bedsore at heel

And Then He Got a Bedsore

One day, Mom noticed that his heels were a bit red. A couple days later he had some oozing blisters. Then, when the blisters broke open, there was a hole all the way down to muscle and I could feel the bone underneath.

A “bedsore” is a disastrous wound. In the last several posts I have discussed skin tears. They are common as people get older. Fortunately, bedsores are less common than skin tears. But bedsores, now more commonly called “pressure sores”,  are much more serious. They often result in prolonged hospitalization and nursing home care. That’s because healing can take many months of wound care. This post is about who is at risk for pressure sores, how they occur, and what they look like.

What causes pressure sores?

Pressure sores are almost invariably related to immobility. Most patients who develop pressure sores need help to walk or spend extended periods in bed. Many have paralysis of a limb. Patients typically have medical conditions such as stroke, Parkinson’s disease, or dementia. Severe chronic illness or frailty can also result in difficulty moving the body around.

The buttocks, tailbone, and heel are common sites for pressure sores. That is because there is bone right under the skin. Constant pressure on the tissue under the bone results in lack of blood flow and injury. Sometimes sores occur when an extremity is pressed against the metal of a wheelchair. One of my patients could not lift his chin off his chest. He then developed a wound on the chest. I have also seen patients who developed pressure sores on their heels after surgery. The heel bone was constantly pressing down on the operating table. The damage can take days to become apparent.

Aside from direct pressure, other mechanical factors can also lead to sores. Skin drags when there is friction between skin and a surface. This can happen when a patient is lifted higher up in bed. “Shearing” occurs when tissue under the skin is pulled apart in different directions. This can happen when a person is sliding down a chair.

The condition of the skin and the tissue underneath also play a key role. Persistent moisture, frequently due to urine incontinence, predisposes to skin injury. Malnutrition, weight loss, and chronic disease weaken the skin and underlying tissues.

What does a pressure sore look like?

Pressure sores are often painless, even when severe. That’s why it’s important to examine the skin carefully and routinely in people at risk. The way a pressure sore looks is described by stages.

Stage 1 and 2 are the least severe and may not appear serious. However, it’s important to notice, treat, and reverse a sore at this stage. Many of the severe pressure sores I have seen started while a patient was cared for at home. Small wounds can worsen rapidly. Once a sore is at Stage 3, treatment is much more difficult.

Stage 1 Heel Sore

The skin itself is not broken open. However, the heel is reddened. Sometimes a Stage 1 looks like a bruise. Redness does not always mean that there is a Stage 1 sore. But the red color on undamaged tissue turns lighter when pressed. After pressure is released the color returns indicating blood flow. This is called blanching. Injured tissue does not blanch because the color is due to injured tissue. The abnormal color stays there when pressed. Stage 1 problems can be harder to notice in patients with dark pigment.

Stage 2 Buttock Sore

The skin has broken open. Sometimes a blister forms. Although there is definite damage, the sore is shallow. A stage 2 sore can happen within hours of unrelieved pressure.

Some Pressure Sores are unstageable

Some sores do not look like Stage 1-4. They may have a thick or irregular scab of dead skin and surrounding skin breakdown. Or there may only be a small opening, with surrounding boggy tissue. Wounds of these types are severe. The damage is hidden from view.


  • Pressure sores are a major concern
  • People with impaired mobility are at highest risk
  • It’s important to recognize a pressure sore at Stage 1 or 2

The next post will be  about prevention of and treatment of pressure sores. What types of mattresses make a difference?

There are other types of serious wounds. I mention them because the management of these wounds is different.

Warmest Aloha,

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PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.

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