Cameo
JOGGER'S TOE
RICHARD K. SCHER, M.D.
Subungu ;:d hematoma, onycholysis, erythema , edema and throbbing pain often result from trauma to the toes. When the 3rd, 4th and 5th toes are involved injury due to jogging or Jogger' s toe should be suspected. Gibbs, i - :i in 1973, defined tennis toe as subungual hemorrhage occurring in the 1st and 2nd toes . He attributed this condition to collision between the toenails of the longest toes and the sneakers. When the foot shoots forward, the toes jam against the top of the sneaker. The resultant force ruptures the blood vessels in the nail bed . Sudden starts, stops and abrupt changes in direction appear to be cau sa tive. Hard playing surfaces also contribute to the injury. In contradistinction to tennis toe, jogger's toe tend s to involve the toes on the lateral surface of the foot. The 3rd, 4th and 5th toes are most commonly involved. Rather than sudden changes in motion, jogger's toe appears to be due to the constant pounding of the foot on the running surface. Inappropriate or poorly fitting foot gear also contribute to the pathogenesis of this condition. The process may begin with erythema, edema and separation of the toe nail from the nail bed. Less severe injury may just result in subungual hemorrhage (Fig. 1). Throbbing pain often accompanies thi s condition. Secondary infection resulting in cellulitis and abscess formation are occasional complica-
From the Department of Dermatolog)' , New York Universit)' Medical Center, New York, New York
Fig. 1.
tions .4 The condition requires little or no therapy as it clears spontaneously whether or not jogging is discontinued. It is essential to differentiate subungual hemorrhage due to athletic activity from that caused by an underlying blood dyscrasia. 4 ·s The poss ibility of an associated fracture of the di'stal phalanx must also be considered. 5 -7 Finally, the subungual pigmentation caused by trauma must be differentiated from the discoloration caused by a melanocytic nevus or malignant melanoma. In the absence of
Add ress for reprint s: Richard K. Scher, M.D., 193 Broadway, Amityville, NY 11 70 1. 00 11 -9059 / 7811 100/ 0719 / $00.60
© International Soc iet y of Tropi ca l 719
Dermatology, Inc.
720
INTERNATIONAL JOURN AL OF DERMATOLOGY
appropriate history and physical findings removal of the nail and biopsy of the nail bed may be indicated.
4.
5.
References 1. Gibbs, R. : Tenni s toe. Arch. Dermatol. 107:918, 1973. 2 . Gibbs, R.: Tennis toe. Arch . Dermatol. 228 :24, 1974. 3. Gibbs, R.: Miscellaneous Condition s of feet usually non-keratotic and of unknown cause (li sted al-
6.
7.
November 1978
Vo l. 17
phabetically). Purpura. In Skin Di sease of the Feet. St. Loui s, Warren H . Green, Inc. 1974, p. 16 1. Pa rdo-Costello, V., and Pardo, A. 0 .: Affections peculiar to the nail s. In Disea ses of the N ail s. Springfield, Charles C Thom as, 1960, p.74. De Nicola, P., Morsiani , M ., and Zavagli, G.: N ail in internal di seases. In Nail Di seases in Internal Medicine. Springfield, Charles C Thoma s, 1974, p. 80. Samman, P. D .: Nail deformities due to trauma. In the Nails in Disease. London, Willi am Heinem ann Ltd, 1965, p. 117. Farrington, G. H.: Subungual hem atom a. Br. Med. J. 1:742, 1964.
Humanism
If this were a sermon, I should have two texts. The first is late Hippocratic, and simply says "where there is love of man, there is also love of the art." My second text, written more than two thousand years later-last year, in fact-may be more familiar: "I'm mad as hell and I' m not going to take this any more! " What makes me "mad as hell" is that all too often in the medicine of today "love of man" is hard to detect; and as regards "love of the art" -well, there may be love of the science of medicine, but anyone who talks of the art of medicine is apt to be regarded as old-fashioned. No matter how scientific medicine becomes, it will always remain an art as far as I am concerned; the problem is to get medical educators to recognize that art and to teach it. Obviously there is "art," for example, in knowing what drugs to give and when to give them, but it is the wider art which concerns me-the art, for example, of handling relatives, the art of coping with grief, and the art of breaking bad news to the patient himself. And there is the art of seein g more than the disease itself-of discerning those disease processes which arise because of such things as job and domestic difficulties. The old-style general practitioner who made house-calls knew all these things. Some may say that the house-call priced itself out of the market; I think it should price itself right back in. Why, in fact, should medical care cost anything at all? Every country, I believe, should guarantee good quality medical care for everyone at no cost whatever. Thi s should be the number one fiscal and economic concern-far ahead of wars and space-shots. Why socialized medicine should so often be equated with sociali st medicine I fail to understand. And why we shoul_q continue to pay a great deal of money to enjoy the debatable benefits of modern medical technology also baffles me; there is much truth in Ivan lllich's dictum that "the medical establishment ha s become a major threat to health ." Panic traditionally engenders legi slative action ; maybe the return of something like the Black Death is necessa ry to bring about radical change in medical thought and practice.-Agnew L. R. C. : Humanism in medicine, Lancet 2 :596 , 1977 .
JOGGER'S TOE
RICHARD K. SCHER, M.D.
Subungu ;:d hematoma, onycholysis, erythema , edema and throbbing pain often result from trauma to the toes. When the 3rd, 4th and 5th toes are involved injury due to jogging or Jogger' s toe should be suspected. Gibbs, i - :i in 1973, defined tennis toe as subungual hemorrhage occurring in the 1st and 2nd toes . He attributed this condition to collision between the toenails of the longest toes and the sneakers. When the foot shoots forward, the toes jam against the top of the sneaker. The resultant force ruptures the blood vessels in the nail bed . Sudden starts, stops and abrupt changes in direction appear to be cau sa tive. Hard playing surfaces also contribute to the injury. In contradistinction to tennis toe, jogger's toe tend s to involve the toes on the lateral surface of the foot. The 3rd, 4th and 5th toes are most commonly involved. Rather than sudden changes in motion, jogger's toe appears to be due to the constant pounding of the foot on the running surface. Inappropriate or poorly fitting foot gear also contribute to the pathogenesis of this condition. The process may begin with erythema, edema and separation of the toe nail from the nail bed. Less severe injury may just result in subungual hemorrhage (Fig. 1). Throbbing pain often accompanies thi s condition. Secondary infection resulting in cellulitis and abscess formation are occasional complica-
From the Department of Dermatolog)' , New York Universit)' Medical Center, New York, New York
Fig. 1.
tions .4 The condition requires little or no therapy as it clears spontaneously whether or not jogging is discontinued. It is essential to differentiate subungual hemorrhage due to athletic activity from that caused by an underlying blood dyscrasia. 4 ·s The poss ibility of an associated fracture of the di'stal phalanx must also be considered. 5 -7 Finally, the subungual pigmentation caused by trauma must be differentiated from the discoloration caused by a melanocytic nevus or malignant melanoma. In the absence of
Add ress for reprint s: Richard K. Scher, M.D., 193 Broadway, Amityville, NY 11 70 1. 00 11 -9059 / 7811 100/ 0719 / $00.60
© International Soc iet y of Tropi ca l 719
Dermatology, Inc.
720
INTERNATIONAL JOURN AL OF DERMATOLOGY
appropriate history and physical findings removal of the nail and biopsy of the nail bed may be indicated.
4.
5.
References 1. Gibbs, R. : Tenni s toe. Arch. Dermatol. 107:918, 1973. 2 . Gibbs, R.: Tennis toe. Arch . Dermatol. 228 :24, 1974. 3. Gibbs, R.: Miscellaneous Condition s of feet usually non-keratotic and of unknown cause (li sted al-
6.
7.
November 1978
Vo l. 17
phabetically). Purpura. In Skin Di sease of the Feet. St. Loui s, Warren H . Green, Inc. 1974, p. 16 1. Pa rdo-Costello, V., and Pardo, A. 0 .: Affections peculiar to the nail s. In Disea ses of the N ail s. Springfield, Charles C Thom as, 1960, p.74. De Nicola, P., Morsiani , M ., and Zavagli, G.: N ail in internal di seases. In Nail Di seases in Internal Medicine. Springfield, Charles C Thoma s, 1974, p. 80. Samman, P. D .: Nail deformities due to trauma. In the Nails in Disease. London, Willi am Heinem ann Ltd, 1965, p. 117. Farrington, G. H.: Subungual hem atom a. Br. Med. J. 1:742, 1964.
Humanism
If this were a sermon, I should have two texts. The first is late Hippocratic, and simply says "where there is love of man, there is also love of the art." My second text, written more than two thousand years later-last year, in fact-may be more familiar: "I'm mad as hell and I' m not going to take this any more! " What makes me "mad as hell" is that all too often in the medicine of today "love of man" is hard to detect; and as regards "love of the art" -well, there may be love of the science of medicine, but anyone who talks of the art of medicine is apt to be regarded as old-fashioned. No matter how scientific medicine becomes, it will always remain an art as far as I am concerned; the problem is to get medical educators to recognize that art and to teach it. Obviously there is "art," for example, in knowing what drugs to give and when to give them, but it is the wider art which concerns me-the art, for example, of handling relatives, the art of coping with grief, and the art of breaking bad news to the patient himself. And there is the art of seein g more than the disease itself-of discerning those disease processes which arise because of such things as job and domestic difficulties. The old-style general practitioner who made house-calls knew all these things. Some may say that the house-call priced itself out of the market; I think it should price itself right back in. Why, in fact, should medical care cost anything at all? Every country, I believe, should guarantee good quality medical care for everyone at no cost whatever. Thi s should be the number one fiscal and economic concern-far ahead of wars and space-shots. Why socialized medicine should so often be equated with sociali st medicine I fail to understand. And why we shoul_q continue to pay a great deal of money to enjoy the debatable benefits of modern medical technology also baffles me; there is much truth in Ivan lllich's dictum that "the medical establishment ha s become a major threat to health ." Panic traditionally engenders legi slative action ; maybe the return of something like the Black Death is necessa ry to bring about radical change in medical thought and practice.-Agnew L. R. C. : Humanism in medicine, Lancet 2 :596 , 1977 .
