What do toenails have in common with Rams and Rhinos? 

You might wonder what rams, rhinos and feet have in common. Unlike the elephant tusk, which is made of similar material to teeth, the rhino horn, and that of many animals, comes from the same protein found covering skin. While fingernails have the power of a weapon, toenails are just tucked away and unnoticed. Because nails are hidden away until a problem arises, they are ignored. Nails are exposed in sandals where the climate is warmer, and nails and toes are more visible. But for us, in the UK, the majority of feet are covered up. This article is on the subject of thick nails associated with medical problems. Yuck, you might say..

You might wonder what the point of toenails is, not least why they cause problems. These densely packed cells make up a flat structure that sits at the end of the toe over a bone called a phalanx and is exposed to pressure. Now, if you had an impressive horn like our rhino, maybe it would make sense as a weapon. The nail might act as a deterrent if pointed, and as a child aged 7, I still can recall the burning pain caused when I upset a girl my age, and she raked my nose with her sharp nails!  Otherwise, as a piece of flat nail, it seems pointless. 

 

Growth

Nail growth is slow at around 0.1mm a day and is exposed to damage along its sensitive ‘growth cells’ called the nail matrix. The matrix is shown in red, but the cells in the lunula region (marked) are sensitive to damage. The white-coloured lunula is named after its half-moon shape. The other part of the nail bed, easily exposed to injury, sits at the end of the nail (hyponychium). The attachment is sensitive to damage, and if you, like me, have wrenched a fingernail before, then you will understand how uncomfortable this is.

Early damage in childhood

Many of us have a damaged little toenail. This often arises when those first pair of shoes are fitted in early childhood. At a young age, a tight shoe will lead to permanent damage. As we age, nails are more resistant, but damage from sports or other activities can lead to damage. Podiatrists talk about case histories, a diarised form of storytelling covering the progress of a condition. As podiatrists, we concentrate on nail health and prevent tissue damage and pain. You can read my post on footwear fitting click here.

Case History: the damaged nail

 

 

 

 

 

Damage after a short walk

After a sixty-minute walk in light trainer-type shoes, the fourth toenail of a man appeared dark and then went clear after a few weeks. He reasoned this was the cause of his pain, and indeed it was (Figure 2a). The nail is a solid structure made from three distinct layers to look like one. The third toe and nail are normal, but the darkness seen with the 4th toenail is blood under the nail. This is called a blood pool, which goes hard and is called a haematoma. The simple act of walking 3 miles allowed the toe to piston back and forward in the shoe. This tore the small blood vessels between the nail and the softer nail bed. Podiatrists call this a sub-ungual haematoma. Sub-ungual infers under the nail.  Five months later, the nail looked as shown in Figure 2b. The nail had distorted, creating a thicker roof and separation. With careful trimming, the nail settled with new growth.

Nail damage does not always have to be permanent. Even a child with tight shoes can have a permanent deformity. Repetitive damage in adults causes the same problem. It is important to ensure the shoe is used for the right task, fits well, and does not move back and forth.

Other medical concerns with nails. Read on… click here

I treated a lovely lady for many years, passed on to me by her cancer specialist (oncologist), who would not let anyone other than me deal with her. The cancer drugs damaged her nails, and in the early stages, the medications used put her at risk of poor healing. Her nails were deformed, discoloured and separated, so a large cavern appeared, causing a build-up of soft debris.

Occasionally, patients develop bad habits and destroy their nails by picking them (onychotillomania). The nail can shrink with thickness or can form cracks and distortions. The most impressive of all nails are those associated with the shape of a ram’s horn and are actually called ram horn nails. The figures above are rather self-evident. The nail has a series of ridges better known in medical circles as onychogryphosis. Management is rewarding, and after 20 minutes, a nail can be made to look presentable. Although rarer today, these are satisfying to treat because most medical doctors would be shocked at their appearance, let alone know where to start. The temptation might even be to ask the vet to look!

Having taught a module on onychology, not to be confused with oncology (cancer speciality), the ingrowing toenail, the fifth commonest referral from the GP, is often of more interest. Some nails affect mobility to the point of disability, and this is why, in old age, foot health care is provided for all when required. With the sad loss of funding in the NHS for elderly foot health care, many have to turn to private means, and often non-podiatrists are employed. While this might be fine for nails that you or I could cut as laypeople, the more difficult nails need specialist care and training. 

 

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Thanks for reading, ‘Thick Toenails’ by David R. Tollafield