Putting My Best Foot Forward

[Editor’s Note: In this article, guest writer Pam Smith is at it again with another article that’s sure to become a classic. This time, she’s writing about… permanent toenail removal. Like legend Marshall Ulrich, the nails of her big toes are–poof!–gone. You don’t want to miss this, unless of course you’re eating breakfast, or lunch, or dinner, or a pre- or post-run snack, or if you’re squeamish about gross toe photos, or clinical descriptions of medical procedures. Seriously, you’ve been warned!]

In the days after Desert Solstice, I was hobbling around the house, wincing with every step, particularly going down stairs. Perhaps you are thinking, Duh, you just ran 100 miles around a track at record pace, what did you expect??! But the truth is I had only mild muscle soreness and certainly nothing that would warrant my zombie-like gait. The real cause of my agony was my big toes, or more specifically, the big toenails, which had developed huge, subungual blisters that throbbed and pulsed with pain.

Losing toenails is something I have dealt with since starting my first season of high school cross country way back in 1989. Yeah, I have been losing toenails for longer than Dakota Jones has been alive! For most of this time, it was just my smaller toes, which was slightly embarrassing during the nine months of California sandal season, but really nothing more than a minor annoyance. But ultrarunning provides a more serious foot assault, such that for the last five years I have suffered through repeated cycles of big-toenail loss. As soon as the new nail is more than 50% grown in, it is only a matter of time (or race scheduling) before fluid accumulates under the nails at a race and I am suffering post-race onycholysis once again. (That’s the official medical term for losing your nails, FYI.) This usually means that two or three times a year I am hobbling around the house in intense pain. And this time I got an extra special bonus: infection! Feet aren’t exactly the most sterile place, you know.

Pam Smith - Desert Solstice plus two days

Two days after Desert Solstice my halluces were throbbing, red masses of pain.
All photos courtesy of the author.

Pam Smith - Desert Solstice plus four days

Four days post-race, the skin broke beneath the base of the nail, creating an oozing (and still painful) mess.

Pam Smith - Desert Solstice plus five days - big toenails gone - censored

Censored version – Five days post race, the nails were infected and I knew I needed to get them off. This initially was sweet relief, but about 30 minutes later the raw nerves were burning in response to their new exposure to the cruel world.
[Click for the uncensored version.]

Five days post race, the nails were infected and I knew I needed to get them off. This initially was sweet relief, but about 30 minutes later the raw nerves were burning in response to their new exposure to the cruel world.

[Editor’s Note: Did you get that? Yes, Pam removed her own toenails. Yes, we can’t fathom it either.]

Now, please don’t tell me I need to change my shoes or try some magical brand of socks. I’ve done it all with no help. When I heard the problem was due to shoes that were too small, I went up a half size and then a half size again. When someone said maybe my foot had too much room to move around, I went with snugger models. And I have tried numerous brands of socks, from wool to just about every synthetic. I rarely get the regular type of blisters, but nothing has helped with the toenail loss.

I had this same issue after Western States this year, but it was a little bit more tolerable since I had a week of post-race vacation and it was warm enough to wear flip flops every day. But I had to go back to work right after Desert Solstice (and spend a few hours on my feet each day), plus it was cold and wet out so I needed good shoe coverage. I was frustrated and my feet were cramping from continuously flexing my soles into rigid claws and walking on the sides of my feet to keep pressure off my big toes. Seriously, how could I run 100 miles and be laid up by a couple of bum toenails?? Those swollen digits were keeping me from getting out and moving around!

So this year for Christmas, I decided to give myself the gift that every girl really wants: permanent toenail removal! Okay, well, maybe not every girl wants that, but I certainly did. I am not the type of woman who sits around the country-club pool with perfectly pedicured piggies. And I am not expecting Matt Damon to invite me to spend the summer with him and his wife on his yacht anytime soon! As far as I am concerned, toenails are nothing but a nuisance. I love to run and I don’t want my toenails getting in the way. As the Queen of Hearts would say, “Off with their beds!” ;)

I assure you this was not an impulse decision from a single, bad outcome. This is something I have been thinking about for a long while. In fact, three years ago when two, new, family-practice docs started running with us, one of my first questions to both of them was, “Do you do permanent toenail removal?” (They didn’t.) And last year I had the opportunity to meet Marshall Ulrich, a legendary adventurer and ultrarunner who has completed the seven summits, finished Badwater 18 times (and won it four), and run across America. But when I had the chance to chat with him, I didn’t ask about any of these wild adventures, just his experience with toenail removal. Marshall tells a funny story of deciding to ablate all his toenails because his family doctor gave him a special pricing deal to have the procedure done at the same time as a vasectomy!

Since I was only interested in permanent toenail removal and not permanent sterilization, I made my appointment with a local podiatrist specializing in foot and ankle surgery, Dr. Scott, who was recommended to me by one of my family practice doc running friends. My original appointment was for Friday, December 27, but with a little luck and rescheduling I got it moved up to Tuesday, December 24.

After getting out for a morning run, I was ready for my 8 a.m. appointment, Ugg boots and flip-flops in tow, ready for my post-surgical needs. Dr. Scott was a good-looking guy with a big smile who didn’t even flinch at the sight of my nasty feet. He just pointed out that they were infected and I should be on antibiotics. He also noted that my halluces (that’s med speak for big toes) curved upward a little more than my other toes and were likely rubbing on my shoe upper (and not the toe box) when I ran, so the size of my shoes would make no difference. He quickly got prepared for the procedure without ever questioning why I would want this done.

Toenail ablation generally involves three major steps:

  1. Doing a nerve block by injecting lidocaine or other local anesthetic at the base of the toe to numb it up,
  2. Removing the toenail, and
  3. Using an acid to kill the nail matrix.

Much of the trauma from this procedure comes from removing the toenails and exposing all that raw tissue, rather than from the actual ablation itself. The genius in going in right after an event was that my toenails were already removed and I could skip this step. The doctor told me he had never done this procedure where he didn’t need to remove the toenail first. He chuckled when I said I deserved a discount, but he didn’t actually adjust my bill.

The nerve block was pretty painful with lightning flashes of pain shooting from the base of my toe to the tip, but the meds quickly took over and each toe was completely numb in less than a minute. He then scraped away a bit of scab and took cotton swabs of phenol and rubbed them along the base. Phenol is an acid composed of a benzene ring and an alcohol group. While only considered a weak acid, it is very reactive with other compounds and thus, corrosive to skin, the respiratory tract, and eyes. (And toenails!!) About seven billion kilograms of phenol are used each year worldwide, primarily as a precursor in plastic production, but it is also used to make such lovely things as epoxies, herbicides, and paint stripper. Oh, yeah baby, swab that good stuff all over my toes!

While Dr. Scott was wielding a highly corrosive substance, I thought it’d be a good time to ask him why he was only board eligible and not board certified. I am not one to beat around the bush! But he explained that unlike MD’s, podiatrists cannot sit for boards at the end of their residency but instead have to complete 150 surgical procedures before they are board eligible and he had only recently accomplished that. It could have been a ‘foot-in-my-mouth’ experience at the podiatry office but I was actually really glad I asked and happy to learn the answer. I think it is a good lesson to ask whatever questions you have when having a medical procedure, but maybe don’t wait till the middle of the procedure!

Pam Smith - toenail surgery prep

Surgery prep

The whole procedure took less than 15 minutes including the elaborate bandage job I got when it was over.

Pam Smith - post toenail surgery

Bandaged toes post-procedure.

My toes were numb for about three hours afterward. When the lidocaine wore off, my toes felt like they had been burned. (They had!) It was painful but it was a different pain than the throbbing pressure of the blisters. By the following morning, the pain had subsided significantly. Being Christmas day with my whole family in town, I had lots of good reasons to take the day off from running. But Thursday morning, I was back to running, doing an easy seven miles with my usual running group. There was mild to moderate pain that seemed to dull as I kept running and nothing bad enough to affect my gait. Unfortunately, I got super sick that evening (as did the rest of my family–some nasty bug completely unrelated to the procedure) and my only running for the next three days was to and from the bathroom! But by Monday, I was out jogging 10 miles with almost no pain. I think not having my toenails removed as part of the procedure gave me the benefit of a speedy recovery. Typical recovery is reported to be around 10 days. The ability to run in those 10 days is mostly dependent on your pain tolerance as I was not given any special restrictions from the doctor to avoid running or being on my feet.

While this may seem like a drastic move, this is actually a fairly common procedure for podiatrists as it is often done for patients with chronic ingrown toenails or to eradicate fungal infections that don’t respond to medication. My insurance did not require a referral and all I got charged was the $35 co-pay. The procedure does have about a 10% failure rate so some people need to have it repeated. For really stubborn cases, the nail matrix can be cut out. (Now that seems drastic!) Dr. Scott wants me to come back in six weeks because he said if the nail is starting to grow back, it is easier to repeat the procedure sooner rather than later, which would add another $35 co-pay to my expenses. But if it saves me weeks of agony over the rest of my running career, it seems like a pretty reasonable deal.

Three weeks after the procedure, my nail beds have a thick, keratin layer, kind of like a callous, but no toenail. I am keeping my fingers (and toes) crossed that the procedure was successful and I won’t need to have anything further done. With a coat of nail polish, it is not that noticeable. And if Matt Damon calls, I could always get a set of fake toenails! Otherwise, I am looking forward to racing in the future without having to worry about post-race toenail pain!

Pam Smith - three weeks post-toenail surgery

Three weeks out.

Pam Smith - three weeks post-toenail surgery - painted

Painted ‘nails’ three weeks out.

Call for Comments (from Meghan)

  • Okay, there must be more of you out there besides Marshall and Pam. Who else has had their toenails removed and what was the experience like for you?
  • For those of you who experience painful toenails post-race, are you ever tempted to try this extreme solution?