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Managing Common Nail Disorders in Active Patients and Athletes

Elizabeth L. Tanzi, MD; Richard K. Scher, MD


In Brief: Sports-related acute nail trauma can cause subungual hematoma and pain, which can be alleviated by fluid evacuation; the differential diagnosis includes subungual melanoma. A careful history will help distinguish splinter hemorrhages related to systemic disease from those caused by trauma. Chronic trauma can damage the nail matrix, leading to longitudinal splits or ridging, pigmentary changes, pterygium, or dystrophy. Mildly ingrown toenails can be treated with cotton placed under the lateral nail edges and proper trimming; severe cases may require surgery. Treatment of acute paronychia includes systemic antibiotics, while chronic paronychia may require topical or systemic antifungal agents.

Nails are cosmetically important for many patients, and fingernails enhance fine touch and facilitate the manipulation of small objects, but the primary function of the human nail is to protect the underlying digit. This protective layer can fail, especially in athletes, because the nails' distal location makes them vulnerable to sports-related injury. Compared with other injuries commonly seen in athletes, such as fractures or tendinitis, nail pathologies may seem unimportant. If neglected, however, these disorders can impede performance or even incapacitate an athlete.

The nail disorders that affect active patients and athletes are usually related to acute injury, chronic or repetitive stresses, climatic conditions, infection, or improper care. Familiarity with normal nail anatomy can help physicians understand the origins of these disorders and facilitate evaluation and management.

Nail Anatomy

The nail apparatus is composed of several parts, including the nail matrix, bed, and plate, the hyponychium, and the surrounding proximal and lateral nail folds (figure 1). The largest structure is the nail plate. Since it is generated at the nail matrix, which lies beneath the proximal nail fold, injury to the matrix may result in significant nail dystrophy. Underlying the proximal part of the nail plate is the white lunula, which is the distal portion of the nail matrix. Where the lunula ends, the nail bed begins. It is composed of vascularized epithelium that is longitudinally ridged in parallel alignment and extends distally to the hyponychium, where the nail plate separates from the nail bed. The proximal and lateral nail folds frame the nail; the cuticle is the keratinized border of the proximal nail fold (1,2).

[Figure 1]

Acute Effects of Trauma

Subungual hematoma. One of the most common manifestations of trauma to the nail unit is a subungual hematoma. An acute subungual accumulation of blood is usually caused by a sudden blunt impact, most often to the great toenail. When the hemorrhage is extensive, it may be exquisitely painful and lead to shedding of the nail plate (3).

Sport-specific patterns. Trauma resulting in subungual hematoma in specific toes is more common in certain sports than others. Sports that require frequent, abrupt stops and quick pivoting, such as basketball, tennis, squash, and racquetball, can lead to hemorrhage of the lateral nail bed because of jamming of the toe into the front of the shoe. This type of hemorrhage (figure 2), known as "tennis toe" or "sportsman's toe," usually affects the nail of the hallux or second toe, depending on which is longer (4,5), and is more common on the lateral than the medial side of the nail. The subungual hematoma in "jogger's toe" most often involves the third, fourth, and fifth toes and may be caused by the constant pounding of the foot on a firm running surface (6). Soccer and football players are more likely to develop hematoma in the nails of the second and third toes because of the way they kick the ball.

[Figure 2]

Although these are typical injury patterns, injury to any nail may occur in any athletic activity (2). Keeping the nails trimmed will help prevent trauma that can damage the nail bed.

Treatment. The treatment of a rapidly expanding subungual hematoma involves puncturing the nail plate with a hot, pointed instrument such as a thermal cautery unit, heated paperclip, or a drill designed for this purpose. This technique relieves pain and may, if done promptly, save the nail (7). When the hematoma involves more than 25% of the visible nail, anteroposterior, lateral, and oblique radiographs should be obtained to investigate the possibility of an underlying fracture (8). Observation is appropriate for less acute cases.

Differential diagnosis. The most important entity to consider in the differential diagnosis is a subungual melanoma, which represents about 2% of all melanomas and accounts for a great proportion of melanomas in nonwhite persons. A significant percentage of patients who have a subungual melanoma have a history of trauma, so a history alone is insufficient for diagnosis. If the cause of the nail discoloration is in question, a biopsy is mandatory. Since subungual melanoma is generally associated with a poor prognosis and early metastasis, a timely diagnosis is of the utmost importance (9).

Splinter hemorrhage. Splinter hemorrhages, which look like what the name suggests, may also be a manifestation of acute trauma to toenails and fingernails, though they are more common in fingernails. They usually arise from a single blow but can also result from repeated minor stresses. They occur when blood from small hemorrhages in the nail bed is trapped in the longitudinal grooves of the nail plate and ridges of the vascular nail bed; the trapped blood then moves distally with the nail plate. Splinter hemorrhages are frequently associated with tennis, jogging, or hockey, but less vigorous activities such as golf and catching a Frisbee can also cause this condition (10,11). Keeping the nails trimmed can help prevent these hemorrhages.

The occasional single splinter hemorrhage, often found in the fingernails of healthy patients, is insignificant (12). However, splinter hemorrhages may also be related to important systemic disease, such as systemic lupus erythematosus and subacute bacterial endocarditis, as well as primary nail disorders, such as onychomycosis or psoriasis. Unnecessary diagnostic testing can be avoided by a careful history, including sports, occupational, and other activities that may traumatize the nails, to help distinguish splinter hemorrhages linked to systemic disease from those related to trauma.

Delayed Effects and Chronic Injuries

Numerous nail deformities develop well after acute injuries or as a result of repeated minor stresses, which are often related to sport-specific activities and conditions. Well-fitting shoes and nail trimming can help prevent these deformities.

Ridging. If the nail matrix is damaged by a single trauma or repetitive impacts, permanent changes in the nail plate may manifest as a longitudinal split or ridge extending the length of the nail. Professional soccer players are prone to transverse ridging of the toenails, especially those of the hallux (figure 3). When the nail plate extends beyond the tip of the toe, the full impact of repeatedly kicking the ball is absorbed by the nail plate and transferred to the matrix. When this occurs, the growth of the nail is changed, and the trauma manifests as ridges across the horizontal span of the nail plate. If significant injury and malpositioning of part of the nail matrix occurs, a permanent ectopic nail may result (13).

[Figure 3]

Pigment changes. Injury to the nail matrix has also been associated with pigmentary changes. Those who practice karate, which can involve sharp, quick blows to the fingernails, may develop multiple transverse white bands with normal pink nail between and no other signs or symptoms. These bands are a result of temporary interference with normal keratinocyte formation in the midportion of the nail matrix and disappear after the offending activity is discontinued.

Pterygium. If the nail matrix is focally destroyed in a significant, forceful injury, a pterygium may develop. When the damaged nail matrix can no longer produce the nail plate, the proximal nail fold fuses to the nail bed, and they grow out to form a permanent, wing-like deformity. Correcting this disorder may require surgery, which is done for cosmetic reasons.

Dystrophy. Chronic, repeated injury to the nail unit can cause significant onychodystrophy (a malformed nail plate), especially in athletes who wear tight-fitting shoes or equipment (figure 4). Hockey players and professional figure skaters are particularly at risk for this type of nail disorder. Thickening of the nail plate (onychauxis) commonly develops in patients who have worn tight-fitting skates for extended periods. In severe cases, these patients may develop pincer nail deformity, a transverse overcurvature of the nail plate, leading to impingement on the nail bed and, possibly, excruciating pain. This condition often requires surgery (2,13).

[Figure 4]

Nontraumatic Conditions

Ingrown nails. Ingrown toenails usually involve the hallux and are caused by improper cutting of the lateral edge of the nail and the pressure of tight-fitting shoes. Inflammation of the lateral nail fold may be the result of a reaction to a foreign body or of an infection.

Treatment depends on the severity of the ingrown toenail. Mild cases can usually be resolved by trimming the nail so that the edges are beyond the soft tissue; if necessary, placing cotton beneath the lateral edges of the nail (figure 5) can help them to grow up and over the soft tissue. Occasionally the portion of the nail plate that is growing into the underlying tissue requires surgical removal. If left untreated, ingrown nails may induce granulation tissue at the lateral nail fold, and infection may occur (14,15).

[Figure 5]

Paronychia. Paronychia (inflammation of the nail fold) may be infectious or noninfectious and is common in athletes. Acute paronychia (figure 6), most often caused by Staphylococcus aureus or beta-hemolytic streptococci, is characterized by edema, erythema, and pain. It may follow a minor trauma or may be the result of an infected ingrown toenail. If it is diagnosed early, treatment involves systemic broad-spectrum antibiotics; otherwise, partial removal of the proximal nail plate may be required.

[Figure 6]

Active patients are also at risk for subacute and chronic paronychia because of the moist environment created by athletic footwear. The initial insult is maceration, followed by infection with Candida species. Chronic paronychia is characteristically less painful and erythematous and has a more indolent course than the acute bacterial type.

These fungal infections may be difficult to eradicate. Topical broad-spectrum antifungal medications such as clotrimazole and sulconazole nitrate in solution are helpful; ketoconazole cream may also be used. These medications should be applied two to three times a day. For more resistant cases, oral ketoconazole, itraconazole, or fluconazole may be prescribed.

Although a wide variety of topical and systemic medications is available for the treatment of chronic paronychia, avoiding predisposing conditions such as excessive moisture and cutting nails properly are the keys to effective treatment (16).

Timely Treatment

The activities and equipment of many sports predispose athletes and active persons to nail disorders. Most of these are the result of acute or chronic trauma, but infection can also cause problems. Fortunately, a thorough history of a patient's activities can guide appropriate and timely treatment of common nail disorders and allow active patients and athletes to continue to exercise.


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Dr Tanzi practices in the Department of Dermatology at St Luke's/Roosevelt Hospital Center in New York City. Dr Scher is a professor of clinical dermatology at Columbia Presbyterian Medical Center in New York City and a fellow of the American College of Physicians. Address correspondence to Elizabeth L. Tanzi, MD, 16-66 Bell Blvd, Apt 631, Bayside, NY 11360; address e-mail to [email protected].