The little toe … so cute, yet so abused. Though the smallest of its brothers, it protects the rest from tight shoes and table legs. While the others balance the body and propel their owner forward, the fifth digit is the most likely to break.
“We call them bedroom fractures,” says Washington, D.C., podiatrist Arnold Ravick. “You get up in the middle of the night and bang your toe on the nightstand.”
At the turn of the 19th century, fashionable women had their pinky toes amputated so they could squeeze into stylish shoes, according to Manhattan podiatrist Johanna Youner.
Today, only specialists appreciate the little toe’s contributions. “Dancers are so much more aware of their balance than the average person, they would really miss it,” Youner says.
The baby toe is prone to conditions that either don’t affect the other digits or afflict them less dramatically. You probably have seen a few of them in your salon. One clue as to why lies within the toe’s structure — and other clues lie within our genes.
The Littlest Digit, Different Indeed
Its location on the outer side of each foot makes the pinky toe both more subject to trauma and anatomically different, says podiatric surgeon Christopher Lamy of Portland, Ore.
Muscles anchor the second, third, and fourth toe and hold each in place, Lamy explains. Some muscles stretch from each side of the toe and grab the metatarsal bones of its neighbors. So for example, some muscles of the third toe attach to the metatarsal bones of the second and fourth toes.
The fifth toe’s muscles attach on the inner side to the fourth metatarsal. But it has no outer neighbor to anchor it, so its outer muscle attaches further down on its own metatarsal, Lamy explains.
This different muscular attachment leads to problems later on.
Because the muscles anchoring the little toe do not have the same counterbalances as the inner toes, the toe structure can weaken with age and allow the toe to rotate toward the outer side of the foot.
“As you get older, the way you walk and the way the tendons pull eventually turn the nail to the side or the bottom, instead of to the top,” Youner says.
This rotation is called adducto varus, which means “rotation toward the center line” (the idea is that the toe usually curves, with the tip pointing toward the center of the body). In these cases, a callus or corn frequently develops at the sidewall or over the nail, depending on where the nail is being rubbed. “Keep that portion of the nail smooth and trim the hard skin that builds around it,” Youner advises.
Adducto varus often occurs with hammertoes, where toes contract into a claw-like position. (It can be genetic or acquired.) The fifth digit’s different muscular structure causes that toe to lie to the side.
“The knuckle, instead of pointing straight up when contracted, points toward the side of the shoe,” Lamy says. “The tip of the toe runs into the side of the knuckle of the fourth toe. People will get calluses between the two toes, with the skin of the fourth toe being pinched by the curved direction of the tip of the fifth toe.”
This clawing can be slowed by gently massaging the muscles around the toes, Youner says. Have your client gently press the toes down each day to exercise those muscles so they keep their normal shape longer.
The small toenail may become thick and discolored. The medical term for this, onychodystrophy, is something of a misnomer: “Dystrophy” means something is no longer functional. The thickened nail in fact continues to protect the toe, Ravick says, but can become so thick that it causes pain.
Technicians may see this especially among clients of color, who already have thicker skin than Caucasians. It also appears in clients who run or have other activities that put the toes under chronic pressure, Youner says.
Experts disagree about what causes this thickening.
Podiatrists Ravick and Lamy say that years of the little toe rubbing up against shoes frequently cause the nail to become thick and discolored, resembling a nail infected with fungus.
Douglas Schoon, vice president of science and technology for Creative Nail Design in Vista, Calif., disagrees, saying that the nail thickness is determined by the length of the matrix, and does not change with pressure and friction. However, an infection can cause the nail’s layers to swell and become discolored, like a roll of toilet paper that absorbs water.
“More than likely, it’s a fungus,” Schoon says. “It can be a bacterial infection as well, but until it gets cultured, no one knows for sure.”
He advises nail technicians to err on the side of caution. “If it looks like there’s a problem going on that (the tech) is unfamiliar with, they should send the client to a podiatrist,” he urges.
To treat onychodystrophy, a prescription product can be brushed onto the nail at home. The newest on the market, Keralac Gel, contains uric acid, lactic acid, and zinc. The acid gradually strips away the nail’s upper layers. In about 70% of cases, the nail returns to its normal color and texture within nine months to a year of regular use, Ravick says.
Or, podiatrists may also file down the nail if it is not infected, Ravick says. In cases where an infection has been ruled out, Schoon suggests that nail technicians use a manual filing technique to reduce the nail’s thickness, avoiding aggressive techniques that could risk cutting the skin or causing the nail plate to separate from the nail bed.
Ravick says clients can prevent the condition — or at least prevent it from worsening — by removing the source of the pressure and friction.
If they continue, pressure and friction can cause a corn or callus to develop over the nail or in the corner of the nail groove (a corn is on top and a callus is on the bottom). Pressure can also damage the nail matrix, leaving a callus instead of a nail.
Clients can apply oil-based emollients such as Vaseline at night or after bathing to reduce the friction that aggravates callus formation, Ravick recommends. “The thick gooey stuff is really helpful there,” he says.
You can sand down the callus gently, but remember that the callus protects the toe against abuse, so leave some intact.
In the worst cases, the toe will defend itself against the pressure by developing an enlargement on the bone, called a bone spur; a callus can form over that as well. This painful condition usually requires surgery.
Susceptible to Fungus
Though the big toe suffers from fungal infections more than the other digits, the little toe, because it gets banged around so much, also is susceptible. The thickened nail of onychodystrophy is sometimes a precursor, as the fungus takes advantage of the weakened nail to invade. In addition, athlete’s foot and the cracked skin it can cause most commonly occur between the fifth and fourth toes.
Most state regulations prohibit technicians from servicing an infected nail.
Ravick notes that an observant and experienced technician can usually tell the difference between a toenail with a fungus and one that has thickened due to other causes.
“If the nail of the small toe is discolored and that’s the only one, I think you’re pretty safe in thinking that’s not a fungal disease,” Ravick says. “When you’re used to seeing the thickened, brown, flaky, cracked nail (infected with a fungus), with a lot of debris around it, and this one looks different, I think you’re pretty safe in sanding it down.”
You should always wear a mask when filing, he advises.
On the other hand, Julia Martinez, a nail tech who works part-time at Hair Hustlers in Carlsbad, Calif., counsels caution when confronted even with potential onychomycosis (fungus in the nail). “Any time the client has a nail that looks a little unusual, it’s best to get a diagnosis from a physician. Sometimes it can be a warning sign there is an even bigger health problem starting,” says Martinez.
A fungal infection may require both a topical and an oral medication prescribed by a doctor.
Centuries ago, tailors typically sat cross-legged on the floor while they worked. The pressure against their little toes sometimes caused them to develop an enlarged first joint of the baby toe.
Nowadays, tailor’s bunion is considered a congenital deformity, not an occupational hazard, and typically forms before adulthood, Lamy says. It has three main forms: the metatarsal head is bigger than normal, or the metatarsal bone is curved, or the angle between the fourth and fifth metatarsals is wider than normal. In any case, the prominent bone, or “bunion,” is more subject to pressure and friction, and can become inflamed.
To prevent problems, wear wide shoes, Lamy suggests.
The bunion can be surgically reduced, either by shaving the bone or correcting the metatarsal angles, Lamy says.
Microdactyly: Big Word, Tiny Toes
Mycrodactyly — or tiny toes — is often a genetic condition and occasionally a birth defect in which the bones may not have formed properly, or the two bitsy bones at the end may not be present at all.
In equally unusual cases, a person may have had surgery that resulted in losing a bone in the toe, or in the bone not developing as he or she grew.
Either way, these tiny toes are bumped and bashed more than usual, resulting in calluses and thickened, split, or teeny nails.
Maria Cheresposy has seen several clients with tiny baby toes in her eight years as a nail technician. She finds the circulation in the toe often is poor and the nail may grow roughly. She cautions against filing the nail smooth, which could damage it.
“I think all the techs here have seen that,” says Cheresposy, now manager of Yamaguchi Salon at the La Costa Resort and Spa in Carlsbad. “You have to push the cuticle back, trim it, and file the ends. You can buff the nail a little bit so the polish adheres. But you should never use an electric file on a fragile nail.”
Slip of a Nail
In some clients, the baby toe is normally sized, but the nail plate is tiny. This may be a genetic condition, and it’s common among people with microdactyly.
It also can be caused by pressure that partially or completely destroys the nail matrix, that area under the skin where the nail develops. In that case, removing the source of the chronic pressure may allow the matrix to heal and the nail to return to normal, Ravick says.
At Hair Hustlers, Martinez tailors her service to the client’s desires regarding their slip of a toenail. “I will leave the nail short and put a little dollop of polish on it. Some who have a larger nail ask for an acrylic overlay. As long as the nail is short and maintained on a regular basis, this is usually not a problem,” she reports. In addition, the acrylic can guard the nail against tearing when it tends to split, she says.
In the DNA
In other genetic variations, some clients may have a tiny sixth toe, or the fifth toe may look like it has a partially formed extra toenail.
“Any of the parts of the toe can be duplicated,” Lamy says. “The simplest form is an extension of the toenail. Sometimes we see an extra-wide fifth toenail. Sometimes, the nail has a cleavage in it,” as if it were trying to grow an extra one.
In some cultures, people view a sixth digit as a sign of supernatural powers and may steer children with this condition toward shamanism. But in the West, the extra digits usually are removed surgically in infancy.
Ainhum Is Rare
A very rare condition affecting mostly African-Americans, ainhum can come on suddenly in a person’s mid-forties. Ainhum is a fibrous growth that develops around the base of the fifth toe and slowly strangles the blood flow. Because the toe dries out and becomes mummified, the disorder also is called dry gangrene. The fibrous band continues squeezing right through the bone, and the dried remnant falls off two to five years after the condition appears.
“They don’t know why it happens,” Youner says, and there’s no treatment except for early amputation of the digit.
Trina Kleist is a freelance writer based in San Diego, Calif.
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