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Imaging Quiz Answer

Running-Related Toenail Abnormality

Brian B. Adams, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 13 - DECEMBER 1999


Diagnosis

Return to case presentation.

The patient was diagnosed as having jogger's toe (figure 2). The condition results from the constant pounding of toes in the shoe toe box and can lead to characteristic subungual hemorrhage, edema, erythema, and onycholysis.

[Figure 2]

Treatment. The patient was counseled to obtain running shoes with a larger toe box and to keep his nails cut properly (see below). No follow-up was available regarding these interventions.

Discussion

Sports-related nail abnormalities result from constant trauma to the nail bed, plate, or matrix (1-10). Different activities lead to variable nail dystrophies. Specific nail changes have been reported not only in runners, as described below (1-10), but also in basketball (7), soccer (6,7), tennis (1-3,8-10), and football players (6,7). Jogger's toe occurs as the result of constant slamming of the toe into the toe box (4). The original report of the condition (4) described erythema, edema, onycholysis, and subungual hemorrhage on the lateral aspects of the third, fourth, and fifth toes. Periungual vesicles and bullae have also been reported (7). Ill-fitted shoes play a major role in predisposing the athlete to this condition (4,7). (See the Exercise Adviser: "How to Buy Shoes," November, page 133.) Interestingly, this patient, who had classic findings of onycholysis and subungual hemorrhage, also demonstrated a callus on the skin distal to the affected nail. The findings are unusual because the second toe was affected rather than the last three toenails as is usually found.

Jogger's toe may be confused clinically with several other nail disorders including onychomycosis, subungual malignant melanoma, and other melanocytic neoplasms. Tinea unguium can be differentiated clinically from jogger's toe; the former usually involves subungual hyperkeratosis and a yellowish discoloration. Fungal culture and potassium hydroxide examination serve as confirmatory tests. A history of athletic involvement and consequent nail trauma is paramount in differentiating jogger's toe from benign and malignant melanocytic neoplasms. In contrast to jogger's toe, subungual melanomas may also produce discoloration of not only the nail plate but also the proximal nail fold (Hutchinson's sign). If melanoma is suspected, lesions require biopsy.

Jogger's toe has been reported to resolve with or without treatment (4). To prevent nail abnormalities caused by running, athletes should make sure that their shoes fit properly and have adequate space in the toe box (7). Furthermore, nail hygiene is important. Improperly cut nail plates can result in undue forces on the nail and cause damage to the surrounding nail structures. To avoid excess force on the nail components, nails should be cut regularly and straight without curving the lateral nail plates. (For more on management of jogger's toe and similar disorders, see "Managing Common Nail Disorders in Active Patients and Athletes," September, page 35.)

Finally, orthotic devices may be needed to keep the forefoot from slamming into the toe box. Simple orthotic devices may be obtained at sporting goods stores and pharmacies and can be placed in the heel of the shoe to improve fit. Referral to a podiatrist may be necessary if over-the-counter devices are ineffective.

Running is not the only sport associated with nail disorders. Football players have been reported to have onychoptosis defluvium (6). The nail plates in soccer players may receive most of the force during kicks, resulting in transverse ridging (6), onycholysis, or nail avulsion (7). Dancers are also at risk for multiple nail abnormalities including distal toe callus, subungual exostosis, and onychocryptosis (ingrown nails) (5). Basketball players also sustain various nail changes as a result of their athletic activity (7).

The most documented nail disorder in athletes is tennis toe (1-3,8-10). This condition is characterized by subungual hemorrhage most likely caused by rapid stops after quick accelerations during play. The toe is slammed rapidly and forcefully into the toe box, resulting in capillary rupture (3). As in prevention for jogger's toe, proper nail hygiene and appropriate shoe sizing are important to guard against other sports-related toe disorders.

References

  1. Roth HV: 'Tennis toe.' J Am Podiatry Assoc 1973;63(2):76
  2. Gibbs RC: 'Tennis Toe.' Arch Dermatol 1973;107(6):918
  3. Gibbs RC: Tennis toe, letter. JAMA 1974;228(1):24
  4. Scher RK: Jogger's toe. Int J Dermatol 1978;17(9):719-720
  5. Howse J: Disorders of the great toe in dancers. Clin Sport Med 120213;2(3):499-505
  6. Mortimer PS, Dawber RP: Trauma of the nail unit including occupational sports injuries. Dermatol Clin 120215;3(3):415-420
  7. Rzonca EC, Lupo PJ: Pedal nail pathology: biomechanical implications. Clin Podiatr Med Surg 120219;6(2):327-337
  8. Eisele SA: Conditions of the toenails. Orthop Clin North Am 1994;25(1):183-188
  9. Hutchinson MR, Laprade RF, Burnett QM 2nd, et al: Injury surveillance at the USTA Boys' Tennis Championships: a 6-yr study. Med Sci Sports Exerc 1995;27(6):826-830
  10. Basler RSW, Garcia MA: Acing common skin problems in tennis players. Phys Sportsmed 192021;26(12):37-44

Dr Adams is an assistant professor in the department of dermatology at the University of Cincinnati College of Medicine and chief of dermatology at the Veterans Administration Medical Center in Cincinnati. Address correspondence to Brian B. Adams, MD, Dept of Dermatology, University of Cincinnati, College of Medicine, Box 670592, Cincinnati, OH 45267-0592; e-mail to: [email protected].


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