The Dreaded Purple Toe
Many runners will at some time develop a purple toenail, usually after long runs or races, particularly marathons, or after extensive downhill running. The medical term for this condition is a "subungual hematoma". A hematoma is a collection of blood, and subungual means beneath the nail. It comes from trauma to the nailbed, fragile tissue beneath the nail. With repeated blunt injury, such as frequent loading against the front end of the shoe, the nailbed begins to bleed. The area beneath the nail is a closed space, and any bleeding is contained within, and usually stops quickly as pressure builds. (Remember the rule of first aid, control bleeding with pressure.)
There is usually minimal, or no pain, at least initially, and the uninitiated runner will often be surprised at the sudden onset of color change. There is no rule that only one toe will be involved. I once saw a runner with nine purple toes after the NYC Marathon! The typical course is an increase in pain for 24-48 hours, of a variable degree, followed by resolution of pain, and probable loss of the nail from the affected toe in several weeks. Typically, the nail gradually grows back. In rare cases, the pain can be severe and incapacitating, and even necessitate a visit to the emergency room. Pain relief is easy to achieve, by draining the blood from beneath the nail and thereby relieving the pressure. The usual method is by heating a paper clip to "red hot" and burning a hole in the center of the nail. Stand back, the pressure can be so great as to create a bloody geyser! Pain relief is abrupt and dramatic. Secondary infections of these hematomas are very unusual, but drainage can increase the risk slightly. Signs of infection include progressive pain, redness, and swelling, all well beyond the local nail area.
The usual subungual hematoma needs little or no treatment. A brief rest period is helpful, during which twenty-minute soaks may be undertaken, accompanied by anti-inflammatory medications. Running can be resumed when pain and tenderness has resolved. If the nail falls off, a band-aid is helpful to protect the underlying sensitive nailbed. Avoid downhill running until pain is absent. If the nail does not fall off, the area of discoloration will tend to grow outward toward the tip of the toe. A word of caution, pigmented spots beneath a nail without prior trauma that enlarge and/or do not move must be evaluated by a doctor, as these may represent a melanoma, a form of cancer,
Like most other running injuries, training factors and footware are often partly responsible for the development of this condition. As noted previously, high mileage and downhill running contribute. However, tight shoes are the most common predisposing problem. A roomy toebox is one of the most important attributes of a proper fitting shoe. This is especially true in the runner with the so-called Mortonís foot. This type of foot has a long second ray, and hence second toe, which may extend beyond the first (great) toe. Many shoes are designed with the greatest depth built into the area for the great toe. A long second toe will impact the end of the shoe, particularly when going downhill. A thicker than normal sock can produce a similar effect.
Happy and healthy running! Dan Wnorowski, M.D.