The pillow remains perhaps the most commonly used heel elevation method in hospitals worldwide. I guess this is because they are readily available, cost nothing beyond what's already supplied for patient comfort, and require no special equipment or training. They are also inadequate for heel protection and can compromise continuity of care.

The evidence is now clear: an Australian multi-centre ICU trial found that purpose-designed heel offloading devices achieved a 0.4% pressure injury incidence, compared to 8.4% with standard care, which typically means pillows and repositioning [1]. That's a twenty-fold difference. Translated into practical terms: for every 1,000 patients, 79 fewer will develop heel pressure injuries when proper offloading devices are used instead of pillows.

This isn't a criticism of clinical staff who use pillows—they're working with what's available and following long-established practice. It's an observation about biomechanics: what a pillow can and cannot achieve when the goal is heel offloading.

Understanding why pillows often fail points toward what effective heel protection actually requires.

When clinicians think about pressure ulcer prevention, they typically focus on pressure—the perpendicular force that compresses tissue against a surface. This is understandable. The condition is called a pressure ulcer. Pressure is in the name.

But pressure tells only part of the story. Shear—the force acting parallel to the support surface that distorts tissue layers relative to each other—may be even more damaging than pressure alone. Research dating back to Bennett's seminal 1979 study demonstrated that when shear is present, the pressure required to produce vascular occlusion is reduced by approximately 50%. At shear levels of roughly 100 g/cm², the pressure needed to stop blood flow was half that required when little shear was present.

This finding has profound implications for heel protection. A device that reduces pressure but doesn't address shear may leave the heel vulnerable to the very damage it was meant to prevent.

Intensive care patients face the highest pressure ulcer prevalence of any hospital setting—14.32% according to international prevalence surveys. The heels account for a substantial proportion of these injuries. And unlike many ICU complications, heel pressure ulcers are largely preventable with appropriate intervention.

Yet in the complex, high-acuity environment of intensive care, heel protection can be overlooked. The focus—rightly—is on keeping the patient alive. Organ support, haemodynamic stability, ventilation, sedation. Heel protection rarely tops the priority list. But if a heel pressure ulcer occurs then this complicates continuity of care.

This article makes the case for implementing prophylactic heel offloading as a standard component of ICU care, and examines what effective implementation looks like in practice.

The terms get used interchangeably in clinical practice. Pressure reduction. Offloading. Heel protection. Redistribution. But they are not the same thing. And the distinction matters to clinical outcomes —particularly at the heel, where anatomy conspires against us.

The 2025 International Pressure Injury Guideline makes this explicit. For heels, the recommendation is unambiguous: heels should be "fully free from contact with the support surface." Not reduced pressure. Not redistributed pressure. Zero contact.

This article explains the biomechanical difference between pressure reduction and complete offloading, why it matters specifically at the heel, and what the evidence shows. Let's be clear about definitions first.

Recent NHS pathway updates include important changes to pressure ulcer prevention guidance, particularly around heel protection and offloading. This article explains the key updates, how they align with current evidence, and the practical implications for services reviewing prevention strategies. It also clarifies the difference between products that reduce pressure and those that fully offload the heel.

Pressure ulcers are a significant problem in the UK, particularly for bedridden patients or those with limited mobility. They occur in up to 23% of patients in acute care facilities and up to 33% of patients in long-term care facilities. At Anatomical Concepts, we are particularly interested in heel pressure ulcers, accounting for approximately 25% of all ulcers.

To prevent these ulcers, we should know the risk factors which are partly "mechanical" and partly "medical". We discuss the major ones and notice how these factors can overlap. We finish by looking at how the PRAFO range of orthoses can help