5-2
- Anti-inflammatories: Motrin 800 mg po tid with food; arthritides may need steroid injection.
Cortisone injection for acute pain: Injection mixture: 1/2 cc long acting steroid i.e., Celestone,
dexamethasone acetate, and 1cc Marcaine 0.5% plain. (See video on CD-ROM) - Consider a Marcaine block to the posterior tibial nerve if previous training and experience.
- Rest is mandatory to allow healing.
Alternative: Arch supports, injection (2cc of Marcaine 0.5% mixed with 1/2cc of dexamethasone acetate or
other long acting steroid could prove helpful for short mission if pain significant).
Primitive: Place soft, supportive material under boot insole arch area. (Ex. eye patch, 4x4 gauze cut to fit)
Patient Education
General: Get better arch support. Avoid walking barefoot if possible. For dive ops, use boot with fin if
operational mission involves movement overland once exiting water.
Medications: Gastritis side effects with NSAIDs.
Prevention: Good shoe support and arch support. Prescription orthotics may be best measure when
obvious faulty foot mechanics present. Good flexibility program.
Follow-up Actions
Return evaluation: Follow-up 1week or check more regularly if teammate. Try 2nd injection and stronger oral
anti-inflammatory if not resolved. Recommend against narcotics if operational.
Evacuation/Consultation Criteria: Evacuation not normally necessary. If conservative measures fail to give
any significant relief, consult podiatry or orthopedics. Custom orthotics will be the best consideration for the
chronic recurrent case. Consult physical therapy for treatment modalities. Athletic trainer also great resource.
Rheumatology consult if inflammatory etiology suspected (i.e., Reiter’s syndrome)
NOTES: Remember to rule out referred pain.
Think mechanical – do not just treat symptoms.
Flexibility program a key factor in treatment and prevention.
Podiatry: Ingrown Toenail
CDR Raymond Fritz, MSC, USNRIntroduction: An ingrown nail occurs when the nail border or corner presses on the surrounding soft tissue.
This condition is painful and often results in an infection once the skin is broken, with the offending nail corner
acting like a foreign body introducing pathogens. An ingrown nail may result from improper trimming of nails,
injury, tight shoes, genetic predisposition and fungal nail infections.
Subjective: Symptoms
Toe pain, especially in shoes; history of recurrent ingrown nails and infections, and previous procedures to
remove the nail.
Objective: Signs
Using Basic Tools: Most commonly involves great toe; soft tissue penetration and secondary infection,
with purulence, tenderness, erythema and edema; excessive granulation tissue in more chronic cases;
malodorous wound when gram-negative bacteria involved.
Using Advanced Tools: C&S in a severe infection before beginning empiric coverage. X-rays are rarely
considered but one should be aware that osteomyelitis secondary to a chronic ingrown nail infection is a
possibility if the condition has been neglected or chronic. X-rays will also reveal a subungual exostosis (bony
growth under the toenail) when present.
Assessment:
Diagnose this problem clinically in the field
Differential Diagnosis (may be secondary diagnosis)
Subungual exostosis - spur on the distal phalanx which pushes upward causing the nail to incurvate.