Involuted Nails

Here at the Footcare Clinic, we often  hear people complain of ingrown toenails. Sometimes they are ingrown, but more often they are 'involuted'.

Involuted nails can be very painful as the two sides of the nail curl towards each other pressing into the skin at the edges of the nail. Looking at the nail from the end of the toe, the nail has a profile similar to a staple, as in the picture below. Sometimes the curvature of the nail is so great that the tip of the nail curls in a circle causing the skin to be pinched. They usually they don't break the skin or become infected but they can become painful due to pressure.

It doesn't take a wild imagination to understand the problems that nails like this can cause. The nipping action of the nail makes them feel very tight and any added pressure on the top of the nail from footwear for example, can cause friction in the nail sulcus and lead to a build up of hard skin. As hard skin develops at the nail edges, the amount of pressure increases and this makes the toes more painful.  

Very often, the shape of the nail increases the total depth of the toe, necessitating a much deeper toebox in footwear. With insufficient room in the toebox, pressure on the nail causes the nail plate to thicken up, leading to increased pressure, more hard skin in the sulcus and even corns. So the circle of events continues.

Some  people with involuted nails never have any problems with them, but the liklihood of the nail pressing on the skin and becoming sore is much greater than in people with flatter nails.

The problems really occur when the pain causes people to cut their nails back in an attempt to gain relief. Sometimes this works, but only for a short period of time. Occasionally this 'self care' can leave small spikes of nail which can then penetrate the skin and  become embedded, causing an infection and an ingrown nail, ( onychocryptosis)

With involuted nails, it is important to cut them straight across the natural line of the nail. Cutting away at the sides often leads to other problems. It is also important to ensure there is sufficient depth in the toebox of a shoe, to prevent excessive downward force on the nail. Professional help is always advised.

If this becomes a long standing problem, then a simple procedure known as a Partial Nail Avulsion can help. This involves removing the side or sides of the offending nail permanently so that the nail that is left behind is flatter, easier to manage and has no curved bits to dig into the sides. 

Restless Legs

"I'm not sleeping well"

"Once my legs start to jump, I know I won't get any peace"

Have you ever felt this way?

Strangely, people tend to mention this whilst in the podiatrist's chair as a topic of conversation, rather than visit their GP. They feel it is something they should tolerate and not "worth bothering" their doctor with. Some even feel they will be laughed at.

It is called 'Restless Leg Syndrome'  and was first described by Ekbom in 1944 as occurring mainly at rest and included 'sensory symptoms'. Legs jump and twitch and are sometimes painful. Sensations similar to electric shocks have been reported, as have crawly and fizzing sensations. All symptoms are worse at night and are improved with exercise. Some people find that staying still for any length of time is difficult and they avoid trips to the theatre, cinema or even travelling by car or plane.

It commonly disrupts sleep causing tiredness through the day and may even lead to depression. Many adults report that their symptoms began in childhood and studies have proved that nearly 2% of children have significant symptoms which are often dismissed as 'growing pains'.  

A strong genetic link has been identified by Daniel Picchietti, a professor of paediatrics in the University of Illinois College of Medicine; who reported that more than 70% of children with the condition have at least one parent with symptoms.

Sometimes it can be secondary to another condition, such as iron deficient anaemia, magnesium deficiency or pregnancy.

Some people have found the condition improves by walking and stretching; taking warm baths; yoga and relaxation; reducing alcohol and caffeine intake. Eating foods rich in magnesium has helped in many instances.  

Ignoring the symptoms may cause stress and an inability to cope. Lack of sleep can cause irritability  and lead to inevitable problems at work.

But there is no need to suffer in silence as your G.P. can help.

For more advice about podiatric issues, click here.

Gout

Gout has a very long history. Hippocrates (c. 460 – c. 370 BC) identified gout (Greek: podogra) as different from other forms of arthritis. It is a member of the family of arthritides, it is inflammation of joints, but it differs because it is caused by the build up of monosodium urate crystals. These are often referred to as uric acid.

Two very brave gentlemen, Faires and MacCarty, investigated the role of these crystals in gout during the 1960's by injecting their left knee joints with them. Within four hours they were experiencing violent attacks of gout and the pain was excruciating.

Surveys have found that gout is an agonising and incapacitating form of  arthritis which "negatively affects daily activities, lifestyle and work "  (N. Lawrence Edwards, MD, Professor of Medicine, Rheumatology and Clinical Immunology, University of Florida College of Medicine) Flare ups are sudden, intense and last an average of 8 days.

Gout sufferers usually produce too much uric acid or are unable to get rid of the excess produced by their bodies. The uric acid forms needle-like crystals which are deposited in the joints. It typically affects one joint, often the big toe (62% of cases) and it can also cause feverish symptoms.

The presence of the crystals trigger an immune response, leading to  inflammation;  joint swelling, pain, heat, redness and stiffness. In some patients the condition can become chronic causing repeated flare ups, joint damage, kidney stones and kidney disease.

Gout tends to run in families, affects about 1% of the population and, it is more common in men than women.

For a long time, alcohol has been considered a trigger for gout attacks.  Little research has been carried out in this area, although one recent study on 197 subjects found that alcohol can  trigger recurrent gout attacks, usually occurring within 24 hours of consumption.

Dehydration is another factor often associated with gout. During periods of increased perspiration, less uric acid is excreted and so at times of high humidity and high temperatures, those prone to gout should drink lots of water. 

A very interesting paper in 2007 (Arthritis Rheum. 2007;56:2048-2054,) connects a reduced incidence of recurrent gout attacks in men over the age of 40 with coffee drinking,

"A study of a nationally representative sample of US adults showed that coffee consumption was associated with a lower serum level of uric acid and a lower frequency of hyperuricemia."

Many gout patients are managed with Allopurinol, the urate lowering drug, with varied success. Allopurinol will not work during an attack as it is not a painkiller and, it may take up to 3 months to be effective against another episode.

If you are unfortunate enough to suffer with gout, one of the most painful conditions known, please reduce your alcohol intake and  increase your fluid levels, especially in hot and humid weather.  Your GP can prescribe painkillers for use during an attack; it's worth paying a visit.

For more information on Podiatry, click here: The Footcare Clinic

Shin Splints

"The pain starts when I begin running, but eases off after a while. My friend had some therapy for shin splints, maybe that's what I need?"

"I'm training for a marathon but haven't kept to the schedule. On  Sunday I ran for 20 miles through the city, to 'catch up'. I now have terrible pains in my shins - I'm worried I may have shin splints "

There really is no such syndrome as 'shin splints', although it is a commonly used terminology. As a diagnosis, it is almost as exact as using the term, 'foot pain'.  When people refer to 'shin splints' they are generally referring to pain in their 'shins', towards the inside of the leg. The pain spreads across quite a wide area of the lower leg and usually affects those people who are involved in intense exercise. It is in fact, self inflicted.

There are a number of specific disorders covered by this title, including  fractures, muscle strains or tears, nerve entrapment and artery entrapment.  Most commonly however, it refers to a condition entitled, Medial Tibial Stress Syndrome. (MTSS) . 

The pain experienced with MTSS is worse at the beginning of training and subsides during the session. As the condition progresses in time, the pain is present with less activity and it may even occur when resting. Running on hard surfaces makes it worse as does suddenly increasing the intensity or duration of training. It can develop into a stress fracture due to repeated trauma on the leg structures

It is more common in women, in whom it is 3x more likely to advance into a stress fracture. The cause is often associated with biomechanical abnormalities. 

To recap; pain in the lower leg is not a 'shin splint' but one of many different disorders.

So if you are suffering with this,

·         stop training,

·         rest the area,

·         use ice on the leg immediately after exercise and,

·         seek the advice of a podiatrist or biomechanist who will guide you through the recovery process.

Fungal Nails

Fungal Nails occur in around 8% of the population in the UK 

There are different types of infection, or onychomycosis, but by far the most common is that which is caused by fungi  tracking from the skin of the foot.

It starts at the end of the nail and moves back towards the 'half moon' leaving yellow or brown patches and streaks as it progresses.  The nail is very crumbly when it is cut and may have a bad odour.

Another type  invades the top of the nail plate directly and causes a white, pitting effect. Less common variations  can cause complete destruction of the nail matrix, but it is worth remembering that  any one person can display a combination of all types and once one nail becomes infected, it can easily spread to the others.

Any fungus likes a warm, dark and moist environment and, these are the conditions you offer your feet when they are constantly encased in footwear.  Of course, the fungus needs to be present in the first instance , but it can be easily picked up from other warm and moist areas such as swimming pool changing areas and shower rooms. Once present, a fungus can survive in footwear  for up to six months. It usually enters the skin through small cuts  or through small separations between the nail and the nail bed.

People with poor circulation, those with diabetes and those with a weakened immune system should take extra care as they are more vulnerable to fungal nail infections.

Two dermatophytes are responsible for around 90% of all fungal infections. Trichophyton rubrum  is usually responsible for the fungus which progresses from the end of the nail towards the half moon, whereas Trichophyton mentagrophytes  is more often associated with the superficial white areas attacking the nail plate. An infection which starts at the 'half moon' moving towards the free edge is usually caused by non-dermatophyte moulds.

At first, a fungal infection will probably not cause any problems other than cosmetic changes in the nail, but it is possible that in severe cases they can become very uncomfortable and even  painful as the nail thickens and causes inflammation of the nail bed.

Treatment can be topical or systemic or both. There are obvious problems associated with any systemic medication and so the first line of treatment is usually topical. As the nail has a very hard top layer, it is advisable to file the nail to enable the antifungal agent to penetrate the nail plate more easily.  Research has also found that applying a urea cream to the nail prior to the antifungal lacquer, allows for better penetration and better results.

                                                                                                                            

 Progress of any treatment is slow. As a toenail grows on average 1.5 - 2mm per month, it can be disheartening when there appears to be little improvement after diligent treatment.  It is important to recognise that the affected part of the  nail will not improve in appearance, but as the yellow and white areas grow and are cut away, new growth should look nice and clear. Complete resolution can take around a year to eighteen months.

Perseverance is paramount. Application of the treatment must be carried out every day, preferably twice a day; alongside allowing the feet to breathe without permanently wearing occlusive footwear.

New therapies are becoming more widely available, such as laser treatment and aromatherapy products.

Body Essentials have developed an aromatherapy product for the treatment of fungal nails, Nourish Your Nails. This has been well reviewed and is definitley worth trying. If your nails are yellowed or if you think you may have a fungal infection in your nails, Nourish your Nails will gently lighten and brighten the nail plate.

Bursitis

Bursae are fluid filled sacs which help protect particular structures of the body from friction. In the foot there is only one naturally occurring bursa which lies between the Achilles tendon at the back of the heel and the heel bone (calcaneus). It helps the tendon slide easily over the bone.

Feet are constantly undergoing repeated stresses during walking and other normal activities. These stresses are compounded by ill fitting shoes. With every step, the pressures and shearing stresses upon the feet cause damage and the body responds by forming bursae. As a consequence there are many bursae on the feet. Again, their purpose is to protect the structures from further damage.

Common sites for these include over the big toe joint, commonly mistaken for a 'bunion' and over the tops of the toes.

From time to time. these bursae become inflamed due to even more pressure or trauma and produce the painful condition known as bursitis.

Bursitis may occur as a result of exposure to cold weather or injury during contact sports. The bursae may also be irritated as a result of any direct trauma, inadequate 'warming up' prior to exercise or excessive repeated exercise as in long distance running. They may be due to friction from a shoe.

 The naturally occurring bursa behind the heel often becomes inflamed in this way, due to the heel counter of a shoe rubbing against it. This is called Haglunds Deformity and is most common amongst females.

Pain occurs as a protective mechanism to warn you to stop doing whatever it is that is causing the pain, to prevent further destruction.  This is not always very easy, or practical. Try the obvious things first and attempt to reduce the inflammation with ice therapy and find some footwear that is comfortable.  Often, immobilising the affected area with some strapping (tape) may reduce the friction. Padded socks or soft gel toe protectors often relieve the symptoms.

If the pain refuses to subside, there may be an infection, arthritis or gout and a visit to your GP or a podiatrist will help to identify the problem.

 A biomechanical assessment may provide evidence of walking difficulties as a causative factor of bursitis, and corrective insoles could prevent the painful condition. 

Ingrown Toenails

The very thought of a true ingrown toenail is enough to my toes curl! (More on curly toes later!)  It is a very painful condition and by the time a patient seeks help, it is often very inflamed and even infected.

Some people are prone to ingrown toenails, due to the natural shape and condition of the nail plate. Others are unlucky enough to suffer trauma to the nail, which causes it to ingrow.

If your nails are very 'tight', almost like a staple, they are possibly 'involuted'.  This type of nail is often inherited and extremely difficult to cut.

 Attempts to cut these nails may leave small spikes down the sides and, unfortunately, they only become apparent when they start causing pain.  The spike of nail literally grows into the flesh at the side, in the sulcus. At first it is only a slight irritation, but very quickly it rubs, pierces the skin and sets up an inflammatory response. As there is a lot of bacteria present, both in and around the nail, it soon becomes infected.

The skin is an incredible organ and as we all know, makes every attempt to heal itself.  Ingrown toenails are no exception.  The inflammatory response encourages the body to repair the skin break, delivering more blood to the area.  The next stage of the healing process is granulation of the wound. This is when a matrix is laid down in the wound for new capillaries to grow.

With a spike of nail present, the wound can't heal.  The body reacts to this by trying to 'reject' the foreign object and produces more granulation tissue, until there is 'hypergranulation' tissue. 

This is a lump which rises above the level of the surrounding skin.  It isn't painful itself, but it does bleed very easily due to the number of blood vessels present.  This is the stage when people usually seek help as looks quite alarming in addition to the pain.

Your GP will often prescribe antibiotics for this, which will help if there is a bacterial infection present, but will not resolve the problem. The only way to 'cure' the ingrown toenail is to have the spike removed.

This is not as painful as it sounds, even if the toe is very sore. An experienced podiatrist can resolve the problem in a matter of minutes, once the location of the spike has been found.

Once the spike has been removed, relief is immediate. The hypergranulation tissue will usually shrink back within hours and the toe will heal completely within days. 

A very easy resolution to a very painful condition!

Incidentally, the medical term for an ingrown toenail is 'onychocryptosis'. A very suitable name for a condition which is crippling.

So, if you think you have left a spike of nail when trimming your nails or have knocked your nail and think it may have split, hot foot it to your podiatrist who will sort you out in no time :)