Pressure Injuries: What You Should Know

A pressure injury (also called a pressure sore, pressure ulcer, or bedsore) is damage to the skin and the tissue under it. It starts when soft tissue is squeezed between bone and a surface — a cushion, mattress, or car seat — long enough to cut off blood flow. After a spinal cord injury you may not feel the warning pain that tells most people to shift, and the skin below your injury is more fragile. Almost every person with SCI has at least one pressure injury in their lifetime (per SCIRE) — so spotting one early is a core skill, and most injuries are preventable.

🚨 Red Flags — When to Seek Emergency Care

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

• A new dark purple, maroon, or black area, or a blister filled with blood or clear fluid, over a bony spot — this can be a deep tissue injury, 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 with any new or worsening wound — infection can spread to the blood, heart, and bone and become life-threatening (sepsis).
• You can see bone, tendon, or muscle in the wound, or there is a foul odor or thick yellow/green drainage.
• You get a pounding headache, sweating, or a blood-pressure spike (autonomic dysreflexia) — with SCI at T6 and above, a pressure injury can trigger this emergency. See the Autonomic Dysreflexia guide.
• A sore over the sacrum, sit bones, or hip has not improved after 2–3 days of strict pressure relief.

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 if you have them.

Understanding Pressure Injuries

Your body weight presses 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.

What you see on the surface is usually the smallest part of the problem. Pressure injuries often begin deep near the bone and work their way up, so the tissue underneath is already worse than the skin looks (per PVA). Treat every spot, however 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 with position (per MSKTC):

• Sitting: the sit bones (ischial tuberosities) are the highest-risk area for wheelchair users, then the sacrum and tailbone (especially if you slide down) and the outer hip points (trochanters).
• Lying on your back: sacrum and tailbone, heels, elbows, shoulder blades, and the back of the head.
• Lying on your side: the hip point, plus the knees and ankles wherever they press together.

For weight shifts, cushions, and the other prevention techniques, 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, using the National Pressure Ulcer Advisory Panel system that PVA, MSKTC, and SCIRE all follow.

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

Stages 3 and 4 most often need wound clinics, special beds, and sometimes surgery.

How to Recognize an Injury Early

• Check your skin by sight, twice a day. Feeling for open areas only finds late injuries. Use a long-handled mirror, your phone camera, or a helper for spots you can’t see.
• Look for color change that does not fade after 10–30 minutes off the area — on darker skin it may look purple, bluish, or shiny rather than red (per MSKTC).
• Don’t rely on color alone. Feel for skin that is harder, softer, warmer, cooler, or swollen than nearby — these changes can show up first.
• Use the blanch test: press the area with a finger. Healthy skin briefly turns pale, then returns to its color within seconds. If it never lightens, blood flow is already impaired. Dark skin may not show visible blanching even when healthy, so combine the test with the checks above.
• Check extra carefully after a long car ride or flight, a new cushion, an illness, or any bowel or bladder change — these are the moments injuries start.
• Keep a skin log — date, location, and a photo taken in the same light — so you can see whether it’s getting worse.

What Raises Your Risk

• Loss of sensation and movement — you can’t feel the cue to shift, and unused muscles shrink, leaving less padding over bone (per SCIRE).
• Moisture — sweat, urine, or stool softens skin. Good bladder and bowel routines protect it — see the Bladder Management and Neurogenic Bowel guides.
• Shear and friction — sliding down in the chair or being dragged across sheets.
• Poor nutrition — too little protein, calories, or fluid leaves skin fragile and slow to heal.
• Spasticity — spasms can rub skin or pull you into high-pressure positions.
• Smoking and nicotine — cigarettes, vapes, and smokeless tobacco narrow blood vessels, starving skin of oxygen — a major risk you can control (per PVA).
• Body weight at either extreme — underweight means less padding; overweight means more pressure and harder transfers.
• Age and years since injury — skin thins and risk rises over time.
• A prior pressure injury — healed skin is never as strong; old sites break down first.
• Other conditions and worn equipment — diabetes, heart, kidney, or lung disease, frequent UTIs, depression, and any cushion or mattress past its life all add risk.

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

• Get off the area completely, right away. Do not sit or lie back on it until the skin has fully recovered.
• Find and remove the cause — a new cushion, a long sit, a wrinkle, a hard surface. This is the single most important step in treating any pressure injury (per SCIRE).
• Inspect several times a day and photograph the spot every 24 hours in the same light.
• Boost protein, calories, and fluids — vitamins A and C, iron, and zinc also support healing (per MSKTC). Ask your dietitian for a protein target.
• Call your rehab doctor or wound clinic if it hasn’t cleared in 2–3 days. A Stage 1 spot that clears with pressure relief is reversible; one that doesn’t needs professional eyes.

How Pressure Injuries Are Treated

The first principle never changes: keep all pressure off the wound so it can heal. From there, treatment depends on depth.

• Offloading and equipment. A deep wound often means strict bed rest on a pressure-redistributing mattress, such as a low-air-loss bed (per MSKTC). The return to sitting is gradual — short stretches, a few times a day, building up slowly.
• Dressings. They protect the wound, absorb drainage, and keep it moist enough to heal while blocking bacteria. A wound nurse chooses the type.
• Debridement. Dead or infected tissue is removed so healthy tissue can heal — gently with moist dressings, or by a nurse or surgeon — and only when there is enough blood flow for healing.
• Treating infection. Antibiotics treat infected wounds; topical antimicrobials may be applied. A deep (Stage 4) wound that reaches bone risks a serious bone infection (osteomyelitis) — your team 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.

When surgery is considered

Some Stage 3 and most Stage 4 wounds will not close on their own. In flap reconstruction surgery, the surgeon removes all dead or infected tissue — sometimes including bone — then covers the wound with a flap of healthy skin, fat, and muscle from nearby or from the back, buttocks, or thigh (per MSKTC). Done well, it heals a wound far faster than months of bed rest and lowers the infection risk. It is a serious commitment, not a shortcut:

• Healing depends on the same things that prevent injuries: support at home, the right equipment, a healthy diet, well-managed health conditions — and no tobacco or nicotine, which 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. Plan ahead for how you’ll fill the time.
• 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 help you weigh the benefits and risks.

A deep injury can cost months off the area, hospital stays, serious infection, and lost time at work and school (per SCIRE). A few minutes of daily skin checks 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.

• Keep a small “skin kit” — long-handled mirror, good light, gloves, 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.
• Write your skin routine on a card or shared note so caregivers and support workers follow the same steps.
• When traveling, bring your own cushion and mirror — airplane seats and hospital stretchers rarely protect your skin, and you can ask for a proper surface if you’re admitted.
• If finding the time feels impossible, ask for support rather than skip it — peers living 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 detail draws on the MSKTC Surgical and Reconstructive Treatment of Pressure Injuries factsheet, early-recognition guidance on the MSKTC Recognizing and Treating Pressure Sores factsheet.

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Your skin is your early-warning system. Most people who keep a steady inspection routine never reach a Stage 3 or 4 injury. Keep this guide where anyone who helps you can find it fast, and pair it with the Pressure Relief & Skin Care guide for day-to-day prevention.