Pressure ulcers are an extremely common complication for individuals with some form of mobility impairment due to reduced sensation, muscle atrophy, bone decalcification, incontinence, and limited mobility—even temporarily. International studies show that as many as 95% of all people with spinal cord injuries will at some point develop a deep pressure ulcer classified as category 3-4. My experience is that 100% will develop a pressure ulcer at some point, but how severe it becomes depends on the knowledge of the affected individual and the healthcare staff responsible for treatment. Pressure ulcers can also affect those who use orthoses or have undergone amputation and use prosthetics, as these can increase pressure.
Feet and Pressure Ulcers
When you develop pressure ulcers, it’s crucial to identify the cause and address the issue.
Are your shoes too tight?
You often need a larger shoe size after becoming paralyzed compared to what you wore before. Sometimes, simply removing the insole can help. If you have a sore, eliminate all pressure in the area! Use sandals or ask for a referral to an orthopedic workshop to adjust your shoes.
If you never wear shoes, the footrest of your wheelchair may cause concentrated pressure on a small area. A footplate offers better pressure distribution.
Is your foot externally rotated, which causes increased pressure on the ankle (malleolus) while lying down?
You may need a pressure relief boot that counteracts both leg rotation and foot drop while also relieving pressure on the heel, such as a ”Lasse cushion” (a foam plastic cushion shaped for foot/leg) or a Prevalon boot with a wedge (soft boot).
Do you have spasticity that causes friction on your heels, leading to recurring blisters?
Use real sheepskin at the foot end of the bed to prevent this, or use relief boots such as MaxXcare Pro Evolution Heel, which can also be worn while sitting or walking a few steps. Don’t puncture the blister, as this increases the risk of infection and delays healing!
Does your spasticity cause your foot to twist outward in the shoe, resulting in pressure ulcers on the outside of the foot? Ask for a referral to an orthopedic workshop for a custom-molded silicone insert with built-in relief.
Do you experience pressure from an orthosis, prosthesis, or cast?
These materials often create pressure at the edges and may need to be padded, especially in areas with reduced sensation.
• Relieve the skin from the orthosis/prosthesis as soon as you notice a red mark or pressure ulcer, and contact your orthopedic workshop for adjustments to prevent it from happening again.
• If you have a broken leg and are paralyzed, padding and pressure relief are essential since the pressure on the heel increases. You will also need more frequent check-ups because you won’t feel pain, and the orthosis/cast can slip down due to swelling, easily causing pressure ulcers.
With quick action and intervention, you can prevent a deeper pressure ulcer from developing.
Compression Socks
If you have pressure ulcers on swollen feet, compression socks are necessary to promote better healing. Some mistakenly believe that compression socks increase pressure on the sore.
For some individuals, however, compression socks can cause pressure ulcers in the ankle or knee creases. If this happens, first try a flat-knitted sock (where the stitches are vertical), as round-knitted socks are more likely to cause pinching in skin folds by following the shape of the leg.
If that doesn’t work, you may need to try custom-made socks. The next option is daily treatment with a a special compression boot device (Intermittent pneumatic compression – IPC) to reduce the swelling.
Wound Treatment
The first step is always to diagnose the wound to ensure the correct treatment based on the type of wound. Then, engage in active wound healing using modern dressings that can stay in place for several days, providing the wound with an optimal environment (correct moisture and temperature). The dressing should be in contact with the wound bed.
If you have a wound that heals but keeps recurring, the root cause has not been properly addressed! If a wound does not heal despite following the correct procedures, surgical intervention (such as a skin graft or pinch graft) may be needed to finally resolve the issue. Most wounds heal with the right treatment, but it’s quite common for people who care for their wounds themselves to fall back into old habits over time. They may change the dressing too frequently, expose the wound to air, or massage it.
Often, people don’t take the necessary steps to solve the underlying issue, such as using offloading devices, because these can affect their independence. Additionally, many cannot afford such devices since they often need to be paid for out of pocket. Others may resist wearing special shoes because they don’t look fashionable or modern. These factors can lead to the wound becoming a persistent problem for years.
Infection
Inflammation in a wound can sometimes be mistaken for an infection, leading to unnecessary antibiotic treatment. Infected wounds can often be managed with local treatments and more frequent dressing changes.
If you have wounds or cracks on your feet, there’s an increased risk of developing erysipelas (a bacterial skin infection). Swollen legs/feet also increase this risk. Erysipelas can spread quickly and requires antibiotic treatment, as it can lead to sepsis (blood poisoning) in severe cases.
Symptoms of Erysipelas:
- Intense, sharply defined redness that spreads rapidly.
- Pain and swelling in the infected area.
- Fever, and sometimes nausea and vomiting.
Key Actions:
- Monitor the area closely.
- React promptly and take immediate action!