Are Ingrown Toenails Preventing You From Running?
Author. Mr Paul Gabriel Scullion. FCPodS podiatric surgeon
If you have ever suffered from problems associated with your toenails and had them incorrectly cared for, then you can certainly appreciate how excruciatingly painful and debilitating they can be. The following article will inform serious tri-athletes about the condition of the infected ingrown toenail and its correct treatment and care.
CLASSIC INGROWN TOENAIL (Onychocryptosis)
This disorder is one of the most excruciatingly painful conditions a human can endure. The pain experienced ranks up there with labour pains in women, toothache and slipped disc. Just ask anyone who has had this condition with someone having inadvertently stepped on it. In my 23-year experience, the only cure is surgical intervention.
Infected ingrown toenail, for the most part, is a self-inflicted condition. People, who are into self-treatment for involuted and convoluted toenails, by digging down the border of the toenail, may often get away with it. Unfortunately, infected ingrown toenail can happen to the unlucky self-treated.
A sharp point (spickule) of the toenail can be the end result of poor self-treatment (Fig 10). As the toenail slowly grows out then this spickule cuts into the sensitive flesh of the nail border. The toe becomes very painful, swollen, red and hot. On occasions, a discharge of pus will develop and in severe cases, a small “strawberry” of tissue will form (granulation tissue Fig 11). At this stage two definite disease processes have begun; Infection and foreign body reaction.
INFECTION AND FOREIGN BODY REACTION
If an ingrown toenail is simply viewed as nothing more than an infection or nothing more than a foreign body reaction on their own, then even the most experienced surgeon can be defeated by this troublesome complaint.
For example, I have performed surgery on a number of patients who have received multiple courses of antibiotics by their family doctor in a failed attempt to try and treat this stubborn condition. It was obvious that their doctor was viewing the condition as just an infection.
Conversely, I have also seen patients who have been assured by their chiropodist that the spickule causing the foreign body reaction has been removed, only to present to my office with pus still oozing from the toenail demonstrating clearly the infection has not been addressed.
When the processes of infection and foreign body reaction together are fully addressed only then is a curative surgical treatment for ingrown toenail successful. Chemical destruction of the nail bed treats both the infection and the foreign body reaction by permanently removing the offending nail. In a recently published scientific paper, the chemical destruction of the nail bed technique was deemed to have a success rate in the high 90% range. Another technique, surgical excision of the nail bed, was demonstrated to have a success rate only as high as 50%.
TREATMENT
Chemical destruction of the nail bed using 80% strength phenol, is my surgical procedure of choice for problem ingrown toenails. With careful selection of a candidate, all instrumentation is sterilised and the foot is prepared with a surgical scrub. A local anaesthetic is introduced to the base of the toe. This gives profound numbness to the toe and nail plate for up to two hours.
A rubber bandage (tourniquet) is applied to the toe in such a manner as to squeeze the blood out of the toe and back into the body. This renders the toe white and bloodless for a controlled and short as possible period of time. The application of a tourniquet-like this allows for a clear view of the surgical site. The full operation takes less than 15 minutes and falls well within safe margins for circulation to be temporarily cut off from a healthy digit.
The toe is carefully checked for total numbness and then attention is drawn to the affected nail border. A specialised surgical instrument is introduced to gently free the soft tissues attached to the top of the nail plate. A cut is made at the free edge of the toenail to allow the insertion of a fine surgical chisel. This instrument is then pushed along the nail plate, under the soft tissue fold and down through the germinating matrix. This incision frees the troublesome section of the nail, which is removed using a fine clamping forceps (Fig 12).
The open wound of the nail border is thoroughly dried and the section of the removed nail plate is checked to ensure that its root is intact. This simple step can be missed. Ripped or torn roots are a known cause for regrowth to occur.
80% strength liquid phenol is then applied to the exposed nail bed tissues (Fig 13). This chemical application is carried out at least twice during the procedure with additional massaging of the phenol soaked tissues using a miniature surgical file (Fig 14), giving particular attention to the germinating matrix tissue where the nail grows from.
Once completed, the rubber bandage is removed and the circulation noted to return. An antiseptic compression dressing is applied and the patient instructed on aftercare with emphasis on foot elevation above the hip for the remainder of the day. The patient is also instructed on twice-daily saline footbaths and strong antiseptic redressing. Healing time is approximately 4 weeks. Of particular note to athletes is the fact that most normal training activities can be continued with just 48 hrs following this surgery, however as much rest as possible will always ensure faster healing.
RECOVERY
When healed the toenail is narrower and over the next several months the soft flesh reforms itself into a new nail border (Fig 15). Results look so good that it is difficult to see where the surgery took place but by comparing one toe with its opposite number on the other foot the difference in width is the only telltale sign.
REMEMBER
Normal and healthy toenails should not hurt. As a podiatric surgeon, I recommend early care at even the slightest sign of trouble is the best action to maintain good health of your toenails. Stay healthy and enjoy pain-free running.
(Permission granted by Mr Scullion’s practice for the use of these illustrations)
I have just come across your informative website and, as a podiatrist in practice for 11 years, I would like to draw attention to the fact that it is not always necessary to go to a Podiatric Surgeon to have nail surgery. In fact nail surgery is often avoidable altogether, there being several first stage treatments which can prove to be entirely successful in treating this painful condition. Most podiatrists who have a B.Sc In Podiatric Medicine (from Belfast and UK recognised universities) are qualified to carry out nail surgery and a list of same is available from the Society of Chiropodists and Podiatrists of Ireland (see the Golden Pages or the website http://www.podiatryireland.com).
In conclusion, the most important thing to remember in the case of an ingrowing toenail is that, at the slightest pain, you should get IMMEDIATE treatment as nail surgery can usually be avoided altogether.
Isobel Guckian B.Sc.(Hons), M.Ch.S, S.R.Ch., RGN
Podiatrist
Feetsavers – The Footcare Experts,
1 Berkeley Road, Dublin 7 and
The Albany Clinic, Lower Fitzwilliam Street, Dublin 2
8500031 (D7)
or 6614884 (D2)
Hi Isobel,
Unfortunately the full article was not published and I discussed this with the editor Seb at the time. I initially intended a photograph showing a very obvious severe infected ingrown toenail with extensive hypergranulation present ( but this was withheld by the editor) and again I would stand over my article within that context of the full article being published, in that surgery really is the only intervention for such a presenting case.
As for conservative treatments I also practise these on a daily basis as not all ingrown toenails present with such severity.
I much appriciate the support you write about our professional organisation and would concur for readers to seek out expert help at the earliest stages of foot trouble.
Yours fraternally
Paul Gabriel Scullion
The website was just established, and Gabriel had a great article, which we edited, simply because for a few weeks old website, we thought that the first article needed to be more attractive to the general public.
My apology to Gabriel, which took the difficult initiative to be published. I did know the main topic was not just ingrow toenails, which is a well documented subject on the web.
A more documented article toward the surgery was needed for athletes like myself who have / had trouble and run 100 of miles a week, and have severe toes infections.
It might be the time to publish the pictures, now that we are well established.
Sebastien Locteau
Editor