspension. The heel must be lifted so that it does not touch the mattress, allowing blood flow to return to the tissue.
The Maxxcare Heel Pro Evolution is designed to fully offload the heel while supporting the lower leg. This helps redistribute pressure away from the calcaneus (heel bone), which is the main area at risk for pressure injury development. The Heel Pro Evolution also protects against shear and friction, because the smooth outer material reduces damaging forces during movement.
Designed for clinical practice, the device is easy to use and provides consistent positioning, supporting reliable implementation in daily care. This makes it suitable not only for prevention, but also as part of a treatment plan for existing heel pressure injuries.
The Maxxcare Heel Pro Evolution is also designed with patient comfort in mind. Its soft, lightweight materials support long-term use, both day and night, helping patients remain comfortable while receiving continuous protection. The device allows safe short-distance walking, such as from bed to toilet, without needing to be removed. In addition, it is fully machine washable at 60°C, supporting high hygiene standards and infection control protocols in clinical settings.
Maxxcare combines clinical effectiveness with patient comfort, helping caregivers implement reliable prevention protocols.
Conclusion
Heel pressure injuries remain a significant clinical challenge in hospitals and long-term care facilities worldwide. Because the heel is highly vulnerable to pressure damage, early prevention strategies are essential.
International guidelines from NPIAP and EPUAP emphasize that prevention should focus on:
- early risk identification
- continuous skin monitoring
- consistent heel offloading
Clinical heel protection systems and dedicated heel offloading devices provide healthcare teams with reliable tools to reduce pressure injury risk.
By combining evidence-based prevention protocols with specialized clinical solutions such as the Maxxcare HeelPro Evolutiuon, healthcare providers can significantly reduce the incidence of heel pressure injuries and improve patient outcomes.
