Got Toenail Troubles?

Toes can be a runner's weakest link. For some, it's the knees, for others, the back. And for many, the toes, or at least one of them, can be the problem that tortures an otherwise trouble-free runner. Any runner can get into toe trouble with the right (or wrong) conditions. From blisters, corns, and calluses to stress fractures and ingrowns, those cute little toes can become a big headache.

Toenails alone can be the source of a long list of troubles. Chief among the potential problems is the ingrown toenail--with or without infection. Other, not too pretty problems, are nail thickening due to fungal infections, black toenails due to repeated trauma, and of course other irritations, inflammations and infections. Here are just a few common causes of troubled toenails.

Ingrown Nails

You may be familiar with the warning, "Don't cut the nails too short." Trimming too short can cause the leading edge of the nail to grow forward and cause pressure on the soft tissue at the toe tip. Although this can happen, by far the more common cause of ingrown toenail, and the pain that goes with it, is the curvature of the nail into the tissue on both the medial (inner) and the lateral (next to the other toes) sides of the nail. You can get the picture by looking head-on at your thumbnail. From this vantage point, it looks as if the nail were clipped onto the top of the thumb. Toenails follow a similar curve.

If there is excessive pressure on the nail against the soft tissue from the forefoot of the shoe, problems can develop. Pressure on the side of the nail, where the toe touches the shoe, can push the soft tissue against the incurved edge of the nail. Then the toe gets inflamed, enlarges, and more pressure is felt on the toe. With enough pressure, the nail edge will break the skin surface allowing bacterial or fungal contamination into the toe, causing infection and even more swelling and pain. The warm sweaty environment of a running shoe makes an ideal site for proliferation of infection. Infection can spread around the rest of the nail, further increasing pressure and pain.

Using local antibiotics like bacitracin and antifungal creams may help, but it's hard to reverse an ingrown, infected nail without an office surgical procedure using local anesthesia. See your podiatrist! Never try to cut the nail "to relieve pressure" yourself. This is a recipe for disaster. It will heal faster and better with a smaller chance of recurrence if you see a podiatrist for treatment. Ingrown toenails do not lend themselves well to bathroom surgery.

Runner's Nail

Long distance runners and ballerinas both may be known for their athletic prowess and war-worn, beat up feet. Thickened toenails are so common among long distance runners, the condition has been dubbed, "Runner's Nail." The thickening and changes in color are caused by repetitive pressure of the shoe on the nail. The resulting thickening makes the nail even more vulnerable to additional problems since it is raised closer to the top of the shoe. These can be treated with a urea compound to soften the nail.

Fungal Toenails

A fungus (like the one that causes athlete's foot) can infect the nail and also cause thickening and discoloration of the toenail. This problem is distinguished from the Runner's Nail by infection. The fungus invades the nail when there is an injury or trauma, which may be so subtle you don't even know it is there. Once infected, a fungal nail is very difficult to treat. New laser therapy works, but prevention is a much better bet. If you notice changes in your toenails, see a podiatrist for diagnosis and treatment.

Black Toenails

Although you can get a black toenail from a sudden, painful trauma that causes bleeding under the nail, for runners it is more likely a chronic, repetitive trauma to the nail caused by short shoes, running downhill, or wearing loose shoes. This repeated micro-trauma causes only a light amount of bleeding and minimal pressure buildup, so little or no pain is felt. In many cases, you only realize this is happening when you notice your toe is discolored. But don't ignore it. The nail can gradually become thicker, and more problems develop.
Eliminate the cause of the irritation, and a new nail will gradually form. It takes six to nine months for a new nail to form, so be patient. If the nail thickens, you can file it down. If there is pressure and pain under the toenail, see a doctor. Drainage from a blackened nail can be a sign of melanoma and should not be ignored.

Why did that toe turn on you?

Trauma, either acute or chronic can contribute to all of these toenail troubles. Trauma--like stubbing a toe--can cause changes in the growth pattern of the nail and eventually it can cause thickening, discoloration, or infection. More often, excess pressure and repetitive trauma is caused by the mechanics of the foot inside the shoe.

Trauma can come from shoes that are too small or shoes that don't grab the midfoot firmly. If the shoe is too small, every step causes the toes to press against the front of the shoe. Tight shoes restrict blood supply to the toes, increasing the risk of infection. If the shoe doesn't grip the midfoot adequately, each time the shoe hits the ground and stops abruptly due to friction, the foot will slide forward unless it is firmly held in place inside the shoe. Momentum forces the foot forward inside the shoe until the toes collide with the front portion of the shoe.
It is important to prevent this sliding or pistoning of the foot inside the shoe. If the shoe comes up high enough on the front of the foot, it can help prevent the foot from sliding forward by holding it at the ankle. Most running shoes, however, don't come up high enough to be effective. In most cases, the lacing across the midfoot has to do the job. You can also glue extra tongue padding in the shoe for a tighter grip on the foot. The extra padding allows the laces to be tighter without pain. Both the padding and tight lacing stop the foot from sliding forward in the shoe.

The best way to prevent most of these problems is to get the right fit. Find a running shoe store where the employees are professionals who understand runners' needs and the differences in the shoes the sophisticated industry is producing. Shop late in the day or after a good run to allow for the natural swelling of the foot. Don't rely on street shoe size or assume that the size is the same from one shoe to the next. Try on both shoes, lace them firmly, and run. A good running shoe store will let you run up and down the block. Get a promise that you can return the shoes after several days of wear inside at home. Don't ever expect running shoes to "break in." They need to fit well from day one.

As you can see, toenail troubles are often from self inflicted trauma or trauma from shoes. If your toenail are looking funny or painful, see your podiatrist for answers to your toenail troubles.

Physical Education in Schools Severely Lacking!

Childhood Obesity in the News Again!

I was watching ESPN this morning while I was eating my breakfast. Yes, this is my usual morning routine as a sports junkie! A story came on that I felt compelled to share with my readers. It highlighted a cause that is near and dear to my heart: Childhood obesity. So many of my adult patients are obese and if we curb this trend in our children, they are much more likely to be healthier adults. As a parent, I make sure my children are as active and healthy as they can be. Obese parents tend to have obese children. We need to break the cycle.

Here are the highlights of this story:

There's a childhood obesity crisis in the country, virtually any expert will tell you, and there is no shortage of reasons: increasingly sedentary lifestyles driven by video games, television and computers; a fast-food society in which soda machines and greasy cafeteria food are ubiquitous in kids' lives; and dwindling opportunities for exercise, particularly during the school day.

Put simply, at a time when every penny is being pinched by every school in every district in every county in every state, physical education is taking a beating. The experts and educators say there is no doubt that the erosion of P.E. has been a major contributor to the skyrocketing obesity rates.

And, of course, the more kids are unhealthy, the less they can exercise. This is their circle of life.
The National Association for Sport & Physical Education -- a non-profit organization made up of P.E. teachers, coaches, athletic directors and other professionals advocating for physical activity -- says students should receive 150 minutes of P.E. per week.

How many schools actually meet this standard….almost none!

For the entire article and video click here.

Take home message: we cannot rely on our schools to provide physical activity for our children. As parents, we need to turn off the TV, video games, and computers. Make our children go outside and play. Make healthy play a family tradition. On cold, rainy days teach your children stretching, yoga, or get small dumbbells and do a strength workout with them. Make it fun and most of all…share it with them! This will make family time a healthy time! Memories are made of this and your child will thank you when they are a healthy adult sharing the same kind of family time with their children!

Toe Jams March Madness Bracketology

Even runners are watching March Madness right now. College basketball will have the nation riveted to their TV and discussing this year's Cinderella stories. The biggest health story of the tournament so far is the jammed big toe of North Carolina's Ty Lawson.

Wayne Ellington had 25 points for the Tar Heels (29-4), who led the entire way and had no trouble beating the 16th-seeded Highlanders in their opening game of the tourney, even with point guard Ty Lawson, who missed his third straight game with this toe injury.

Ellington’s day more than offset the loss of Lawson, who has been slow to recover from a jammed right big toe suffered in practice two days before the regular-season finale against Duke. Lawson played 36 minutes in that game, but the toe swelled unexpectedly the day after and forced him to miss both of the Tar Heels' ACC tournament games.

Lawson has said he is feeling better and battling more stiffness than pain, adding he thinks he'll play Saturday. Is this too soon? Will he be able to play up to his normal potential?

And more important to most readers at home, what does this do to the bracketology? Even President Obama has picked the Tarheels to win the national championships, but if Lawson is not 100%, can they win?? Many athletes who have suffered a jammed big toe (a.k.a. turf toe) will tell you it takes months to get over that kind of injury. Many a season has been tarnished by turf toe. The latest was the San Diego Charger’s LaDainian Tomlinson whose entire season was a disaster due to turf toe. Ask him, he will tell you what a pain in the toe!

What is turf toe?

Turf toe is a condition of pain in the base of the big toe. This usually caused from either traumatically jamming the toe, or pushing off repeatedly when running or jumping. The most common complaints are pain, stiffness and swelling. The pain can be so severe that pushing off in football is virtually impossible.This injury is especially common among athletes who play on artificial turf, hence the name “turf toe”. The hard surface combined with running, jumping and cutting in football and soccer, make turf toe a frequent injury. Some also blame the choice of athletic footwear. The more flexible shoes, especially used in competition, provide less support to the forefoot joints, possibly contributing to the incidence of turf toe.

How does turf toe occur?

When a player sustains a turf toe injury they are actually tearing the capsule that surrounds the joint at the base of the big toe. Tearing this joint capsule can be extremely painful. Furthermore, tear of the joint capsule can lead to significant instability and even dislocation of the joint at the base of the toe. This may lead to accelerated cartilage wear and arthritis of the big toe known as Hallux limitis or rigidus. This wear-and-tear arthritis can end a promising career prematurely.

How is turf toe diagnosed?

Turf toe is diagnosed based primarily on the physical examination of the patient. X-rays may be taken to ensure there is no fracture or evidence of arthritis. Occasionally an MRI is needed to evaluate the surrounding tendons or to rule out an occult stress fracture.

What is the treatment of turf toe?

Treatment of turf toe consists of trying to control the inflammation of the joint capsule. Treatment protocol can include:
1. Rest
2. Ice
3. Elevation
4. Taping or padding to off-weight the toe joint
5. Anti-inflammatories
6. And in chronic cases steroid injections to the joint may be helpful
7. Long term use of a functional foot orthotic to balance the forefoot in the athletic shoe is quite helpful.

Athletes diagnosed with turf toe should avoid stress to the joint for about three weeks to allow the joint capsule to heal. Once returning to activities, functional orthotics can be used to limit the motion of the big toe and prevent further damage to the joint capsule.

Will turf toe return?

Unfortunately, turf toe can return, often more severe than the initial injury, and rehabilitation may be very slow. Most athletes have trouble when they try to come back to sports too soon after sustaining a turf toe injury. Surgery is rarely needed for treatment of turf toe unless this has been a chronic injury and spurs are present in the joint limiting motion. If a bone spur has formed, and severely limits the motion of the toe joint, surgery to remove the spur may be helpful.

Prevention and early treatment is really the key! Unfortunately for the North Carolina men’s basketball team, recovery may be too late for a national championship; but you never know…..they call it Mrach Madness for a reason...anything can happen!

Girls on The Run Changes Lives and Relationships!

Girls on the Run in Southlake, TX

My 11-yr-old daughter, Alex, and I have been participating in “Girls on the Run” at her school, Durham Intermediate, in Southlake. The program has given us the opportunity to run together and share a moment in time that has been very special. She is learning more about her body and having open discussion about it with me! I encourage all women who run to share their love of exercise with their daughters. Fourth, Fifth and Sixth grade level is ideal.

Studies show that girls between the ages of eight and twelve are still receptive to adult influence, while beginning to feel peer pressure. It's an age psychologists call the latency period of development when girls begin to confront important life and relationship issues. As a prevention program, Girls on the Run initiates healthy decision making about difficult issues and really talking to their parents/caretakers before it's too late.

In addition, learning healthy exercise habits early in life increases the chances that participants will value their own physical fitness as adults. Recent studies show that only those who develop exercise habits in their teen years or earlier are likely to maintain those habits for life. It's well documented that regular, moderate exercise improves cardiovascular functioning, and reduces the risk of developing breast cancer, osteoporosis (brittle bones), and obesity. In addition, girls of this age are more open to the positive peer influences, positive adult role models and the confidence enhancing which are all parts of the GOTR experience.

Many moms have posed the question, “Is it safe for my young daughter to run that far?”

"Children's bodies are well suited for endurance exercise, and numerous studies have shown that children show many positive physiological adaptation to endurance exercise training. The keys are gradual progression and common-sense adult supervision. If those conditions are met, running 3 miles is a reasonable goal for most young people."

from Russell R. Pate, Ph.D. with the Department of Exercise Science at the University of South Carolina

If you are interested in the program, contact Girls on the Run. If you want to join us for the local race this year you can register on-line:

GOTR of DFW Metroplex
4/25/09 @ 8:00a.m. – New Balance Girls on the Run 5K
Address of Event:Andrew Brown Park W 360 N Denton Tapp Road Coppell, TX

Share your love of running with your child….it may make the difference of their lifetime!

Off-The-Shelf Arch Supports vs. Custom Orthotics: The Debate Continues

They are at it again. The debate that has been going on since the late 1970’s when custom orhtotics became the mainstay of treatment for plantar fasciitis. “Millions in Potential Health Care Savings: Prefab Orthotics Found More Effective” was a press release today from a company that...guess what?…makes an off-the-shelf arch support! Are you kidding me???

Now don’t get me wrong, I think there is a place for prefabricated arch supports in our treatment plans and not everyone needs a custom orthotic; but to say that prefab is BETTER than custom is ludicrous! Let's use common sense! They sited a poor study done in California on patients with plantar fasciitis and then backed it up with a totally flawed study from 1996! That’s all they have??? What about the millions of patients that have been helped by custom orthotics across the country? Several thousands right here in the Dallas/Fort Worth area!

Just another ploy to get patients to potentially waste their money on off-the-shelf inserts prior to visiting their podiatrist! A copay is much cheaper and I am so sick and tired of seeing peolpe waste hundreds of dollars on things they find on-line. Then spend months in physical therapy or even need surgery to try to conquer their plantar fasciitis; when they could have gotten better much faster IF the first thing they did was call the podiatrist!

I’m done venting, but for more information on why custom orthotics work check out my patient information pages.

Cowtown Marathon Teaches RunDoc to respect the Distance!

Cowtown Marathon kicked my butt! I'll admit it. I have again been humbled. It happens to all of us from time to time. I thought I was in good enough shape even though I had been lazy in my training lately. Too many things to do, not enough time. I was taught again to respect the distance. Yesterday's Cowtown Marathon in Fort Worth, TX was typical of the marathons I have run in the last two years: Freezing (25 degree wind chill factor), 30 mph wind in your face half the time, and added killer, rolling hills to the mix. I have not had good race karma. I thought White Rock Marathon in December was bad, but this was much worse and very hilly. For the record, I HATE COWTOWN! The last time I had run this race was in 1999. My peeps talked me into running it again because the Austin Marathon weekend timing didn't fit the schedule and this was closer to home. Never again....But truly it was not all the race's fault. It was poorly organized with random water stops and almost no spectators, but that's not why I had a bad day. I've been traveling too much, hadn't run enough (only one 20) and was mentally and physically tired. My absolutely wonderful running peep, Dr Steve Buksh, ran the whole way with me and should get a huge reward for not killing me when I started whining then ultimately crying (yes, that bad of a day). My hamstrings went into a seizure at about mile 16 from all the hills and we walked a good 2 or 3 miles. By 23 miles, I could barely run and looked like an epileptic. Definately not my day...but the lesson learned is to respect the distance. No matter how many times you have run 26.2 miles, it is still a formidable task and not for the weak or unprepared. The marathon humbled me yesterday and I learned my lesson....always respect the distance.

Now we can talk about delayed onset muscle soreness tomorrow when I can barely walk :)

Run Happy ....and respect the marathon or she will beat you into submission!