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Description: The OPMA has taken the past 10 years of articles, media clips, foot health facts and general public information and bundled them in year groupings for ease of reference. There are 3 additional parts to this series.

Foot Health Advice 2002-2008 Foot Health Advice 2002-2008 Contents Misinformation About Toenail and Foot Health.................................................................. 2 Pick the Right Shoes For Comfort ...................................................................................... 4 Buyers Guide to Foot Wear ................................................................................................. 6 Plantar Fasciitis (Heel Spurs) .............................................................................................. 9 Examining the FingerNails of Elderly Patients ..................................................................11 Introduction ........................................................................................................................11 Observing the Nail Shape and Surface ..............................................................................12 Observing Nail Color ..........................................................................................................22 Generalized Discolorations of the Nail Plate ......................................................................27 Processes Around the Nail .................................................................................................31 Cases ................................................................................................................................34 1 Foot Health Advice 2002-2008 Misinformation About Toenail and Foot Health EAST HANOVER N.J. June 28 PRNewswire-FirstCall -- An estimated 35 million Americans have an active live infection known as onychomycosis (fungal nail infection) underneath their toenails but 90 percent of them don t even recognize the name of the infection according to a new survey conducted by Roper Public Affairs. Further more than half (57%) of those surveyed who have the condition believe that over-the-counter (OTC) medications will treat the symptoms adequately despite the fact that no over-the-counter treatment has been proven to effectively treat the infection and no OTC treatment is approved for this use. The survey conducted in May 2004 which included more than 900 adults also revealed that nearly nine in 10 consumers age 35 and older who have symptoms of fungal nail infection (87%) recognize that changes in their toenails indicate a health problem but nearly one-fourth (24%) have waited a year or more before doing anything about it and nearly one-third (32%) say they have not sought treatment yet. The condition also has a psychological and emotional impact nearly two-thirds (61%) of those with onychomycosis would feel better about themselves if they had healthy looking nails. More striking is that seven of ten (70%) of adults surveyed say their doctor has never discussed proper foot care with them. From this survey we see that people delay or don t seek treatment for onychomycosis. However left untreated nail fungal infection will not go away and may become worse painful or spread to other nails said Warren Joseph DPM attending podiatrist at the Veterans Affairs Medical Center in Coatesville Pennsylvania and an expert in lower extremity infectious diseases. Upon noticing changes in nail color or thickness people should see a physician and ask for treatment -- only prescription medication is proven to effectively treat onychomycosis. The condition runs in families and some people are predisposed to infection. Additionally the fungus that primarily causes onychomycosis can spread from foot to foot on the floors of showers and locker rooms. People with onychomycosis may unknowingly spread the fungus to others due to behaviors such as walking barefoot -- a common practice among survey respondents. Indeed a vast majority (76%) walk barefoot fairly frequently around their home and over 51 percent walk barefoot when taking a shower at a club gym or other public places. The survey was sponsored by Novartis Pharmaceuticals Corporation. Onychomycosis or fungal nail infection is characterized by thick flaky or discolored nails. It is primarily caused by dermatophytes or living fungi which live in many common places such as locker rooms around swimming pools showers gardens and on unsterilized manicure or pedicure tools that have been used on others with the infection. Dermatophytes are also responsible for other fungal infections such as tinea capitis (scalp) tinea corporis (body) tinea cruris (groin) and tinea pedis (athlete s foot). Most fungal nail infections are caused when the fungus gets under the nail following an injury. The infection is more common under the toenails where the condition is preceded by athlete s foot. Once infected the nail separates from the nail bed becomes increasingly brittle and crumbles away. Since risk increases as people age onychomycosis is more common in the elderly. Hence onychomycosis is likely to become increasingly common as a growing proportion of the population survives into old age. People with diabetes or AIDS are more likely to develop onychomycosis which can lead to more severe complications in these populations. People with diabetes may have increased risk for secondary bacterial infections which can in turn lead to gangrene and foot ulcers. Lamisil Tablets are a highly effective treatment for mild to severe fungal nail infection and are the most prescribed treatment for fungal nail infection worldwide. Healthcare professionals have prescribed Lamisil Tablets to more than 14 million people in the U.S. Lamisil (terbinafine hydrochloride) Tablets are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium). Lamisil Tablets aren t for people with liver or kidney problems. Rarely serious side effects in the liver or serious skin reactions have occurred so doctors may do a simple blood test to check for liver problems. Other side effects including headache diarrhea indigestion and rash were generally mild. For more information about onychomycosis and treatment including full prescribing information visit http web 20041016090228 http . 2 Foot Health Advice 2002-2008 Novartis Pharmaceuticals Corporation researches develops manufactures and markets leading innovative prescription drugs used to treat a number of diseases and conditions including central nervous disorders organ transplantation cardiovascular diseases dermatological diseases respiratory disorders cancer and arthritis. The company s mission is to improve people s lives by pioneering novel healthcare solutions. Located in East Hanover New Jersey Novartis Pharmaceuticals Corporation is an affiliate of Novartis AG. Novartis AG (NYSE NVS) is a world leader in pharmaceuticals and consumer health. In 2003 the Group s businesses achieved sales of USD 24.9 billion and a net income of USD 5.0 billion. The Group invested approximately USD 3.8 billion in R&D. Headquartered in Basel Switzerland Novartis Group companies employ about 78 500 people and operate in over 140 countries around the world. For further information please consult http web 20041016090228 http . For more information and for a copy of the complete prescribing information please contact Media Kate King Novartis Pharmaceuticals Corporation Office 862 778 5588 Joseph Guarino Ruder Finn Office 212-715-1654 Investor Relations Jill Pozarek Novartis Corporation Office 212 830 2445 SOURCE Novartis Pharmaceuticals Corporation June 28 2004 3 Foot Health Advice 2002-2008 Pick the Right Shoes For Comfort Nike says its Shox line which features shoes for walking running and cross-training on special platforms is designed to help shield the feet from pounding the pavement and the track. The shoes retail for 100. For an extra 10 Nike lovers can visit to customize the women s Bella (running) and Energia (cross-training) models choosing colors and personalized mottos to brighten their workouts. Dr. Keith Kenter a sports orthopedist at the University of Cincinnati says he hasn t seen any research that shows the Shox shoes offer any extra benefit but they look really cool don t they Whatever shoe you choose Kenter and other experts advise trying on several different brands to find the right fit. You ll be able to tell which one s right he said. Athletes who plan to stick to just one activity should choose sports-specific shoes says Dr. Kristin Titko a podiatrist with the Cincinnati Center for Foot Care. Basketball shoes should support the ankles to help prevent sprains and twists. Tennis shoes should provide plenty of cushioning in the front toe area so that when you re dragging your toe during the serve you don t irritate the toe Titko says. Running shoes should fit well enough that the toes don t get irritated from rubbing against the shoe she says. Runners whose shoes don t fit well are apt to see blood build up under the toe nails as the toe gets jammed against the shoe and the nail gets lifted up and rips under the skin Titko says. It s painful it s disgusting and then your nail falls off and looks all nasty while it grows back. Long-time runners find a shoe that fits and stick with it. Steve Ludwig of West Chester Township is on his third pair of Asics Gel Kayanos. He likes the shoe s comfort and stability and the wider toe box. When Ludwig shops for running shoes he looks for support (he has flat feet) lightweight construction breathability (he likes an upper mesh for air flow) and of course price. The suggested retail price for Gel Kayanos is 135. As wear begins to show on my current shoes I start looking at the paper and try to catch a sale he says. Instead of throwing away the old shoes he uses them for everyday wear eventually relegating them to what he wears for yard work. Mary Jo McKibben looks for cushioning and long wear and she refuses to pay more than 100 for running shoes. She likes Asics Gel Cumulus which retail for 80. The last thing I look for is style. The Gel-Cumulus changes style every few months so you never know what you re going to get the Springfield Township woman says. My current pair are baby blue and a previous pair were purple and silver. But as long as they are comfortable I don t care. Rachel Dawson of Hyde Park likes Nikes. It s the only brand that fits my feet well she says. And marathoner Tom Quinlan of Hebron goes with a classic The Nike Pegasus which the company calls its best-selling running shoe of all time. I heard a long time ago that if they fit well and work well for you and you don t have a lot of injuries then you stick with them Quinlan says. He estimates he s been wearing the Pegasus which now retails for 80 for more than 20 years. Titko advises trying out the kinds of moves you ll need to perform in the shoes when you re trying them on. Most importantly the shoe has to be comfortable from the minute you put it on because shoes don t stretch out they wear out she says. 4 Foot Health Advice 2002-2008 Salespeople can help properly fit athletic shoes. Top-level athletes prone to foot or ankle injuries can also see sports medicine specialists like Kenter to see if the shoe is really the problem. It s also important to replace your athletic shoes on a regular basis Kenter says. Worn-out shoes hurt and can increase the risk of injury. By Peggy O Farrell Enquirer staff writer E-mail pofarrell September 6 2004 5 Foot Health Advice 2002-2008 Buyers Guide to Foot Wear 5 1 2007 The Situation A lot of teens find themselves in jobs where they must stand all day -- they may be a cashier at a grocery store a clerk at a clothing store a stock person at a department store a hamburger flipper at a fast food place. These types of jobs can be tough on the feet - if they aren t properly attired. Here s some information on what types of shoes you can wear on the job if you want to avoid sore feet. Your Poor Feet Your feet are probably the most overused and under appreciated parts of your body. They re certainly among the most complex - with 52 bones (26 bones per foot) 38 muscles more than 200 ligaments and thousands of nerve endings per pair. - Women s Wear Daily September 94 (confirmed with a Podiatrist) The feet are the most used and abused parts of the body Dr. Koven told us. If your feet hurt every step can be an assault. Your feet have to last you a lifetime so you should take care of them. When You Work Long Hours Standing for long periods of time on hard surfaces puts a lot of stress on your feet. It also puts stress on your knees and lower back. But basically the main problem you ll have will be foot fatigue or tired feet. Our feet were not meant to stand on hard surfaces or concrete floors all day. These types of surfaces are unyielding and offer no relief for the foot. If someone is required to stand on their feet all day they have to be very careful about what types of shoes they wear. According to one of the Podiatrists we spoke with the worse case scenario involves the cashier who is stationary for her his whole work shift. Standing in one place is harder on your feet than walking. The feet and legs don t move. Standing in one place all day is a very abnormal activity for the feet - our feet are designed to take us places - and standing affects our feet negatively. Note Whether or not you get more serious foot problems (than tired feet) depends a lot on the type of feet you have to start with and your family history. Genetics account for a number of predispositions toward foot problems. We inherit bone structure and if your mother or father have a history of mal-alignment of the joints and muscles and foot problems then it s quite possible that you ll have some too... Put Your Foot Down What to Look For in Footwear ...the foot s worst enemy is usually the shoe... - Women s Wear Daily Sept. 94 The best advice for anyone according to Dr. Miltchin is to get a shoe that absorbs shock. When you walk you strike the ground with a certain amount of force (a little bit more than your body weight) and that force is felt all the way up the body and into the spine. Your feet absorb this shock particularly your heels. To prevent this force from injuring feet legs and joints you should wear a shoe that does some of the work of absorbing this shock. A good shoe for working long shifts will have shock-absorbing material in the heel and forefoot. How do you evaluate this in a shoe Dr. Miltchin says A good shock absorbing shoe should feel like you re walking on air nice and light and comfortable.. . Dr. Koven said there should be a little bounce to the heel when you walk. A shock absorbing sole can be made of a number of materials including rubber and crepe. Most athletic shoes provide shock-absorbing soles. Dr. Wong-Sing says the shoes you wear on the job should be firm and supportive. There should be some rigidity in the shoe. We like Dr. Koven s test for assessing whether shoes will be good ones for those working long hours on their feet 6 Foot Health Advice 2002-2008 Test 1 Take your shoe put it in two hands - the toe in one hand and the heel in the other. Push your hands together as if you were going to clap. If you can push your two hands together it s not a good shoe. If you can bend it a little that s good. The sole of the shoe should be flexible enough to bend with the walking foot s rolling heel-to-toe movement. The shoe should bend slightly around the toe area but if you can bend it easily in half it isn t going to give your foot much support at all. Test 2 The heel counter which is the part of the shoe that raps around the heel of your foot should be fairly rigid or stiff. The shoe should support the heel in the heel cup. To test this hold the shoe in one hand with your thumb on the bottom of the heel and your index finger on the upper-most part of the heel counter. Try to push your fingers together. If you can t that s good. If you can that shoe is not going to provide your foot with much stability in the shoe. Good shoes will pass both of these tests says Dr. Koven. Most athletic shoes will pass these tests. A problem can be that many of the brandname running or athletic shoes are very expensive. You don t have to spend 150 for a good pair. Look for a less expensive athletic shoe one that is reasonably priced -- one that has leather or canvass components (or man-made materials) and one that passes the two tests and the other requirements we have talked about. Oxford type shoes are also good. Podiatrists used to recommend shoes made of natural materials like leather but now there are many synthetic materials that are just as good. The sneaker manufacturers have advanced a lot in this area the Podiatrists told us. A note on Doc Martins Doc Martins were the original working shoe in England. They were designed to be firm. They are a very well made shoe. One Podiatrist said Doc Martins are a lot like the old orthopaedic shoe of years gone by. The sole is a good shock absorbing sole and the leather is prepared in such a way that it provides support for the foot. They tend to be very comfortable. Dr. Miltchin recommends a good walking shoe because they are made with the same requirements a worker should be looking for in a shoe they absorb shock well are lightweight the materials they are made of are breathable (allow for ventilation) and they have reinforcements on sides of the heels so that the foot doesn t wobble back and forth within the shoe. Dr. Miltchin also likes the shoes made by the Roots company. They are well made and highly shock absorbing but you don t have to spend that much to get a good shoe. Dr. Wong-Sing said that laced shoes are better than slip-ons because they allow you to get the tensions adjusted correctly for your particular feet and provide you with more support. He doesn t recommend leaving sneakers untied. Some Other Minor Considerations Don t wear high heels if you are on your feet for long periods of time. Save them for special occasions. The shoe should be made of materials that are breathable - allow for ventilation. Most athletic shoes take this into account. If a foot is completely enclosed it heats up and that can cause some foot problems. There shouldn t be any seams or roughness in the shoe that can irritate the foot. When Shopping For Work Shoes Shop late in the day - The best time to purchase shoes is after you have been on your feet for awhile. Feet are a little bit larger at the end of the day then they are at the start. Why As the day progresses feet tend to swell because gravity pulls the fluid in our body down to our feet. Also as our activity level increases so does the swelling in our feet. Wear the type of sock you intend to be wearing with those shoes when you try them on at the store. 7 Foot Health Advice 2002-2008 Walk around in the shoes. Check for any tightness or rubbing. If the shoes don t fit when you try them on don t buy them the Podiatrists told us. You cannot break them in. Buy and wear the right sized shoes. Buy shoes that fit. (Seems obvious but some people don t always follow this rule...) Ill- fitting shoes can cause problems. If the shoe hurts in the store it will hurt later. Don t be a slave to fashion when it comes to shoes... Shoe construction - make sure toes have room to spread naturally -the shoe should be roomy in the toe area when you re standing. Ask the shoe clerk a lot of questions. Day In Day Out... If you can don t wear the same footwear two days in a row. Why We perspire in our shoes and it s a good idea to let the moisture the perspiration in the fabric evaporate -- it will stop the growth of bacteria and odour. Let the air circulate in your shoes overnight or over a couple of days. Other Helpful Things If you are in this stationary standing type of job such as cashier. Dr. Wong-Sing recommends that you walk around when you can shift your weight around go up on your toes create some motion -- mobilize to get the blood flow your legs and feet. Socks Socks should be changed daily. ( ) Socks made with natural fibres like cotton and wool are good. Natural fibres hold moisture and absorb it away from the skin. However all of the doctors conceded that some new synthetic fibres are very good. Rules About What You Can Wear at Work There are dress codes at many work places. Most times you can get around that many times by getting an athletic shoe that is all black or in a solid colours. Probably most employers will allow conservative looking shoes. Old Shoes Should Retire Don t want to walk around with shoes that are worn out. Everything wears out eventually. There shouldn t be any holes or rips in your shoes. Some shoes will wear out in three or four months some will take six months or a year to wear our. It depends a lot on the activities an individual is doing and the individual. Once the tread in the bottom of a shoe has worn a hole in the shoe it s time to get a new pair. What if You Already Have Aching Feet What do the Podiatrists think of over-the-counter foot soaks epsom salts etc. If it feels good do it -- it s certainly not detrimental. You benefit in two ways 1) you feel a little better and 2) your feet are cleaner. They have no problem with them as long as you dry well and the soaking is not done in boiling water. The water should be warm to the don t want to burn your feet. An Ending Thought Feet are not supposed to hurt. They are supposed to take us from place to place. We use our hands the whole day we use our bodies the whole day we use our mouths the whole day and they don t hurt. The same should be true of feet. Everyone thinks that it s okay if their feet hurt after a long day s work but it s not so. If your feet hurt at the end of the day that means something s wrong. Check the types of shoes you are wearing. If you have good shoes and your feet still hurt go to see a foot specialist and have them checked out. Sources Dr. Neil Koven Podiatrist Toronto Dr. Wong-Sing Podiatrist Vancouver Dr. Harley Miltchin Podiatrist Toronto 8 Foot Health Advice 2002-2008 Plantar Fasciitis (Heel Spurs) 5 1 2007 What is Plantar Fasciitis Plantar Fasciitis is an inflammation of the plantar fascia of the foot. The plantar fascia is a ligamentous connective tissue band that spans the entire sole of the foot. (See image) It takes origin from the heel bone (calcaneus). Plantar fasciitis is an overuse injury causing heel pain which may radiate forward into the foot. Plantar fasciitis is also commonly referred to as Heel spur although they are not strictly the same. A heel spur is a bony growth that occurs at the attachment of the plantar fascia to the heel bone (calcaneus). A heel spur can occur (with repetitive pulling of the plantar fasia) on a foot with no symptoms at all and a painful heel can have no heel spur present. A rupture to the plantar fascia following trauma or injury can sometimes occur at the origin of the arch ligament and result in inflammation and heel pain. What are the symptoms of plantar fasciitis Heel pain under the heel and usually on the inside at the origin of the attachment of the fascia. Sometimes there may also be pain along the outside border of the heel. This may occur due to the offloading the painful side of the heel by walking on the outside border of the foot. It may also be associated with the high impact of landing on the outside of the heel if you have high arched feet. Pain is usually worse first thing in the morning. After a few minutes it eases as the foot gets warmed up but can get worse again during the day especially if walking a lot. Who does plantar fasciitis commonly effect Plantar fasciitis or heel spurs are common sports which involve running dancing or jumping. Runners who excessively pronate (feet rolling in or flattening) are particularly at risk as the biomechanics of the foot pronating causes additional stretching of the plantar fascia. Common causes of plantar fasciitis The most common cause of plantar fasciitis is very tight calf muscles which leads to prolonged and or high velocity pronation of the foot. This in turn produces repetitive over stretching of the plantar fascia leading to inflammation and thickening of the tendon. As the fascia thickens it loses flexibility and strength. Some practiioners think you will see pronation by dropping and rolling in of the arch. This is not always the case. Sometimes it can only be seen with foot scans especially if the patient has a high arched foot. Other causes include high arch or low arch feet (pes cavus planus) and other biomechanical abnormailities which should be assessed by a podiatrist physiotherapist biomechanist Treatment for Plantar Fasciitis What can the athlete do for plantar fasciitis 9 Foot Health Advice 2002-2008 Rest until it is not painful. It can be very difficult to rest the foot as most people will be on their feet during the day for work. By walking on the painful foot you are continually aggrevating the injury and increasing inflammation. However a good plantar fasciitis taping technique can help the foot get the rest it needs by supporting the plantar fascia. Tape is applied in strips across the plantar fascia taking the stress off the foot which allows the inflammation to settle and healing to take place. Click here for step by step instructions with streaming video. Apply ice or cold therapy to help reduce pain and inflammation. Cold therapy can be applied regularly until symptoms have resolved. Stretching the plantar fascia is an important part of treatment and prevention. Simply reducing pain and inflammation alone is unlikely to result in long term recovery. The plantar fascia tightens up making the origin at the heel more susceptible to becoming inflamed. Tightening of the plantar fascia happens in particular over night which is why pain is often worse in the morning. A plantar fasciitis night splint is an excellent product which is worn over night and gently stretches the calf muscles and plantar fascia preventing it from tightening up overnight. What a Sports Injury Professional can do Prescribe anti-inflammatory medication such as ibuprofen. Prescribe orthotics. An orthotic insole can restore normal foot biomechanics and reduce overpronation which is a contributary factor for plantar fasciitis related heel pain. Tape the foot and instruct the athlete how to tape the foot. This is an excellent way of allowing the foot to rest. Apply sports massage techniques to reduce the tension in the plantar fascia and aid stretching of the tissue. Use a corticosteroid injection - usually best combined with biomechanical correction with orthotics. X ray to see if there is any bone growth (calcification). An X-ray may be able to show bone growth which may be a cause of pain but research has shown that the presence of a bony growth does not necessarily mean the athlete will feel pain. Bony growth can worsen even after symptoms have completely resolved. Shockwave Therapy (either high frequency or radial) is a treatment modality that is currently being employed to treat chronic presentations of this condition. Surgery by means of minimal incision endoscopic or traditional (open) technique is reserved for those recalcitrant cases where conservative measures have failed to provide symptomatic relief. More information on plantar fasciitis including answers to the following questsions is available from your podiatrist How can I stretch the plantar fascia Which other stretches are important How are sports massage techniques applied How often should I stretch How often should massage be applied How is tape applied to the foot How should I return to full training How can I prevent plantar fasciitis recurring What treatment options best suit the nature of my complaint 10 Foot Health Advice 2002-2008 Examining the FingerNails of Elderly Patients Introduction Human fingernails located on the dorsal aspect of the terminal 40% of the distal phalanx of each finger are complex structures involving 3 different layers The nail plate (the nail). This is the keratinized structure which grows throughout life The nail bed (ventral matrix sterile matrix). This is the vascular bed that is responsible for nail growth and support. It lies protected between the lunula (the half moon seen through the nail) and the hyponychium (the posterior part of the nail bed epithelium) and The eponychium (cuticle). The epidermal layer between the proximal nail fold and the dorsal aspect of the nail plate. The primary purpose of the nail is protection. Abnormalities of the nail are often caused by skin disease and infection (most often fungal) but may also indicate more general medical conditions. This discussion does not address localized trauma or nail infections but offers examples of nail abnormalities that may occur with systemic disease. Check to see whether the nails are normal by looking at the following (Figure 1) Softness and flexibility of free edge Shape and color Quality of paronychial tissue and Growth rate (about 6 months from cuticle to free edge). Time of events can be estimated from location. Figure 1. The normal nail. Examining the Nails Elderly people carry the last 6 months of their medical record on the approximately 10 square centimeters of keratin comprising the fingernails. Examining the fingernails can help the clinician detect a number of general and specific factors including the 11 Foot Health Advice 2002-2008 following Overall vitality Inner emotional state Cerebral dominance Occupations and hobbies Medical history Nutritional status Cardiovascular function Rheumatic conditions and Dermatologic problems. The patient s manicure can reveal state of health nutritional status past events personality occupation and one s inner state. Systemic illness should show the nail changes in each of the nails on one hand. The thumb may reveal more extensive changes given its increased size. It is useful to follow the following sequence when examining the nails Check the nail shape Examine the nail color Survey processes around the nails Compare hands and Note skin conditions. It is critical to examine the nails in adequate light. Gently rotate the nail in the light so that the reflection highlights all aspects of the nail. Notice the lunula the pale crescent moonlike coloration at the base of the nail. Leukonychia stria and a pointed tent-like lunula suggest an excessive manicure and pushing on the cuticle. Paronychias suggest stress and poor attention to hygiene. This can reflect depression dementia or psychiatric illness. Nail Growth Nail growth is continuous. It takes about 6 months for a fingernail in an elderly person to completely grow out. Cold temperature can slow growth rates but not to any clinically significant degree (pun intended). The middle finger nail grows the fastest followed by the forefinger and ring finger. Aging slows the growth rate from approximately 3 months in childhood to 6 months in 70-year-olds. Nails in elderly people are also thicker than in younger people. Thin nails in a postmenopausal woman raise the possibility of metabolic bone disease. The nails of the dominant hand grow slightly more quickly than the nondominant nails probably because minor trauma accelerates nail growth. Conversely immobility slows the growth rate of fingernails. Understanding the growth rate is important because the time interval from a critical event can be estimated from the location of a nail lesion. For example a white line appearing transversely halfway up the nail suggests an acute illness 3 months earlier. Regular observation will demonstrate its progression to the end of the nail edge. Nail Polish Distance from base and line of polish gives approximate date of application (nails grow 0.1 mm day). Picking at polish reflects nervousness and agitation. Toenail polish suggests unusual flexibility or a friendly helper. Observing the Nail Shape and Surface Clubbed Fingernails Clubbing involves a softening of the nail bed with the loss of normal Lovibond angle between the nail bed and the fold an 12 Foot Health Advice 2002-2008 increase in the nail fold convexity and a thickening of the end of the finger so it resembles a drumstick. To determine whether nails are clubbed have the patient place both forefinger nails together and look between them. If you can see a small diamond space between them (Schamroth s window) then the nails are not clubbed (Schamroth s sign) (Figure 2). Figure 2. Schamroth s sign. Causes of clubbing (not exhaustive) include the following (Figure 3) Pulmonary and cardiovascular causes (80%) o Lung cancer pulmonic abscess interstitial pulmonary fibrosis sarcoidosis beryllium poisoning pulmonary arteriovenous fistula subacute bacterial endocarditis infected arterial grafts aortic aneurysm Gastrointestinal causes (about 5%) o Inflammatory bowel disease sprue neoplasms (esophagus liver bowel) Hyperthyroidism (about 1%) Note Chronic obstructive pulmonary disease does not cause clubbing. Figure 3. Example of clubbed fingernails. Koilonychia Koilonychia are spoon-shaped concave nails (Figures 4A 4B). This occurs normally in children and usually resolves with aging. 13 Foot Health Advice 2002-2008 To determine whether a nail is spooned perform the water drop test. Place a drop of water on the nail. If the drop does not slide off then the nail is flattened from early spooning. An experienced clinician can look at the nail and perform a mental water drop test. Causes include the following Iron deficiency Diabetes mellitus Protein deficiency especially in sulfur-containing amino acids (cysteine or methionine) Exposure to petroleum-based solvents Systemic lupus erythematosus and Raynaud s disease. Figure 4A. Spooned nail. Figure 4B. Spooned nail. In 1846 Joseph Honor Simon Beau described transverse lines in the substance of the nail as signs of previous acute illness. The lines look as if a little furrow had been plowed across the nail. Illnesses producing Beau s lines include the following 14 Foot Health Advice 2002-2008 Severe infection Myocardial infarction Hypotension shock Hypocalcemia and Surgery. Intermittent doses of immunosuppressive therapy or chemotherapy can also produce Beau s lines. Severe zinc deficiency has also been proposed as a cause of Beau s lines. By noting its location on the nail the approximate date of the illness associated with it can be determined (Figures 5A 5B). Moreover the depth of the line provides a clue to the severity of the illness. Figure 5A. The location of Beau s lines half way up the nail suggests illness 3 months ago. Figure 5B. Two Beau s lines suggest illnesses about 2 months apart. Thin Brittle Nails 15 Foot Health Advice 2002-2008 Thin brittle nails can indicate the following (Figure 6) Metabolic bone disease (nail thinness is correlated with osteopenia) Thyroid disorder Systemic amyloidosis (indicated by yellow waxy flaking) and Severe malnutrition. Figure 6. Note the thin nails in this woman with severe osteopenia. Onychorrhexis is the presence of longitudinal striations or ridges (Figure 7). It can simply be a sign of advanced age but it can also occur with the following Rheumatoid arthritis Peripheral vascular disease Lichen planus and Darier s disease (striations are red white). Central ridges can be caused by Iron deficiency Folic acid deficiency and Protein deficiency. 16 Foot Health Advice 2002-2008 Figure 7. Example of a central nail ridge. Central Nail Canal (Median Nail Dystrophy) When a central nail canal is present the cuticle is usually normal (Figure 8A). Central nail canal is associated with Severe arterial disease ( Heller s fir tree deformity -- a central canal with a fir tree appearance -- may occur with peripheral artery disease (Figure 8B) Severe malnutrition and Repetitive trauma. Figure 8A. Example of central nail canal. 17 Foot Health Advice 2002-2008 Figure 8B. Central nail canal with Heller s fir tree deformity. Nail Pitting Nail pitting -- small punctate depressions -- are caused by nail matrix inflammation which can be the result of Psoriasis (random appearance of pits) (Figure 9) Alopecia areata (geometric rippled grid) (Figure 10) Eczema and Lichen planus. 18 Foot Health Advice 2002-2008 Figure 9. Indication of psoriasis. Figure 10. Indication of alopecia areata. Nail Beading With nail beading the beads seem to drip down the nail like wax (Figure 11). It is associated with endocrine conditions including the following Diabetes mellitus Thyroid disorders Addison s disease and Vitamin B deficiency. Figure 11. Nail beading. Rough Nail Surface When nails look sandpapered and dull consider (Figure 12) 19 Foot Health Advice 2002-2008 Autoimmune disease Psoriasis Chemical exposure and Lichen planus. Figure 12. Example of a rough nail surface. Nail Thickening Slow nail growth produces thickness (Figure 13). In such cases the following should be considered Onychomycosis Chronic eczema Peripheral vascular disease Yellow nail syndrome and Psoriasis. 20 Foot Health Advice 2002-2008 Figure 13. Example of a nail thickening. Onycholysis Onycholysis is distal separation of the nail plate from the underlying nail bed (Figure 14). It is associated with the following Thyrotoxicosis Psoriasis Trauma Contact dermatitis Tetracycline Eczema Toxic exposures (solvents) Blistering from autoimmune disease and Porphyria cutanea tarda (onycholysis and skin blistering from sun exposure). Figure 14. Traumatic onycholysis (involving only 1 nail). Severe Nail Curvature (Beaked Nails) Curved or beaked nails are caused by resorption of distal digit (Figure 15). Consider the following Hyperparathyroidism Renal failure Psoriasis Systemic sclerosis 21 Foot Health Advice 2002-2008 Figure 15. Example of severe nail curvature. Complete Nail Destruction Complete local nail destruction can be caused by local mechanisms including trauma and paronychia. Generalized conditions that might cause complete nail destruction include the following Toxic epidermal necrolysis Chemotherapy Bullous diseases and Vasculitis. Observing Nail Color Abnormalities of the Lunula If the lunula is absent consider anemia or malnutrition (Figure 16). A pyramidal lunula might indicate excessive manicure or trauma (Figure 17). A pale blue lunula suggests diabetes mellitus. If the lunula has red discoloration consider the following causes among others (Figure 18) Cardiovascular disease Collagen vascular disease and Hematologic malignancy. 22 Foot Health Advice 2002-2008 Figure 16. Absent lunula. Figure 17. Pyramidal lunula. 23 Foot Health Advice 2002-2008 Figure 18. Lunula with red discoloration. Transverse White Lines (Mee s lines) Any acute illness can produce transverse milky white lines. In addition they might be caused by heavy metal toxicity (classically arsenic) or chemotherapy. The time of event may be determined from the location of the lines on nail (Figure 19). Figure 19. Note the Mee s line approximately one third of the way up the nail suggesting a significant illness 2 months previously. Leukonychia Striae Leukonychia striae are white splotches caused by minor trauma to the nail matrix (Figure 20). The timing can be determined by the location of the splotches on the nail. 24 Foot Health Advice 2002-2008 Figure 20. Example of leukonychia striae. Note location of white splotches which can indicate timing of the traumatic event. Longitudinal Brown Lines Longitudinal brown lines form because of increased melanin produced by nail matrix melanocytes (Figure 21). They are associated with Addison s disease Nevus at the nail base Breast cancer Melanoma (check for periungal pigmentation) and Trauma. Figure 21. Longitudinal brown lines. Splinter Hemorrhages 25 Foot Health Advice 2002-2008 Splinter hemorrhages are caused by hemorrhage of the distal capillary loop (Figure 22). Note the thickness of these areas. They are associated with the following Subacute bacterial endocarditis Systemic lupus erythematosus Trichinosis Pityriasis rubra pilaris Psoriasis and Renal failure. Figure 22. Splinter hemorrhages tend to be fat. Terry s Half and Half Nails With Terry s half and half nails the proximal portion is white (edema and anemia) and the distal portion is dark. These nails imply either renal or liver disease (Figures 23A 23B). 26 Foot Health Advice 2002-2008 Figure 23A. This example of Terry s half and half nails suggests liver disease (no brown lines). Figure 23B. Half and half nails imply renal disease when there is a brown band at the junction of the erythema and the free edge. Image courtesy of w Generalized Discolorations of the Nail Plate Nail discoloration is a useful method for identifying potential problems. White Nails White nails can be caused by anemia edema or vascular conditions (Figure 24). Consider the following Anemia Renal failure 27 Foot Health Advice 2002-2008 Cirrhosis Diabetes mellitus Chemotherapy and Hereditary (rare). Figure 24. Example of white nails. Pink or Red Nails With pink or red nail discoloration the following should be considered (Figure 25) Polycythemia (dark) Systemic lupus erythematosus Carbon monoxide (cherry red) Angioma and Malnutrition. 28 Foot Health Advice 2002-2008 Figure 25. Example of pink and red nails. Brown-Gray Nails Brown-gray nails may suggest the following (Figure 26) Cardiovascular disease Diabetes mellitus Vitamin B12 deficiency Breast cancer Malignant melanoma Lichen planus Syphilis and Topical agents including hair dyes solvents for false nails varnish and formaldehyde (among many others) 29 Foot Health Advice 2002-2008 Figure 26. Example of brown-gray nails. Yellow Nails Yellow nails suggest the following (Figure 27) Diabetes mellitus Amyloidosis Median ulnar nerve injury Thermal injury and Jaundice. Consider yellow nail syndrome if a patient has lymphedema and bronchiectasis. 30 Foot Health Advice 2002-2008 Figure 27. Example of yellow nails. Image courtesy of Used with permission. Green or Black Nails Green or black nails indicate the following (Figure 28) Topical preparations including chlorophyll derivations methyl green and silver nitrate (among others) Chronic Pseudomonas spp infection and Trauma. Figure 28. Example of black nails. Used with permission. Processes Around the Nail Paronychial Inflammation Paronychia is associated with separation of the seal between the proximal nail fold and the nail plate that provides entry for bacteria and leads to a localized infection of the paronychial tissues of the hands (Figure 29). Symptoms may include inflammation swelling and or scaling. 31 Foot Health Advice 2002-2008 Figure 29. Example chronic paronychial inflammation. Periungal Telangeictasia Periungal telangeictasia is caused by dilated capillary loops and results in atrophy of the cuticle (Figure 30). It is strongly associated with collagen vascular disease including the following Systemic lupus erythematosus Dermatomyositis (especially with Gotton s papules over knuckles) and Scleroderma. 32 Foot Health Advice 2002-2008 Figure 30. Example of periungal telangeictasia. Image courtesy of Used with permission. Mucus Cyst A mucous or myxoid cyst is a collection of degenerative collagen that can cause swelling and ridging of the nail above the cyst forming a gutter (Figure 31). 33 Foot Health Advice 2002-2008 Figure 31. Example of a mucus cyst. Cases The following are examples of patients in whom examining the fingernails may help identify their conditions. 34 Foot Health Advice 2002-2008 Slide 1. 78-year-old with multiple conditions. Slide 2. 84-year-old man with a painful ankle. 35 Foot Health Advice 2002-2008 Slide 3. 68-year-old man with esophageal cancer. Slide 4. 62-year-old woman with dermatomyositis. Acknowledgments The author would like to thank the University of Virginia GME Office for funding support Jim Thomas MD of for permission to use images from their extensive dermatologic atlas and the internal medicine residents at the University of Virginia for pre-testing and their helpful feedback. 36