Recognising Pressure Damage on Heels and Ankles

Why heels and ankles are so vulnerable

Heels and ankles sit right over bone with very little padding in between. The skin is thin, the blood supply has travelled a long way down the leg to get there, and those areas take the full weight of the leg whenever someone lies on their back. That combination makes them one of the most common sites for pressure ulcers in the UK — and often the first place damage appears.

For anyone who is immobile, unwell, sedated, recovering from surgery or sitting for long periods, damage can begin within a couple of hours. Add in factors such as diabetic neuropathy, peripheral arterial disease, ankle swelling, or a recent hip or knee operation where the heel rests on the mattress for hours on end, and the risk climbs sharply. Many hospital and community teams now check heels specifically as part of routine pressure ulcer risk assessment, and the same vigilance belongs at home.

What pressure damage actually looks like

Pressure damage on the heel does not always start as an open wound. Early changes are easy to miss, especially on darker skin tones, so it helps to know the range of what you might see:

• Early damage: intact skin with redness that does not fade when you press it lightly with a finger. On darker skin, look instead for purple, blue or black discolouration, or an area that feels warmer, firmer, boggy or more swollen than the other heel.
• Superficial damage: a shallow open wound, a graze, or a blister that may be clear or blood-filled.
• Deeper damage: a wound that extends into fat, tendon or bone. These can look surprisingly small on the surface.
• Dark patches and hard black areas: a persistent purple or maroon patch, or a wound covered by black, leathery tissue, needs urgent assessment — deeper damage may be hidden underneath.

Always compare one foot with the other. Ask the person whether the area feels numb, tingling, burning or sore. Pressure damage can be painful before the skin ever breaks, although nerve damage can mask the warning signs entirely.

Check footwear, socks and anything else touching the skin

Anything in contact with a heel or ankle is a potential source of pressure, friction or shear. A few minutes of checking pays off:

• Slippers and shoes: too loose and the foot slides and rubs; too tight and it squeezes. Feel inside for seams, folded labels, loose insoles, stones or coins.
• Take footwear off at night unless a podiatrist or nurse has advised otherwise.
• Socks and tights: avoid tight elasticated cuffs that leave a groove in the skin. Choose soft, seam-free socks that fit properly.
• Compression stockings: wear only as prescribed, and check the skin underneath every single day.
• Splints, casts, ankle-foot orthoses and walking boots: check the edges and straps, and report any rubbing straight away.
• Tubing and straps: catheter tubing, oxygen tubing and feeding lines can easily sit across an ankle or under a heel. Reposition them at each check.

Bedding and positioning at home

The aim is simple: heels should float clear of the mattress, not rest on it. The easiest method is a pillow placed lengthways under the calves so the heels hover just above the surface with a small gap. Do not put the pillow directly under the heels themselves — that concentrates pressure and can press awkwardly on the Achilles tendon. Purpose-made heel offloading boots and foam wedges are available through community nursing teams and specialist suppliers.

• Ripple, foam and air mattresses help, but a mattress alone rarely protects heels — a heel-specific device is usually needed as well.
• Never use ring or donut cushions around a heel or ankle. They create a ring of pressure around the very area you are trying to protect.
• Smooth out sheets, nighties and pyjama legs. Crumbs, creases and wrinkles in bedding cause friction and shear.
• Do not drag someone up the bed. Use a slide sheet or ask for help — shearing forces damage skin quickly.
• Do not rub, massage or vigorously towel-dry reddened skin, and never apply hot water bottles, heat pads or ice to the feet. Numb feet burn easily.
• Keep heels clean and dry, pat gently after washing, and moisturise the skin — but not between the toes.

A daily two-minute check

• Look at the back, sides and front of both heels, the ankle bones, and the skin behind the Achilles tendon.
• Use a hand-held mirror if bending is difficult, or check on behalf of someone who cannot see their own feet.
• Feel for warmth, hardness, swelling or a spongy patch. Cool skin with discolouration can indicate poor circulation — report it.
• Check under dressings, plasters, bandages and the edges of any splint or brace.
• Note or photograph any change with the date, so you can describe how it has progressed.
• Encourage gentle ankle circles and regular repositioning — even small movements help restore blood flow.

When to ask for help

Contact the GP, district nurse or community nursing team if you spot a blister, an open wound, a black or purple patch, discharge, a bad smell, or an area that is spreading or becoming more painful. Ask about a referral to a tissue viability nurse — early input can stop a small problem becoming a serious wound.

Seek urgent help if there is fever, redness tracking up the leg, or a foot that becomes cold, pale, blue or suddenly numb. Call NHS 111 if you are unsure, or 999 if the person is seriously unwell. It is also worth thinking about the bigger picture: good nutrition, steady hydration and well-controlled diabetes all help skin resist and recover from pressure damage. Protecting heels and ankles is not complicated, but it does need doing every day.