Pressure Injuries: What You Should Know

A pressure injury (also called a pressure ulcer, pressure sore, bedsore, or decubitus ulcer) is damage to the skin and the tissue beneath it. It happens when soft tissue is squeezed between a bony part of your body and a surface — a wheelchair cushion, mattress, car seat, or commode — for too long, cutting off the blood flow that feeds the tissue. People with spinal cord injury are at high, lifelong risk because they often cannot feel the warning pain that tells most people to shift, and because changes below the level of injury leave the skin more fragile and the bones with less padding.

Most pressure injuries are preventable, and the ones that do appear are usually caught early and healed at home when you and the people who help you follow a steady routine. A deep injury that reaches muscle or bone is a different story: it can mean months in bed, surgery, a serious infection, and a long pause in work, school, and independence. Almost every person with SCI experiences at least one pressure injury over a lifetime (per SCIRE), so knowing how to spot one early is a core skill, not an optional one.

🚨 Red Flags — When to Seek Emergency Care

Call your rehab doctor or go to the ER the same day if:

• You see a new area of skin that is dark purple, maroon, or black, or a blister filled with blood or clear fluid over a bony area — this can be a deep tissue injury that is far worse underneath than it looks.
• The area is warm, swollen, hard, or has red streaks spreading outward.
• You have fever, chills, or feel generally unwell along with any new or worsening wound — infection from a pressure injury can spread to the blood, heart, and bone and become life-threatening (sepsis).
• You can see bone, tendon, or muscle at the base of the wound, or there is a foul odor or thick yellow/green drainage.
• You have a sudden pounding headache, sweating, or a blood-pressure spike (autonomic dysreflexia) — in people with SCI at T6 and above, a pressure injury can trigger this medical emergency. See the Autonomic Dysreflexia guide.
• An injury over the sacrum, sit bones, or hip has not improved after a few days of strict pressure relief and good nutrition.

Tell the medical team plainly: “I have a spinal cord injury and cannot feel this area. I need a full skin assessment.” Bring dated photos of the area from the last few days if you have them.

Understanding Pressure Injuries

Healthy skin needs a steady supply of blood, oxygen, and nutrients. When you sit or lie in one position, your body weight presses the tissue against bone and squeezes the small blood vessels shut. On a hard, unsupportive surface, skin can start to break down in as little as 30 to 60 minutes (per SCIRE). Moisture (sweat, urine, or stool) and shear — the sliding force when you slip down in your chair or are dragged across a sheet — speed the damage.

The most important thing to understand is that what you see on the surface is usually the smallest part of the problem. Pressure injuries often begin deep in the tissue near the bone and work their way up to the skin, so by the time the surface looks damaged the tissue underneath is already worse (per PVA). Treat every spot, no matter how small, as a real injury.

Where pressure injuries happen

The high-risk spots are the bony prominences — places where bone sits close to the skin — and they shift depending on whether you are sitting or lying down (per MSKTC).

When sitting (in your wheelchair, car, or on any seat):

• Sit bones (ischial tuberosities) — the single highest-risk area for wheelchair users.
• Sacrum and tailbone (coccyx) — especially if you slide down or recline.
• Greater trochanters — the outer points of the hips.

When lying down:

• Sacrum and tailbone, heels, and the backs of the knees and ankles.
• Greater trochanter when on your side; if your knees or ankles touch, those spots are at risk too.
• Elbows, shoulder blades, back of the head, and the rim of the ears during long periods in bed.

If you have scoliosis or sit unevenly, more weight may fall on one side — a good seating setup helps spread it. For the techniques that prevent injuries at these spots, see the Pressure Relief & Skin Care guide.

The stages of a pressure injury

Pressure injuries are described in stages by how deep the damage goes. The staging system below follows the National Pressure Ulcer Advisory Panel, the reference used across PVA, MSKTC, and SCIRE materials.

• Stage 1 — The skin is not broken, but there is a patch of redness or color change that does not fade (blanch) when you press it and does not return to normal after pressure is off for 10–30 minutes. The area may feel firmer, softer (“boggy” or “mushy”), warmer, or cooler than the skin around it. This is the warning stage — and the one most often missed.
• Stage 2 — The top layer of skin (epidermis) is broken, leaving a shallow open sore that may look like a scrape, blister, or shallow crater. The second layer (dermis) may be involved.
• Stage 3 — The wound extends through the skin into the fatty tissue below. It looks like a deeper crater. Bone, tendon, and muscle are not yet visible, but watch closely for infection.
• Stage 4 — The wound reaches all the way down to muscle and possibly bone, and may extend into tendons and joints. There is usually dead tissue and a high chance of infection.
• Unstageable — The base is covered by dead tissue (slough or a scab called eschar), so the true depth can’t be seen until that covering is removed.
• Deep tissue injury — Intact skin that is purple or maroon, or a blood-filled blister, signalling damage in the tissue underneath. It can evolve quickly even with good care, and is harder to spot on darker skin — look for the firmness, temperature, and color changes described below.

Stages 3 and 4 are the ones that most often need wound clinics, special beds, and sometimes surgery.

How to Recognize an Injury Early

• Look for redness or color change that does not fade after you stay off the area for 10–30 minutes. On lighter skin this is pink or red; on darker skin it may look purple, bluish, shiny, or simply different from the skin around it (per MSKTC).
• Don’t rely on color alone, especially on darker skin tones. Compare the spot to nearby skin and feel for it being harder, softer, warmer, or cooler, or for swelling. These changes can show up before any color change you can see.
• Use the blanch test where you can: press the area with a finger; healthy skin briefly turns pale, then returns to its normal color within seconds. If it stays one color and never lightens, blood flow is already impaired. Note that dark skin may not show visible blanching even when healthy, so combine this with the firmness and temperature checks above.
• Check by sight, not just by feel. Feeling for an open area only finds late injuries; early ones are color and texture changes you have to see — use a long-handled mirror, your phone camera, or a helper for spots you cannot view directly.
• Pay extra attention after a long car ride, a flight, a new cushion or mattress, an illness, or any change in your bowel or bladder routine — these are the moments injuries start.
• Keep a simple skin log (a notebook or phone note with the date, location, and a photo taken in the same light and angle). It turns “is this getting worse?” from a guess into something you can see.

Risk Factors — What Raises Your Risk

Pressure injuries come from a mix of forces on the outside and changes on the inside. Knowing your own risk factors tells you where to put extra attention.

• Loss of sensation — Without the discomfort that normally cues a position change, you can sit too long without knowing it.
• Loss of movement — Reduced ability to shift means longer stretches of unbroken pressure, and unused muscles shrink (atrophy), leaving less padding between skin and bone (per SCIRE).
• Moisture — Sweat, urine, or stool softens skin and invites breakdown and infection. Good bladder and bowel routines are part of skin protection — see the Bladder Management and Neurogenic Bowel guides.
• Shear and friction — Sliding down in the chair or being dragged across a sheet strains the deep tissue and scrapes the surface.
• Nutrition — Too little protein, calories, fluid, or key vitamins and minerals leaves skin fragile and slows healing (per SCIRE).
• Spasticity and contractures — Muscle spasms can rub skin against surfaces or pull the body into high-pressure positions.
• Smoking and nicotine — Cigarettes, vapes, and smokeless tobacco narrow blood vessels, so skin gets less oxygen — a major, controllable risk (per PVA).
• Body weight at either extreme — Being underweight means less padding; being overweight means more pressure, more moisture, and harder transfers.
• Age and time since injury — Skin loses firmness and padding with age, and risk rises the longer you live with SCI.
• A prior pressure injury — Healed skin is never quite as strong; old injury sites are the most likely places for a new one.
• Other health conditions — Diabetes, heart, kidney, or lung disease, poor circulation, frequent UTIs, reduced immune function, depression, and low body temperature regulation all add risk (per PVA).
• Worn or wrong equipment — A cushion, mattress, or commode seat that is past its life or poorly fitted concentrates pressure. Check and replace gear on schedule.

Nutrition for Healthy, Healing Skin

• Eat enough protein every day. Protein is the raw material your skin uses to stay intact and to rebuild a wound. Ask your dietitian for a target based on your weight.
• Stay well hydrated. Dehydrated tissue is more fragile and heals more slowly.
• Don’t skimp on calories, vitamins, or minerals. Vitamins A and C, iron, and zinc all support skin and wound healing; if you have a wound, your team may add a supplement while it heals (per MSKTC).
• Aim for a steady, healthy weight. Both extremes raise risk.
• If you develop a wound, treat eating as part of the treatment. Many people with a pressure injury are under-nourished, which is one reason wounds stall.

What to Do at the First Sign (Non-Emergency)

• Get off the area completely and immediately. Stay in bed or use a different position until the spot has fully recovered. Never sit or lie back on a red or warm area.
• Find and fix the cause. A new cushion, a long sit, a wrinkle in clothing, a hard surface — identifying and removing the cause is the single most important step in treating any pressure injury (per SCIRE).
• Step up inspections to several times a day and photograph the spot every 24 hours in the same light so you can tell whether it is improving.
• Boost nutrition and fluids right away.
• Call your rehab doctor, wound clinic, or seating specialist within a day or two. Do not wait to “see if it gets better.” A Stage 1 area that clears with a few days of pressure relief is reversible; one that doesn’t needs professional eyes.

How Pressure Injuries Are Treated

Once a wound has formed, treatment is a team effort, and the first principle never changes: keep all pressure off the area so it can heal. What else is involved depends on the depth.

• Offloading and equipment. Healing starts and ends with taking weight off the wound — often strict bed rest for a deep injury, on a pressure-redistributing mattress (such as a low-air-loss or air-fluidized bed) for a healing sacral or hip wound (per MSKTC). When you eventually return to sitting, it is gradual: short stretches, a few times a day, building up slowly so you don’t re-injure the spot.
• Wound care and dressings. A range of dressings protect the wound, absorb drainage, and keep it moist enough to heal while blocking bacteria. A wound nurse chooses the type and how often to change it.
• Cleaning and debridement. Dead or infected tissue is removed so healthy tissue can heal — gently with dressings and moisture for small amounts, or by a nurse or surgeon for larger amounts. Debridement is only done when there is enough blood flow for the area to heal.
• Treating infection. If infection is present, antibiotics are used; topical antimicrobials may be applied to the wound. Watch for the infection signs in the Red Flags above.
• Osteomyelitis (bone infection). When a deep (Stage 4) wound reaches the bone, there is a risk of a serious bone infection. If your team suspects it, they may order x-rays, an MRI, or blood tests to check (per SCIRE).
• Other therapies. Electrical stimulation and other treatments are sometimes used to help severe wounds heal; your wound team will advise what fits your situation.

When surgery is considered

Some Stage 3 and most Stage 4 injuries do not close on their own and are repaired with flap reconstruction surgery (per MSKTC). The surgeon first cleans out all the dead or infected tissue — which can include removing some bone — then covers the wound with a “flap” of healthy skin, fat, and muscle moved from a nearby area or, less often, from the back, buttocks, or thigh. Done well, surgery can heal a wound far faster than the months of bed rest it would otherwise take, lowering the infection risk and getting you back to your life sooner.

It is a serious commitment, not a shortcut. A few things to know:

• The factors that affect healing are largely the same ones that prevent injuries: a good support system, the right mattress and cushion, a healthy diet, controlled blood pressure and other conditions, and no tobacco or nicotine — these especially, because they choke the blood supply the flap needs to survive.
• Spasticity must be well controlled before and after surgery, so spasms don’t tear the flap.
• Recovery means weeks of bed rest and a slow, supervised return to sitting. Planning ahead for how you’ll fill the time helps.
• Surgery does not restore sensation, so the area stays at risk afterward — lifelong prevention matters as much as ever.
• Possible complications include the wound reopening, the flap not surviving, bleeding, or infection — your surgeon will walk you through whether the benefits outweigh the risks for you.

The Consequences of a Deep Injury

It helps to know what is at stake, because it explains why the daily routine is worth it. A deep pressure injury can mean (per SCIRE, MSKTC):

• Months off the area — long bed rest while it heals, sometimes a year or more for the most severe wounds.
• Long, costly hospital stays and repeat hospitalizations.
• Serious infection that can spread to the blood, heart, or bone and become life-threatening.
• Lost time at work, school, and the activities and relationships that matter to you.
• Reduced independence and a greater need for help from family and caregivers while you heal — and because you move less during that time, a higher risk of new UTIs, breathing problems, and autonomic dysreflexia.

None of this is meant to frighten you. It’s the reason a few minutes of skin checks and relief each day are one of the best investments you can make in your freedom.

What Many People Find Helpful

Many people with SCI go decades without a serious pressure injury once skin checks become as automatic as brushing their teeth — done at the same time every day, with everything they need within reach.

• Keep a small “skin kit” — a long-handled mirror, good light, gloves, and barrier cream — where you’ll actually use it.
• Treat the first two weeks with any new cushion or mattress as a break-in period, with extra-frequent checks.
• Make sure caregivers and personal support workers know your routine. Write your skin protocol on a card or a shared note so anyone helping you follows the same steps.
• When traveling, bring your own cushion and mirror — airplane seats, hotel beds, and hospital stretchers rarely protect your skin well, and you can ask for a proper surface if you’re admitted.
• If finding the time feels impossible, that’s a sign to ask for support, not to skip it. Peers who live with SCI often have the most practical tips of all.

Evidence & Sources

Synthesized from PVA Consortium consumer guides, MSKTC factsheets, SCIRE Community evidence summaries, eLearnSCI/ISCoS consumer modules, and Reeve Foundation booklets (retrieved 2026-06-24). See RESEARCH-SOURCES.md for complete provenance and cross-bucket details. Staging language follows the National Pressure Ulcer Advisory Panel system used across these sources; surgical and reconstructive detail draws on the MSKTC Surgical and Reconstructive Treatment of Pressure Injuries factsheet, and early-recognition guidance on the MSKTC Recognizing and Treating Pressure Sores factsheet.

Printable One-Pager Notes

• Target length for a single printed page: 1000–1300 words with this structure. This guide runs long for definitive depth; the renderer may paginate the treatment and surgery sections to a second sheet.
• The Red Flags block and the early-recognition checklist must stay in the upper half of the page.
• Use 11–12 pt body text and generous line spacing when printing from the site renderer.
• The emoji heading (🚨) prints correctly on modern printers; if your printer drops emojis, write “RED FLAGS — EMERGENCY” by hand at the top.
• Leave a small blank area for a simple body outline marking the sitting and lying pressure points if the renderer does not place a figure there.

Your skin is your early-warning system. Most people with SCI who keep a steady inspection routine never reach a Stage 3 or 4 injury. The few who do can almost always trace it to a single day the routine was skipped because of travel, illness, or “just this once.” Keep this guide where you — and anyone who helps you — can find it fast, and pair it with the Pressure Relief & Skin Care guide for the day-to-day prevention techniques.