Toes are funny things. I’m not saying they aren’t important: they help us fill out our socks and that should count for something. In all seriousness, toes aid in propelling the human body forward. Because of this, they are vital to us since that means toes help us walk. But they can be the source of significant pain and pathology.

There isn’t space in this publication to describe the variety of conditions that occur to the human toe, cramped and abused inside a shoe. As you might imagine, the inside of a shoe is a breeding ground for a variety of pathogens. A particularly common complication develops when there is recurrent, localized pressure to a small area of skin on a digit. The skin thickens and calluses, the latter due to an increase in production of the outer layers of our integument. This is a natural process that provides our bodies with some protection against injury.

This would seem to be a protective mechanism which eventually goes bad. With the passage of time, voila, one has developed what the layman calls a corn. These often start as merely unsightly but, as is often the case in medicine, these kinds of problems often worsen. Whatever the source of pressure may be, with time, the skin learns to make callus better.

There are a multitude of causes for these lesions, from bent toes, aka hammertoes, to a bone spur forming on a toe joint. How about a neighboring toe that is moving out of position, as with a bunion deformity where the great toe is sliding over towards the second. Again, chronic pressure is exerted on the skin, leading to these changes, specifically a callus, thickening of the skin, and eventually a painful corn.

Predictably, many factors affect this process. Some people inherit a skin type which is prone to callus formation. Less pressure or irritation is required in these individuals to form extra callus tissue. When skin is poorly hydrated, callus formation is enhanced. Someone who uses a moisturizer regularly is going to have less build-up than another, all other factors being equal. But these products vary greatly in their components and so their effectiveness. Bold claims in an ad often have no relation to actual benefits.

Trauma can be traumatic without occurring in a moment. The term used for trauma occurring over time, or on a recurrent basis, is called ‘repetitive microtrauma.’ And this will frequently lead to inflammation when soft tissues, structures like skin, capillaries, ligaments, tendons, are the recipients of these forces. Most people have some familiarity with the hallmarks of acute inflammation, redness, swelling, pain, heat. These findings can frequently be seen surrounding the prominent callus of a corn.

Although not equal to the fingers, the distribution of sensory nerves is quite high in the skin of these small appendages. This explains why significant pain can be produced by such a small, seemingly inconsequential lesion. Not infrequently, a nerve will become caught up in the inflammation, and a whole new type of pain may be noted, sometimes a burning or shooting pain. Nerves don’t like pressure and they will let you know it when there is.

Alternatively and quite different is the development of infection. The space between the toes tends to harbor some virulent and dangerous bacteria. Moisture can accumulate, which will soften the skin and can lead to bacterial invasion. This is not an uncommon occurrence, although, once again, a multitude of

factors must come into play since not every corn gets infected. But when they do, these are associated with significant morbidity.

Depending on the individual, the pressure and inflammation associated with a corn can result in tissue ischemia, meaning inadequate blood flow, to the skin under the callus. Skin death can result, meaning an open sore, an ulcer, is produced. Due to the (often) years of trauma (generally of the repetitive microtrauma variety), healing can be very difficult since the skin is no longer healthy.

As should be predictable, numerous treatments are available, although arriving at a real solution is less common. A lack of appropriate medical attention is usually the greatest obstacle. As mentioned, there are certainly many individuals who experience relief with the use of a different type of shoe. Padding of some sort is a typical “home” remedy but leads to varying degrees of relief. Some of these have an acid meant to eat away at the callus which can just as easily chew up skin.

When sufficient callus is produced, trimming, aka debridement, when performed by a healthcare provider, can reduce the mass of material pressuring the skin and nerves. When someone takes it upon themselves to perform this, the results can vary. Rather than relief, too often a self-inflicted injury occurs. When thoroughly debrided, the pain will be decreased. But since this isn’t addressing the cause of the pressure, recurrence is pretty much guaranteed (unless some other change is manifested).

A hammertoe, i.e. one that is bent down, may elicit callus production at the deformed joint. Many surgical procedures exist to straighten a curled digit, some of them extremely simple and straightforward. When the cause is a bone spur, removing the prominence solves the problem. A natural concern here regards healing: some procedures are more traumatic than others, requiring more blood to heal.

Many Americans have a callused lesion of this type but suffer little. How to know if yours will become a more notable condition demanding your attention? These often take years to develop into something more serious and yet are easier to treat early in the process. You know the cliché “an ounce of prevention, etc, etc.” If you have an inkling yours is worsening in some way, have it checked out. Maybe it’s a corn that can be resolved? Or maybe it’s something else!?