Key Pearls On Treating Pressure Ulcers

Clinical Editor: Kazu Suzuki, DPM, CWS

These expert panelists discuss how to offload pressure ulcers in the heel and ankle, which patients are at high risk for pressure ulcers and whether one should debride dry heel eschar.


What is your offloading device of choice for heel and ankle pressure ulcers?


Nicholas Giovinco, DPM, emphasizes that offloading an ambulatory patient poses a great challenge. While total contact casts work well, Dr. Giovinco says they require regular maintenance and replacements. In addition, he notes that sturdy, removable devices designed for offloading in ambulatory patients can sometimes cause new ulcers on other parts of the foot due to the hard nature of the construct (such as steel or carbon fiber).

   Both Kazu Suzuki, DPM, CWS and Desmond Bell, DPM, CWS emphasize the importance of determining whether the patient is ambulatory. If the patient is ambulatory, Dr. Suzuki says he or she would benefit from a rigid PRAFO boot (Anatomical Concepts) that enables some extent of ambulation. If the patient is completely or mostly bedridden, he always prefers soft heel floating boots. Dr. Suzuki says they are more comfortable than the standard PRAFO boots and one can expect better patient adherence.

   Dr. Suzuki’s institution uses Prevalon boots (Sage Products), giving a pair to every admitted patient with heel pressure ulcers or high-risk patients. He says the boots are washable if they get soiled.

   In addition, Dr. Suzuki notes a new kind of “hybrid” boot combines rigid PRAFO boots and soft heel offloading boots, citing the development of soft heel offloading boots with sole traction pads. He says Heelift boots (DM Systems) are an example.
“It may be a nice alternative to having a pair of both rigid and soft boots,” suggests Dr. Suzuki.

   Dr. Bell also prefers using devices such as the Heelift for the patients who are at the greatest risk for developing pressure ulcers or as part of the offloading protocol in patients with existing heel and ankle ulcers. Ideally, he says the ulcers should “float” within the selected device and the device should be soft with material construction that will prevent additional shearing.

   When offloading pressure ulcers of the heel and/or ankle, Dr. Bell also considers the status of the wounds (as far as showing clinical improvement) as well as vascular status, condition of the surrounding skin, the presence of infection and nutritional status.

   While splint devices that are characterized by a rigid outer frame and a soft inner lining may be appropriate for more ambulatory patients, Dr. Bell says the hard material of the frame can create new areas of pressure in the minimally or non-ambulatory patient.

   Dr. Suzuki cautions that using a regular pillow to elevate the heels is “just not good enough” with the current standard of care in pressure ulcer treatment. He says the pillows often do not stay in place longer than a few hours.

   For Dr. Giovinco, applying padded heel protection appliances over the dressings works well. He notes these devices are characteristically “oversized” in appearance and Velcro often holds them in place. Although there are several devices that work suitably, Dr. Giovinco says not many of them offload ambulatory patients without increasing their risk of falling.

   Noting that some of the newer devices show promise in diverting pressure, he says they can require custom fitting. The success of that application depends upon the workmanship of the orthotist and other factors, according to Dr. Giovinco.

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