In the absence of Christie the Wordsmith (referencing a segment from National Public Radio), we will define Nail Dystrophy in the second of two articles on the athlete’s nail problems. As you will recall from the last issue, ingrown toenails are a relatively common problem to all ages. Usually in the young, they are the result of improper trimming (thus leaving a "spicule" behind) or trauma (which splits the nail and part grows into the flesh). The term Dystrophy may apply to any part of the anatomic or physiologic system. Its roots mean (Latin from the Greek) BAD (dys-) NOURISHMENT (trophe).

Today the term is used less literally, and implies improper development (with accompanying degeneration from any fundamental abnormality). You may be familiar with the use of the word in the disorder, muscular dystrophy, an inherited condition of (usually) crippling weakness. Nail dystrophies are nowhere near as big a deal, but they are more common and may be of varied causes and nuisances to an athlete.

A nail dystrophy, inherited or acquired, may be the result of deformity or infection in any of the anatomical parts - nail matrix, nail bed, nail plate, nail fold or even the bone under the nail. It is a "catch all" term. We will describe some more common problems and suggested care.

Black Toenail

Runners and team players who sprint are prone to black toenail. The is really bleeding in the nail bed caused by pressure from your toes jamming against the inside of the shoe.

This "bruise" is similar to one you would get from hitting your thumbnail with a hammer, except it is caused by smaller, repetitive trauma. In the long run, once the pressue is gone, it may be very black and funny looking, but it is not a big concern. In the short run, the pressure from the trapped fluid (a blood blister, actually) may hurt a lot. If you are unable to live with or relieve the pressure yourself, you may wish to see a doctor who will provide that service for you. In the absence of pressure, and if no permanent damage was done to the nail matrix, the nail will eventually grow out without the black hue.

Thick Toenails

We’ll save you the anxiety provoked by reading (or hearing) the Latin name for this. Thick nails are often the result of pressure to the nail matrix. Just as skin calluses, the nail matrix produces a thicker ail in an attempt to relieve the pressure on a prominent area. The thickened nail plate may then pose extra pressure itself. Sometimes nails become like this from a single trauma to the nail matrix - like dropping a two-by-four on your toe - or from the same chronic jamming that promotes a black toenail.

Removing a thick (or black) toenail often gives the nail a chance to start a new, and be replaced with a normal looking nail. Usually, however, a thick toenail is there to stay. It should be trimmed and filed (for length and thickness), to avoid the consequences constant pressure can cause. If it is unmanageable, a pedicurist can be helpful. If there are underlying concerns (such as poor circulation or diabetes, for example), it is best to have a doctor provide the periodic care. Nails that are a particular nuisance can be removed permanently, and the nail bed will "toughen up" with a callus to provide protection in the absence of a nail.

Fungal Nails

A fungus is a microorganism, similar to bacteria or yeast, that just LOVES to reside in skin and nail beds. It is a fungus (one of many) which causes Athlete’s Foot. Similar fungi can invade the nail bed and matrix and cause dystrophic thick nails. These nails are thick and discolored, crumbly, and have "junk" (the medical term being subungual debris) underneath them. Often a fungus invades a susceptible nail - this is, one that’s been previously injured (black toenail) or one that has some amount of circulatory compromise. Many older individuals have fungal nails, as do serviceman and women who "live" in combat boots in less than desirable climates. Serious case of fungal nails can cause a complex cycle of skin nail re-infection.

Fungal nails themselves or nothing more than a nuisance. The pressure from their thickness and subungual debris needs to be relieved periodically with care (just as the uninfected thick nail does). Vitamin E oil and various fungiod tinctures from the pharmacy may help in the management, but it is rare to resolve advanced fungal nails. This is because the microorganism is a very slow grower and can linger for a long time while your nail is taking five to six months to grow from matrix to the tip of your toe. Oral medications often have side effects to your body that are much worse than living with fungal nails.

Incurvating Nails

The three dystrophies mentioned to this point are each probably caused by factors in the environment. Incurvating nails, however, may be a problem without a history of trauma or microorganism invasion. You may inherit the tendency for your nail plate, as you get older, to curve at the edges. As you can see from the diagram, this makes ingrown nails more likely. Also, the nail folds on either side are likely to callus in response to the constant pressure. This along with the incurvated nail itself can hurt even if the nail does not pierce through the flesh. The skin adjacent to the nail fold may need to be removed periodically (as would any callus or corn); a small (that is wee) bit of cotton or lambswool under the growing edge and corner of nail may help relieve recurrent pressure.

Bone Spur Under the Nail

Bone can spur in response to tugging (from plantar fascia as in a heel spur) or pressure (acute or recurrent trauma). Sometimes incurvated nails are accompanied by a bone spur under the nail. Usually the spur is from

• Constant jamming (so called tennis toe)
• Pressure (For example, when doing a job that requires kneeling all day, you knees and great toes take a lot of pressure.)
• Single injury (This may show-up years after something was dropped on the toe.)

The nail may be forced to grow "around" the protruding bone, hiding the underlying problem and appearing as would a truly incurvated nail. A test to distinguish the true case is performed as so: pressure directly over the nail (straight down) is more likely to hurt a spur. Pressure from side to side (squeeze) is more likely to hurt from an incurvated nail. X-rays will confirm the presence of a bony spur. Sometimes, the prominence is all or part cartilage which is not clearly seen on x-rays. If the presence of the spur hurts or causes recurrent ingrown nails, it can be relatively easily removed in the doctor’s office. Prognosis is good, and time of decreased activity is minimal.
Blisters and Warts

The nail skin interface at the nail fold is a site where other skin problems can arise. Blisters, caused by ill-fitting shoes (or the wrong shoe for the right sport), can arise adjacent to nails. If this a recurrent problem, the skin may toughen to the point of callus. Warts can affect any skin, and when they are in a nail fold, they may be particularly painful.

No one is immune to nail problems. Often they need only one time attention or low-key periodic care. Proper diagnosis and identification of any of these concerns is the first step. Attention to the symptoms, that is making you more comfortable, is the goal of treatment. Often CURING the dystrophy is not.

Written By: Elle J. Merkle, DPM

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