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 DOI: 10.1177/1938640010382293

2011 4: 14 originally published online 4 October 2010Foot Ankle SpecOzkan Kose, Mustafa Celiktas, Bulent Kisin, Selahattin Ozyurek and Seyhmus Yigit

Is There a Relationship Between Forefoot Alignment and Ingrown Toenail? A Case-Control Study  

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DOI: 10.1177/1938640010382293. From the Diyarbakır State Hospital, Orthopaedics and Traumatology Clinic, Diyarbakir, Turkey (OK, MC, BK, SY), and Izmir Military Hospital, Orthopaedics and Traumatology Clinic, Izmir, Turkey (SO). Address correspondence to Ozkan Kose, MD, Diclekent Bulvari, Ataslar Serhat Evleri, D Blok Daire 13, Kayapinar 2100, Diyarbakir, Turkey; e-mail: drozkankose@hotmail.com.

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Copyright © 2011 The Author(s)

⟨ Clinical Research ⟩

Is There a Relationship Between Forefoot Alignment and Ingrown Toenail?A Case-Control Study

Ozkan Kose, MD, Mustafa Celiktas, MD, Bulent Kisin, MD, Selahattin Ozyurek, MD, and Seyhmus Yigit, MD

Because of these discrepancies in the

literature, it is hard to conclude that a certain

foot type is a predisposing factor for

ingrown toenail.”

“

Abstract: Biomechanical imbalance between the hallux and the second toe and external compression of the lat-eral nail fold are proposed as the main reasons for ingrown toenail. Therefore, any anatomical predisposition facilitat-ing this compression may play a role in the occurrence of ingrown toenail. The purpose of this study is to investigate the relationship between forefoot alignment and ingrown toenail. The authors ret-rospectively reviewed radiographs of 81 patients with ingrown toenails and com-pared them with 100 healthy subjects regarding forefoot alignment. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and interphalangeal angle (IPA) were measured, and feet were clas-sified according to digital formula as Egyptian, Greek, and square. The mean HVA was 14.5° ± 5.0° in the case group and 13.2° ± 5.9° in the control group. The mean IMA was 9.1° ± 2.5° in the case group and 8.6° ± 3.1° in the control group. The mean IPA was 11.9° ± 4.1° in the case group and 12.0° ± 5.1° in the control group. There was no statistically significant difference between the groups regarding HVA, IMA, or IPA (P = .123,

P = .198, and P = .925, respectively). The distribution of foot types between groups was also similar (P = .967). This study has failed to demonstrate any abnormal-ity in forefoot alignment in patients with symptomatic ingrowing toenails, and it is suggested that treatment should not be based on the correction of the anatomy if no abnormality exists.

Levels of Evidence: Prognostic, Level IV

Keywords:  ingrown toenail; oncycryptosis; etiology; nail disorders

Ingrown toenail, or onychocryptosis, is a commonly encountered foot problem in routine orthopaedic practice resulting 

in pain and disability.1 Although consid-erable time is spent dealing with conser-vative and surgical treatment methods of this particular problem, the etiology of the condition is not well understood.2 Several risk factors have been advocated in the pathogenesis, including improper nail trimming, tight-fitting shoes, excessive 

sweating, bad foot hygeine, trauma, inher-itance, certain systemic diseases, medica-tions, and anatomic abnormalities.1,3-7

Biomechanical imbalance between the hallux and the second toe in an ill-fitting shoe is the most commonly cited theory in the etiology, since the lateral margin 

of the hallux is more frequently involved. According to this theory, extrinsic com-pression of the lateral nail fold between the hallux and the second digit initi-ates a cascade of events starting with irritation and skin breakage and finally results in the typical inflammation, infec-tion, and granulation tissue.8-10 Therefore, any anatomical predisposition facilitating this compression may play a role in the occurrence of ingrown toenail.

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Foot & Ankle Specialistvol. 4 / no. 1 15

The purpose of this study is to inves-tigate the relationship between forefoot alignment and ingrown toenail.

Materials and MethodsWe retrospectively reviewed all patients 

who underwent surgery for symptomatic ingrown toenails in our clinic between May 2008 and May 2010. Patients with medial or bilateral ingrowing nail edge, with subungal exositosis, or lacking pre-operative foot radiographs were excluded from the study. A total of 81 patients  with lateral border ingrown toenail were eligible and included in the analysis (Figure 1). Foot radiographs of the con-trol group were obtained from patients presenting to our emergency department with blunt foot trauma, in the same age range. They were randomly selected from the Picture Archiving and Communication Systems and institutional clinical data-base. Patients with a history of ingrown toenail and patients having fractures, old united fractures, and congenital deformity or malformation were excluded from the control group.

All of the measurements were carried out by one author, who was blinded to the clinical information of the patients. AP foot x-rays were used to measure the hallux valgus angle (HVA), first and sec-ond intermetatarsal angle (IMA), and interphalangeal angle (IPA) of the great toe (Figure 2). The feet were classified according to predefined criteria. Three types of feet were identified by the digi-tal formula: the Greek foot, in which  the first toe is shorter than the second toe; the Egyptian foot, in which the first toe is longer than the second toe; and the squared foot, in which the first toe is the same length as the second toe (Figure 3).

Continuous variables were calculated and are reported as means ± standard deviations and were compared using the Student t test for independent sam-ples. Categorical variables were described using frequency distributions and com-pared using the c2 test. All tests were considered significant at an a level of P < .05.

ResultsThe mean age was 23.3 ± 9.8 years in 

patients with ingrown toenails and 25.2 ± 10.4 years in the control group. There were 34 female and 47 male patients in the case group and 31 female and 69 male patients in the control group. No sig-nificant difference in age or gender was found between the 2 groups (P = .203 and P = .126, respectively). The mean HVA was 14.5° ± 5.0° in the case group and 13.2° ± 5.9° in the control group. The mean IMA was 9.1° ± 2.5° in the case group and 8.6° ± 3.1° in the con-trol group. The mean IPA was 11.9° ± 4.1° in the case group and 12.0° ± 5.1° in the control group. There was no statisti-cally significant difference between groups regarding HVA, IMA, or IPA (P = .123, P = .198, and P = .925, respectively). The dis-tribution of foot types between groups was also similar (P = .967). A summary of the data is presented in Table 1.

DiscussionVarious anatomical characteristics of 

nail structure have been investigated as potential risk factors for ingrown toenail. Langford et al11 stated that 3 critical anatomical predispositions (increased nail fold width, decreased nail thickness, and medial rotation of the toe) exist in most patients with ingrown toenail. Other extrinsic fac-tors act only as triggers in patients with these anatomic precursors.11 Li et al12 reported a series of anatomical abnor-malities on the distal part of the great toe in patients with ingrown nail: an upturned pulp deformity, nail fold hypertrophy together with a deeper nail groove, incurvatum of the nail plate, and upturned abnormality of the dis-tal part of the distal phalanx. Parrinello et al13 found a high and significant cor-relation between the shape of the prox-imal aspect of the nail plate and that of the phalangeal base. On the other hand, Pearson et al14 showed that there was no difference in either curvature or axis between subjects with and without ingrown toenail.

Figure 1.

Lateral margin ingrown toenail. Black arrow shows the typical hypertrophied nail fold and granulation tissue.

Figure 2.

Method of measurements. Hallux valgus angle (HVA), the angle between the longitudinal axis of first metatarsal and proximal phalanx of the great toe. Intermetatarsal angle (IMA), the angle between the longitudinal axis of the first and second metatarsal. Interphalangeal angle of the great toe (IPA), the angle between the longitudinal axis of the proximal and distal phalanges of the great toe.

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February 2011Foot & Ankle Specialist16

Some investigators showed a relation between certain foot type and ingrown toenail. Viladot15 reported that Egyptian foot is a risk factor for ingrown toenail. However, Günal et al16 showed that the incidence of ingrown toenail is higher in Greek and square foot. They speculated that counterpressure of the second toe on the lateral nail fold is greater in these foot 

types.16 Similarly, Ogawa and Hyakusoku17 found a high percentage of Greek and square foot in patients with ingrown nail. On the contrary, we have found no rela-tion between foot type and ingrown toe-nail. Because of these discrepancies in the literature, it is hard to conclude that a cer-tain foot type is a predisposing factor for ingrown toenail.

Venkatachalam18 presented a casewith recurrent ingrown toenail after first metatarsophalangeal joint fusion with excessive medial rotation. This case supports the biomechanical imbal-ance and excessive pressure between the first and second toe. Furthermore, Darwish et al19 demonstrated thatabnormal internal deviation of the hallux—in other words, increased HVA and IPA—was associated with ingrown toenail. However, in this current study, there was no significant difference in angles that represent the forefoot alignment in subjects with or without ingrown toenail.

Our conclusion can be supported by 2 other observations. First, not all peo-ple with hallux valgus have recurrent ingrown toenail. Second, even simple nail avulsion can be curative for ingrown toenail without changing any anatomical axis of the forefoot.

In this current study, we measured the forefoot alignment with HVA, IMA, IPA, and foot type. We included only patients with lateral nail fold involve-ment, because the theory proposing bio-mechanical imbalance between first and second finger theory explains the causa-tion of lateral nail fold ingrown toenail. We found no association between fore-foot alignment and ingrown toenail. The angles that represent the alignment of the forefoot were similar, and the foot types were equally distributed in both groups. This study has failed to demonstrate any abnormality in forefoot alignment in patients with symptomatic ingrowing toenails, and we suggest that treatment should not be based on the correction of the anatomy if no abnormality exists. 

References1.  Heidelbaugh JJ, Lee H. Management of 

the ingrown toenail. Am Fam Physician. 2009;15:79(4):303-308.

2.  Ikard RW. Onychocryptosis. J Am Coll Surg. 1998;187(1):96-102.

3.  Cohen JL, Scher RK, Pappert AS. Congenital malalignment of the great toenails. Pediatr Dermatol. 1991;8(1):40-42.

4.  Alam M, Scher RK. Indinavir-related recur-rent paronychia and ingrown toenails. Cutis. 1999;64(4):277-278.

Figure 3.

Types of feet according to digital formula. (a) Egyptian foot. (b) Greek foot. (c) Square foot.

Table 1.

Summary of the Data

Ingrown Toenail Group (n D 81)

Control Group (n D 100)

Significance, P Value

Age, y, mean ± SD 23.3 ± 9.8 25.2 ± 10.4 .203

Sex, male/female, n 47/34 69/31 .126

HVA, °, mean ± SD 14.5 ± 5.0 13.2 ± 5.9 .123

IMA, °, mean ± SD 9.1 ± 2.5 8.6 ± 3.1 .198

IPA, °, mean ± SD 11.9 ± 4.1 12.0 ± 5.1 .925

Foot type, n .967

Square 35 45

Egyptian 33 39

Greek 13 16

Abbreviations: HVA, hallux valgus angle; IMA, first-second intermetatarsal angle; IPA, interphalangeal angle of the great toe.

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14.  Pearson HJ, Bury RN, Wapples J, Watkin DF. Ingrowing toenails: is there a nail abnormal-ity? A prospective study. J Bone Joint Surg Br. 1987;69(5):840-842.

15.  Viladot A. Metatarsalgia due to biomechan-ical alterations of the forefoot. Orthop Clin North Am. 1973;4:165.

16.  Günal I, Kosay C, Veziroglu A, Balkan Y, Ilhan F. Relationship between onychocryp-tosis and foot type and treatment with toe spacer: a preliminary investigation. J Am Podiatr Med Assoc. 2003;93(1):33-36.

17.  Ogawa R, Hyakusoku H. Does Egyptian foot present an increased risk of ingrown  toenail? Plast Reconstr Surg. 2006;117(6):2111-2112.

18.  Venkatachalam S. Ingrowing great toenail following metatarsophalangeal joint fusion for hallux valgus: a case report and pro-posed mechanism of aetiology. J Foot Ankle Surg. 2001;7:113-115.

19.  Darwish FM, Haddad W, Ammari F, Aoudat Z. Association of abnormal foot angles and onychocryptosis. Foot (Edinb). 2008;18(4):198-201.

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