Nail injury due to hyperextension

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Hi everyone,

Would appreciate any views advice on a patient that I'm seeing,
70 yr old very fit and healthy male, high activity in that he walks up and down mountains! He has done the lot himilayers etc, he has no problems apart from trauma to his big toenails - which ultimately become painful and eventually fall off. Both are slightly onycauxic but not gryphotic. Nothing untoward foot posture wise, there is slight equinus approx 5-7 degrees dorsiflexion both soleus and gastrocs, all lower limb muscles 5/5 when testing resisted power, there is extensor substitution with hyper extension of both hallux swing-heel strike.

The patient believes that most of the problems happen on descent, so there is obviously trauma whether it be from the hyperextension or anterior slippage in his boots. It is difficult to check the sizing of his boots as they are specialised walking boots which take cramp ons etc so are solid at the toe box. He says that he gets measured in Cotswolds and gets the boots ordered.

I have given him a stretch regime, and given toe flex exercises to try and address the extensor substitution but not sure how much impact this will have.

If anyone has any other ideas or ways of reducing the hyperextension I would really appreciate it

Thanks all

Bartypb

 

I have treated something like that in the past.
In the beginning i just showed the patient how to tape the toe slightly into plantairflexion. This already helped but was just temporary.
Some other thing that helped was a small element in the front part of the inlay.
Just under the interphalangeale joint of the hallux i made one element of shore 40 to push it up and you see the distal phalangeale joint go into plantairflexion. He didn't got no injured nails anymore.
Hope this can help.

 

I've had similar cases with mountain athletes, and most effective has always been the ultimate complete removal phenolization nail of his first finger.
Reminding the premise that prior to the fall, first tighten the laces of his boots, but at his age, I should have learned.
Sincerely

 

It seems possible that he is descending on dirt as he would on ice with the crampons. As mentioned above if the boot are laced so that the foot does not slide into the front of the toe box and he put the toe down first when descending on dirt, that might prevent the reflex bringing the toe up against the toe box.