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Hi all,
I have just seen a patient who is in training for a marathon and is suffering from very large blisters under both 1st nails. It is quite painful and is stopping him train as hard as he wants to. I have asked him to come back with his trainers so I can check if there is enough room in the toe box. Both of his 1st distal phalanx are slightly dorsiflexed. I have not seen blisters like this before and was hoping for some advice on treating this. Thanks

 

Releasing the fluid under the nails and cutting them short should reduce the pain. Check the trainers for room. If need be remove the sockliner and replace with something thinner. Looking into the function of the first ray, Hyperextended distil phalanx tends to go with functional hallux limitus in my experience.

Could always suggest he tries barefoot running....

 

Silly question but how would I release the fluid? Am thinking scalpel slice through nail?

 

Ok Yvonne so if we break this down- the patient is getting irratation on the nail which is causing blisters, what would be the cause of this. 2 you have listed. One more I can think of subungal existosis (S?)

All of these are from pressure shoe to nail-nail to nail bed-Treat the blisters check to toe box for room. If the toes are sitting up and the shoe deformed, you may want to consider making a 1 cm cut in the shoe upper so the toe can sit up with less resistance from the shoe.

Hope that helps

 

Or If I have patients who get bleeding under the nail from running, get then to heat a sewing needle white hot, push it through the nail, works a charm.

 

A "slice" is probably the hard way. I'd go with a needle drill bit. myself.

The hot paperclip is the classic and I've used it on myself but I'm not sure if its an "approved treatment" if something goes wrong!

 

Since most subungual blisters/blood blisters extend to the anterior edge of the nail plate, I typically will use a #11 scalpel blade just under the anterior lip of the nail (with digital pressure on the proximal nail bed to push the subungual fluid anteriorly) to release the subungual fluid pressure. When I previously worked at the aid stations Western States 100 Mile Endurance Run, this technique was the quickest and safest way to treat these very common nail problems in runners. Certainly rhis technique is a lot less time-consuming and probably safer than the more standardly recommended red-hot-metal through the nail plate treatment.

One other way to prevent hallux subungual hematoma, without buying new running shoes, is to simply cut a hole for the hallux in the dorsal shoe upper. I remember doing that for my own running shoes 35 years ago when I was a distance runner in high school and bought a pair of shoes that was too short but I didn't have the money to buy another pair of new shoes. I now call this type of treatment for runners......."shoe surgery".

 

Thanks, that's great. I will release the fluid today and check his shoes. I didn't consider a subungal existosis.I will bear it in mind. All your advice is greatly appreciated.

 

It was most definitely his trainers. The seam was causing the repeated trauma. As my patient had been increasing his distance, the nails were taking more of a beating. I managed to release the fluid from piercing the blister just under the nail. He is considering cutting his shoes to prevent reoccurance. Thanks for all the advice.