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Posts for: February, 2021

By contactus@podiatryassociates.ca
February 17, 2021
Category: education
Tags: ingrown toenail  

 

So interestingly i just did a quick Google search just as you would to find the origin of your 

ingrown toenail.

Unsurprisingly the three sources i viewed Mayo clinic, NHS (National health 

service UK) and WebMD all come up with the same well expounded opinions with slight 

variations.

All of them basically say YOU are the problem. You bought the wrong shoes, you cut the nails wrongly and so on.

 

After 30 plus years in practice and having spoken with hundreds of podiatrists I can 

unequivocally say they are wrong. Ingrown toenails are virtually always caused by the way our foot functions or more precisely how our big toe joint functions. ( ok there’s the odd exception).

 

The why? is a question for another time, but for now consider what happens is, our big toe joint jams, or locks when we are about to toe off. We have no option but to rotate our foot outwards propelling us off the inside of the big toe and into the air. In that instance of propulsion  a significant proportion of our body weight is driving the flesh on the side of our toe against the nail and the toe itself is being driven laterally onto its neighbouring toe (the 2nd toe) with similar peaks of pressure and tissue displacement. Multiply that force over the course of a day let alone a lifetime and its very easy to see the causative agent not only behind ingrown toenails, but thickened damaged nails ripe for fungal infection, bunion development, interdigital corn and callous formation and a host of deformities in the lesser toes.

 

Certainly poor fitting/designed shoes will exacerbate this situation,  self treatment often will pour gas on the flames, and individuals can and will traumatize toes causing an ingrown toe nail to occur, but this is the exception not the norm.

 

The most frequent cause of this jamming of the big toe is associated with heavily pronated or flat feet. The vast majority of the patients referred or presenting to our offices seeking surgical correction of persistent painful ingrown toenails have visually significant pronation (rolling in) in the  offending foot or feet. 

When viewed on our Pedigait system (video gait analysis) the causative biomechanical influences can be clearly identified. Many of the painful conditions that are referred to us stem from the mechanical method by which we stand and walk. Treating the symptom without addressing the cause can prove frustrating, painful, time consuming not to mention expensive. The booming business of treating planter fasciitis or heel spur syndrome being one of the best examples of this paradox.

Anyway I’m loosing the plot again! Back to our ingrown toenail, how should it be managed properly?  

  

 Management!

        

As a general rule management starts with a good history taking. Is this a one off? How frequently and how severe have they been? What has been done in the past, both professionally and self care? Associated health issues (increasing systemic health risks), and so on. Suffice to say a bit of chit chat is necessary before any treatment can be suggested or delivered. 

Most often if its a first time or no professional treatment has be given previously we will attempt a conservative debridement with the patient participating in short term management to achieve resolution. Strict guidelines are given so as to determine success or triggering the need for subsequent care. This usually takes care of the one off ingrowths due to accidental trauma, over exuberant nail care, an unfortunate special occasion shoe choice or a weekend warrior experience in Algonquin park.

For the more chronic cases the nail has changed shape as previously explained due to the mechanical forces caused by gait. Thus no amount of cutting, shaping, nail bracing, or for that matter orthotic intervention will reverse the structural change of the nail in a meaningful way. The best course of action is to permanently address the problematic nail profile by surgical intervention while identifying the underlying functional cause and recommending this be addressed subsequently.

Regularly we get referrals from other podiatrist who choose not to perform these procedures or are not surgically licensed. Upon resolution we usually recommend that the patient return with a biomechanics examination and diagnosis to their local podiatrist to prevent other associated issues arising from the functional instability.

 

The surgical procedure is relatively simple and the link below is an example of how we describe the process required to achieve first anesthesia and secondly a cosmetically pleasing and pain free solution. We also go through post-operatively what our patients can expect to feel, see and how they can influence the speed of healing and lack of pain.

 

 

https://youtu.be/RWx0U1MxZF0

 

 

Of the patients we see with a primary diagnosis of ingrown toenails, just over 60% have a history of one or more previous surgical interventions to correct the problem. Some are shocking in their degree of pain, complexity and darn right mismanagement. 

I have two stand out cases from my past to illustrate. 

 

The first of which was a 13years old referred from a neighbouring health district. He had been treated by his well intentioned family physician over the previous four years for ingrown toenails. He had several bloody debridements over those years with varying degrees of anesthesia and his mother reported that her pharmacy had records of 14 separate instances of antibiotic prescription pertaining to toe infections. I can’t quite do justice to the visual presentation of his toes on the first encounter. The second was in our Brantford clinic where the gentleman narrated a history of 7 prior surgeries, the last of which was performed as an in-patient in the care of orthopaedics and resulted in his inability to work for 2 weeks as an assistant director in the cinematic industry. 

Interestingly when he returned for his one week followup visit with us, he was Livid! why had he suffered for so long and missed so much work for something that he now knew in hindsight to be a relatively simple procedure and fix.

In retelling these events I do so to illustrate an almost daily occurrence in our offices. Most podiatrist offer this service and over time we may customize or personalize our delivery but the approach is tried, tested and found to produce excellent results.

 

So if you’ve been suffering from an ingrown toenail for the first time or it has been an unwelcome companion in your life for a while, come in and let us have a look and discuss how best you can resolve your particular issue.

Here is a link I found to a TV show we did on ingrown toenails 

back in 2013 with some great visual references to what i described in the text above.