Pressure Injuries (Pressure Sores)

Pressure injuries are the most common serious complication after SCI — about a third of people get one during their first hospitalization, and most will face at least one over a lifetime. They're also largely preventable. This is the short version of what to do.

What They Are

Unrelieved pressure on skin over a bony area cuts off blood flow. Without sensation to tell you to move and without the ability to shift your own weight, the tissue starves and dies — fast. A sore can start in hours and take months to heal, so prevention is everything.

Where They Form

Almost always over bony prominences: the sitting bones (ischial tuberosities), tailbone (sacrum), hips (trochanters), heels, ankles, elbows, shoulder blades, and the back of the head. If you sit most of the day, the sitting bones and tailbone are your highest risk.

Prevention — the Whole Game

• Shift your weight every 15–30 minutes in your chair. Lean forward, lean side to side, or use tilt/recline. A few seconds isn't enough — offload for a full minute or two.
• Reposition every ~2 hours in bed, using the 30° side-lying position and floating your heels (see sleep & positioning).
• Inspect your skin twice a day with a mirror — look for redness that doesn't fade, and check it during bathing.
• Use a proper pressure-relief cushion and mattress, fitted to you (see equipment).
• Keep skin clean and dry — moisture from sweat or incontinence weakens skin.
• Eat enough protein (see nutrition) and don't smoke — both directly affect skin resilience.

The Four Stages

• Stage 1 — intact skin with redness that doesn't blanch (turn white) when pressed. Reversible if you offload now.
• Stage 2 — partial-thickness loss; a shallow open sore or blister.
• Stage 3 — full-thickness loss into the fat layer.
• Stage 4 — deep wound exposing muscle, tendon, or bone.
• Also: Deep Tissue Injury (maroon/purple intact skin — damage underneath) and Unstageable (base obscured). Stages 3–4 are limb- and life-threatening (sepsis risk).

Treatment

Rule one: completely offload the wound — stay off it entirely. A sore on the sitting bones may mean strict bed rest until it heals. Beyond that, treatment means proper wound care, treating any infection, optimizing nutrition (more protein, more calories), and finding and fixing what caused it (a bad cushion, a missed weight shift, a seam). Deep stage 3–4 wounds often need surgery (a muscle/skin flap) and a long recovery. Get a wound-care specialist involved early.

Your Cushion Is the Front Line

Most recurring sores at the sitting bones trace back to seating. If you've had more than one episode of breakdown in the same spot, don't just re-heal it — fix the seating system that keeps causing it:

• Get a formal seating evaluation at a seating clinic with an ATP, ideally with pressure mapping (a sensor mat that shows exactly where you're loading). Ask your physiatrist or rehab hospital for the referral — don't let a supplier just ship you another cushion.
• Step up the technology if you keep breaking down. Good air-cell and gel cushions (ROHO, Jay — see our cushion comparison and equipment guide) handle most people. If sores recur anyway, ask specifically about custom-molded seating such as the Ride Designs Ride Custom 2, which is cast to your anatomy and designed to off-load your at-risk bony prominences entirely rather than padding them.
• Yes, custom costs thousands — and it's worth fighting for. Compare it to the cost of one flap surgery and a year in bed. Insurance does approve custom seating when recurrent breakdown is documented and the seating clinic writes the justification; appeal denials. If insurance won't move and you're breaking down, this is a legitimate reason to fundraise — protect your benefits while you do it (how).
• Recheck after every body change — weight gain or loss, surgery, new chair. A cushion fitted to the body you had two years ago may not protect the body you have now.

What Nobody Tells You

• Hours, not days. A serious sore can begin in a single afternoon of unrelieved sitting. The 15–30 minute weight-shift rule is not optional.
• The cause is usually findable. A new cushion, a wrinkled sheet, a hard transfer surface, a too-long car ride — when a sore appears, hunt down what changed.
• One stage-4 sore can cost you a year. Bed rest, surgery, lost independence. Prevention is dramatically cheaper than treatment.
• Check the spots you can't see. Use a long-handled mirror or your phone camera for the tailbone and sitting bones — that's where they hide.

Sources & Further Reading

Sources include lived experience and published clinical guidance:

• Pressure Ulcer/Injury Prevention and Treatment Following Spinal Cord Injury — Consortium for Spinal Cord Medicine Clinical Practice Guidelines (Paralyzed Veterans of America)
• Skin Care & Pressure Sores factsheet series — Model Systems Knowledge Translation Center (MSKTC) (see the factsheet library)
• National Pressure Injury Advisory Panel (NPIAP) —
• Pressure Sores — MedlinePlus (U.S. National Library of Medicine)

SCI.help articles are information, not medical advice. Practice varies by injury level, provider, and institution — always confirm specifics with your own care team.