“The toenail has two primary functions—protect the tip of the toe and oppose the ground reactive forces when you walk.” —Dr. Randall Kline, “Stepping Into Better Health” RPM contributor,
By Dr. Randall Kline, DPM, FACFAS, FAPWCA
Allied Bone & Joint
While a toenail seems to play a minor role in overall health, injury or ingrowth can lead to chronic pain, infection or difficulty in performing your favorite sports activity. With football season upon us, I’m seeing an increase in toenail injuries—many times, a lineman whose feet get stepped on every play. However, athletes involved in non-contact sports incur nail injury as well.
The toenail has two primary functions:
– Protect the tip of your toe,
– Oppose the ground reactive forces when you walk.
As you walk and propel forward with each step, the toenail pushes down on the tip of your distal phalanx (bone under the nail) as the ground pushes upward, keeping your bone straight. If your nail is lost through injury, this opposing force is lost, and the bone begins to turn upward like the tip of a ski.
There are four primary nail injuries that I see with athletes: An ingrown nail, a thickened nail, a nail lost through repetitious micro trauma, and nail deformation from underlying exostosis.
Ingrown nails are most commonly due to the position of the toe or direct impact injury. If you are a hyperpronator, the great toe may eventually roll the nail toward the ground medially and move the toe itself against the second digit. Both of these movements can ultimately lead the nail-fold to push over the nail, while at the same time, push the sides of the nail into the skin.
Other toenails can have similar ingrowth from the pressure of the other toes, but most commonly, the ingrowth occurs in the great toes. Symptoms include; redness, swelling, drainage, purulence, malodor and chronic pain.
What you can do:
- Wear shoes that fit properly, both during athletic activity and when in more formal attire. ν Trim your nails with the contour of your toe. Keep the nails short, but not back below the skin line. ν If ingrowth occurs, minor irritation at the tip of the toe may be allowed to grow out of its position; wash the site with soap and water daily.
What your physician can do:
- Treat any infection that may be resulting from the ingrowth. ν Remove the offending nail border. ν If the ingrowth is recurrent and extends down to the base of the nail, a permanent removal of the nail border may be warranted. This type of treatment has a 95 percent permanent efficacy in literature and can be done in the office.
Thickened nails/Dislodged nails can be from several sources, including; trauma, repetitive micro-trauma or fungus.
Beyond th cosmetics, these can create pressure in the shoe leading to discomfort, ingrowth and/or infection. Reasons could range from the length of the toe compared to the others, any malposition, such as a hammertoe or fungus.
If such a nail or nails become symptomatic, consultation would be advisable to determine the underlying cause to seek the appropriate remedy. Treatment choices would include adjustments to types of shoes worn, debridement of the nail more closely with the contour of the toe, topical or oral anti-fungal if appropriate, correcting any positional abnormality in the toe, or removal of the nail itself.
Subungual Exostosis is the medical term given to a boney prominence residing under the nail bed, which most often will deform the nail’s external contour. Such a growth most commonly occurs from direct force against the toe such as collision or direct impact.
I incurred such an injury myself while lifting weights—sliding a larger plate off of the bar, while forgetting about the smaller plate in front of it, (lesson; don’t watch football highlights unless resting between sets). The impact of the 10-pound weight from a waist height drop produced microfractures in the dorsal distal phalanx of my great toe. Remarkably, the nail did not dislodge, but as time went on, a small osteophye grew at the site of impact, changing the contour of the nail.
What you can do:
- Wear appropriate shoes for the activity you are doing. This may not fully prevent an injury (as in my case), but will most certainly lessen the severity. ν Trim the nail shorter than the underlying prominence.
What your physician can do:
- Take an x-ray to evaluate the underlying bone. The size and shape of the prominence can be determined, as well as evaluation for any other injury such as fractures or damage to the nearby joint. ν If the injury is severe, a procedure can be performed to remove the underlying boney prominence, or simply to remove the nail if desired.
Please keep in mind that an injury to the tip of your toe could be a medical emergency. If the nail is dislodged or bleeding is found beneath the nail, there is a chance of injury to the nail bed itself. Such an injury could expose the underlying bone to bacteria resulting in osteomyelitis. Also, an injury with sufficient impact to dislodge a nail could also result in an open or closed fracture of the toe. Evaluation by medical personnel should be sought immediately to prevent long-term consequences.
As the fall athletic season is upon us, I wish you a safe, productive year of challenges and growth.
Dr. Randall Kline is a board-certified podiatrist specializing in injury, wound and diseases of the foot and lower leg. Contact Allied Bone and Joint at (574) 247-4667 or visit the AlliedBoneandJoint.com website for more information.