Runner's Toe: Medical Strategies for Treating Subungual Hematomas

Subungual hematomas, commonly referred to as runner's toe, involve bleeding beneath the nail bed that causes discoloration and potential nail loss. The condition typically presents with red, purple, or black discoloration and can lead to partial or complete detachment of the toenail. Dr. Jacob Wynes, a podiatric surgeon at the University of Maryland School of Medicine, notes that while the injury frequently affects the longest toe, it can impact any digit.

The primary cause is repetitive trauma to the toenail during physical activity. Dr. Rull James Toussaint, chief of the foot and ankle division at the University of Florida College of Medicine, identifies downhill running, high mileage, and improper footwear as key contributors. These factors increase friction between the toe and the shoe, rupturing blood vessels in the nail bed. Dr. Kristin Hullings, an assistant professor of clinical orthopaedic surgery at Temple University, adds that acute injuries like stubbing a toe can also cause the condition, though those cases warrant a medical examination to rule out fractures.

Treatment depends on the state of the nail. If the nail remains intact, attached, and painless, it will likely grow out on its own, according to Toussaint. In these instances, the focus shifts to preventing further damage. When the nail partially or fully detaches, the goal is to keep the exposed nail bed clean and protected to prevent infection. Hullings advises that a fully detached nail requires more careful management than a partially detached one because the nail bed is completely exposed and fragile.

Cleaning the affected toe is the first step for any case involving nail loss. Wynes recommends using mild soap and water or a saline solution to remove dirt. For partially detached nails, Hullings suggests leaving the attached portion in place as it acts as a protective splint. However, loose edges should be trimmed to prevent snagging on socks or sheets. Wynes emphasizes trimming as little as possible to preserve the remaining nail structure while ensuring smooth edges.

Applying a topical antibiotic ointment to the exposed nail bed helps prevent infection and promotes healing. Wynes states that this keeps the area moist. A non-adherent bandage should cover the toe and be changed daily. Hullings specifies that the bandage must not fuse to the healing tissue to avoid pain and damage during removal. Standard adhesive bandages are suitable, whereas hydrocolloid bandages are not recommended due to their sticky surface.

Runners with mild to moderate cases can continue exercising by wearing silicone sleeves over the affected toes. Wynes recommends these cushions to protect healing nails, even when used over bandages. The sleeves reduce friction and pressure on the nail bed during physical activity.

Prevention requires correcting the underlying cause, which is often improper footwear. Toussaint advises runners to visit a professional shoe store for a foot measurement to determine the correct size, width, and toe box dimensions. Wynes suggests measuring feet at night when they are most swollen and ensuring at least one thumb's width of space between the longest toe and the shoe's upper edge. Wearing breathable, moisture-wicking socks also helps prevent heat and moisture buildup, which can increase friction and damage the nails.