Conway McLean, DPM

Quick, what body part is most out-of-sight? How about that which is farthest away? Have you ever wondered what part of your body is most confined? The answer is obvious: your toes! These apparently simple structures are hidden away from site and easy to ignore. They are the structures farthest from our eyes, boxed up inside a shoe, and rarely visualized.

Despite our ignorance of these important appendages, they can attract great attention when a problem develops. The number of painful conditions occurring in these digits is almost innumerable, from an irritated corn to an infected toe bone, a bent toe to the all-too-common ingrown nail. If examined over time, the abuse these particular digits receive is significant.

The average person takes about ten thousand steps a day, and the foot moves dramatically inside a shoe with each step. Thus, the friction, pressure, and subtle injury to the cutaneous structures (the skin and associated layers) is cumulatively tremendous. It should not be surprising many people develop pain from the digits of their feet.

Anatomically-speaking, the toes are endowed with a high concentration of nerve endings, not as much as the fingers, but close. Unfortunately, they tend to have very little in the way of a soft tissue interface, ie padding, those tissues protecting the skin from the hard, unyielding surface that is bone.

The consequences of pressure to the tissues overlying bone are multiple and sometime severe. Skin reacts to chronic pressure in some predictable but deleterious ways, although pain is often not an immediate part of this process. Many painful conditions affecting the toes become symptomatic only after years of use (and abuse).

One individual who was suffering from terrible toe pain comes to mind. The use of dressier shoes carries with it the dangers of a less anatomic toe box and this senior citizen certainly dressed well. Her shoes tended to the fashionable, resulting in recurrent pressure to the digits.

Over time, she developed a sore in between her little toe and the next. Unfortunately, this area has been found to harbor some particularly nasty bacteria, which, in this case, led to the development of a bone infection of the small toe, requiring surgery and a long course of antibiotics.

Obviously, wearing shoe gear is a necessity. It can also be a critical factor in the development of many toe problems. The manner in which many people choose their shoe gear, especially size, is often inappropriate, illogical and unhealthy. Many shoes sold today are poorly shaped or badly designed, marketed for their style but not function. Predictably, the result is a shoe causing small but significant recurrent pressure (aka trauma) to the superficial skin structures. Skin reacts to this localized pressure by going through a slow, predictable transformation.

The skin thickens, produces callus, which reliably adds to the pressure. Nerves become irritated and the local soft tissue inflamed. Sounds painful? It can make walking, as well as the wearing of any shoe gear, agonizing.

A consideration which often goes unappreciated is the amount of movement of the foot inside a shoe. Ambulation is a dynamic, complex process, with a host of changes occurring with each and every step. This naturally equates to motion of the toes inside a shoe, furthering traumatizing the skin structures. Certain shoe designs aid in better foot mechanics, while others do not. The result may increase stress and injury to these small appendages.

As stated, there are a multitude of toe problems that one may experience. Perhaps one of the most common is the development of bent toes, generally termed a hammertoe. Again, there are many different causes (although incorrectly sized shoes is rarely one of them).

Regardless, a toe that sticks up will tend to experience the aforementioned pressure and irritation to a much greater degree. Again, this oft-repeated process of pressure without padding leads to problems, specifically pain.

What of the health of these small members? As with all living tissue, blood supply is critical to the vitality of the skin and other structures. Those with arterial disease, a silent but progressive condition, will experience atrophy (thinning and weakening) of the skin. This means the skin is less healthy, less able to withstand the rigors of walking in shoes for those infamous ten thousand steps a day.

Unhealthy skin will crack, split or ulcerate much easier than if well supplied. The subsequent pathology, an ulcer, will not heal without enough of a blood supply. And the longer a wound of this type stays open, the more likely it will get infected.

A much different cause for chronic skin trauma to this region is from bone spurs. This is sometimes the result of an arthritic process. Yet, just as common, various irregularities of the contour of toe bones will result in mild but recurrent pressure. Unlike the finger bones, generally smooth and symmetrical, the phalanges of the feet tend to be “bumpy”, with various spikes and knobs. Depending on their location, these bony prominences can result, with time (ie the passing years), in piercing pain.

I have not even touched upon the many forms of nail pathology. Nor shall I, but instead mention an equally common problem: athlete’s foot infections. This condition, often found between the toes, is usually occult, meaning the afflicted individual is unaware of the contagion. Unless someone is carefully inspecting this particular region of their body, they won’t know of its presence. Tinea pedis, the aforementioned athlete’s foot infection, often won’t even cause itching, but can lead to a fissure, a crack in the skin. As mentioned, this space harbors some virulent bacteria. This opening can allow them access to deeper compartments of the foot, a dangerous, potentially limb-threatening situation.

Mentioned above are some common maladies affecting the digits of the lower extremity, but this is really the “tip of the iceberg”. What about blunt trauma, more commonly referred to as “stubbing your toe”? By the way, it is my duty to inform you, contrary to popular (and false) opinion, broken toes can be treated. Doing so speeds the healing process and reduces pain. And what about the ulcers that can develop at the tip of the toe when one has a hammertoe deformity.

Clearly, the toes can suffer from a multitude of problems. But many of these conditions are preventable or easily treated. Protect the toes (they’re called shoes) and care for them and they will continue to do their job of helping with balance and assisting in gait (the process of walking). Keep an eye out for abnormalities, and when pain develops get them looked at. Discussions pertaining to treatment options will follow in a future edition. The toes have their own special problems; they are unique structures performing a special task. Actually, they aren’t that unique: there are nine others!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.