More people are complaining about their ingrown toe nails as winter comes and closed shoes are being worn more.
The most common cause of an ingrown toe nail is poor self-treatment, but there are numerous other factors, divided into intrinsic and extrinsic.
Common intrinsic(internal) factors are the basic shape of the nail – especially at the edges – we all have different curvatures and angles and some nails have increased curvature on one side only.
Another factor is the structure and function of the foot (the biomechanics). If a flexible foot rolls or flattens excessively toes can rub against each other, causing pressure. Other factors can be sweaty feet and thin skin, caused by age, medication or circulation.
However, it is the extrinsic factors that really produce the problems – poor self-cutting and shoe pressure top the list. (Sometimes even health care professionals and therapists can cause ingrowns!), tight socks and injuries can also be added to this list.
In the clinic, the appearance of ingrown toe nails varies from a small pink swelling, to an inflamed growth or ‘proud flesh’, like a small cherry, lying over the nail plate. The pain seems to depend on the individual’s pain threshold more than the condition itself.
The offending nail can be just a small ‘shoulder’, pressing into the sulcus or a sharp spike of nail which penetrates the skin. The skin tries to heal itself when a spike penetrates it and that process leads to the formation of ‘proud flesh’ or hypergranulation tissue. Of course if the toe becomes infected then pus is also present.
Treatment for ingrown toenails varies with the cause and duration. The simplest treatment is correctly cutting out the offending portion of nail. In the more painful and complicated cases this is done under a local anaesthetic.
The permanent solution under local involves an operative procedure where the complete side of the nail including the matrix, is cut out and the matrix space is destroyed with a strong caustic. After about a month the side where the nail was looks normal – the cavity heals completely. This is a procedure that podiatrists do very well as an outpatient procedure.
Obviously avoiding ingrown nails is the best, but nobody should suffer with them when skilled podiatric care is available.
Deciding to have bunion surgery can be one of the most difficult health decisions to make. ‘Bunions’ are a cause of distress to many thousands of people -mostly women -worldwide. Last year, I wrote about bunions and my opinion was and still is – “avoid bunion surgery if at possible, unless it is ruining your life and crippling you with pain”.
The ‘bunion’ referred to here is the bony deformity characterized by a big toe that deviates towards the rest of the toes, possibly accompanied by a second toe which is bent and overlies it.
When any surgical intervention is considered, be it the podiatrist enucleating a corn, removing part of a toe-nail or the orthopaedic surgeon realigning the foot in bunion surgery, all of us strive to do our best to achieve a satisfactory outcome, by exercising our skills to the utmost.
So you can imagine my concern to have two patients recently complaining bitterly about their unhappiness with the result of their bunion surgery. Add to this my surprise at the ‘twenty-something’ who wants surgery because she doesn’t like the look of her feet and her bunion (this one is the small thickening of the metatarsal bone with no deformity), prevents her from wearing the high fashion shoes she needs for work.
What can you say to a middle-aged, active woman who decided to have her bunion (deformed type) corrected, but after three months can only wear trainers with the toe cut out, has a swollen foot, pain and discomfort, difficulty driving, plus all the associated emotional stress? Or how do you respond to a similar woman who is now in constant pain and has had altered her walking style because the foot is rigid at the big toe joint?
To the best of my knowledge the procedures were technically successful and there is no deformity anymore. In addition we all react differently to a surgical “assault” and time does allow better healing. Also, there are numerous variations of operations and techniques available for bunion correction surgery.
Firstly – go back to the surgeon and discuss your options.
Secondly – see if a podiatrist can assist with biomechanical correction or alignment and footwear advice.
With my 2 patients, one has had orthotics made and the other I referred to the surgeon, who has recommended further physiotherapy, with the possibility of another operation to remove the steel plate that is in the foot.
I will still refer patients who meet my criteria outlined above for consideration for surgery, because the final decision to undergo sugery is always taken by the patient. Unfortunately, there can be no absolute guarantees since the structure of each foot is so complicated.
So what to do about ‘bunions’? Is there an underlying systemic disease such as rheumatoid arthritis?
We must consider the patient’s age. Is the patient overweight? What is the biomechanical structure and function, not only of the feet but lower limbs and body? Have all possible conservative measures such as night splints, orthotics, insoles, appropriate footwear, been exhausted?
Be guided by the severity of loss of function, pain, discomfort and limitation of daily activities. Will the patient be able to adhere to all the post-operative requirements, expected by the surgeon?
Eventually, all these factors (plus others), must be seriously thought about before undergoing bunion surgery.