Toenail Pain: Causes, Treatment, and When to Seek Care

Everything You Need to Know About Toenail Pain

Toenail pain may seem like a minor concern, but in some cases, it can dramatically impact your ability to go about your day. While this type of pain may develop quickly after an injury, or trauma, it can also come on more gradually if an ingrown nail or an infection is to blame.

This article will outline the most common causes of toenail pain, the symptoms that frequently accompany it, and the treatments that can help alleviate it.

AndreyPopov / Getty Images

Various conditions can cause pain to develop in your toenail.

Ingrown toenails (onychocryptosis) occur when the nail plate of a toe begins to grow into the surrounding skin (called the periungual fold) on either side of it. When this happens, the affected skin area can become inflamed and painful.

This problem is extremely common and accounts for approximately 20% of foot issues seen by family healthcare providers. While any toe can be affected, the big toe is the most common toe to develop an ingrown nail.

Toenails that become ingrown in the surrounding skin begin to cause inflammation in this area. As a result, the surrounding skinfold usually becomes puffy or red in appearance. In addition, a skin lesion may form and, in more advanced cases, foul-smelling drainage may be emitted from the toe.

Toenails are also particularly susceptible to fungal infection (onychomycosis) because they are frequently in the dark and in moist socks for prolonged periods of time.

While mild fungal infections don't typically lead to soreness, more advanced cases can cause the nail plate to separate from the nail bed and cause toenail pain. Up to 10% of the general population and 50% of people over the age of 70 experience this problem.

The hallmark sign of a toenail fungal infection is discoloration or thickening of the toenail, with many turning a yellow or brownish hue. Fungal infections may also cause the toenail to split in two or begin to separate from the nail bed itself. In many cases, indentations or irregularities also appear on the nail's surface.

Trauma to a toenail can also cause pain to develop in the region. This type of soreness frequently occurs as a result of an acute injury, like stubbing your toe or dropping something on it. It can also happen because of repetitive microtrauma (a slight injury), like the toe rubbing against the inside of a narrow shoe, over an extended period of time.

By whatever cause, injury to the toenail usually causes the small blood vessels under the nail plate to leak blood (subungual hematoma) and can make the area tender to the touch.

A traumatic toenail injury can cause the area beneath the nail to turn a red, purple, or black color. This discoloration commonly resembles a tiny bruise on the nail bed. In addition, depending on the severity of the injury, a toenail trauma may also partially lift the nail from the nail bed or cause it to fall off completely.

Any toenail pain that occurs after a trauma should be examined promptly by a healthcare provider. This is especially true if it is accompanied by uncontrolled bleeding or if another area of the toe or foot is also injured. In addition, pain that is intense in nature or getting progressively worse should be evaluated to ensure it is appropriately treated.

See a healthcare provider for any foot or toe pain if you have a condition that affects circulation or healing, including neuropathy, diabetes, or peripheral artery disease.

A healthcare provider may use the following tests to determine the cause of your toenail pain:

Mild to moderate ingrown toenails are usually treated conservatively by modifying your footwear to avoid constriction in the affected area and soaking the toe in warm, soapy water.

Occasionally, a steroid cream or a pressure-alleviating tape is also used to reduce skin fold irritation. In severe cases, a portion of the nail may even need to be surgically removed to effectively resolve the problem.

Fungal toenail infections can be treated with a variety of medications, depending on the type of fungus that is involved. Oral medications such as Sporanox (itraconazole), Diflucan (fluconazole), and Lamisil (terbinafine) are the most widely used medications for this issue.

Topical medications may also be administered to the nail, though they have been found to be less effective than oral medications. In addition, regular nail trimming has been shown to improve the success rate of oral medications when treating toenail fungus.

Minor trauma to a toenail is often treated at home. Wash your toe gently with mild soap and water. Protect the nail from further damage by wearing open-toed shoes and covering it with a sterile bandage. To address pain, apply an ice pack (with cloth between the skin and the ice) for 20 minutes every two hours. Elevate the foot above your heart.

If the nail is raised or loose, you may have broken your toe or an infection has developed. If you see signs such as pus drainage or a red streak, see a healthcare provider for treatment. They may drill a hole in the nail to relieve pressure or trim a loose nail. It is not recommended that you do this at home.

If a toenail trauma causes your nail to fall off, your nail may take up to nine months to grow back.

Ingrown nails and fungal infections are common causes of pain in the toenail. An injury or trauma to the area can also be to blame. In many cases, toenail pain is accompanied by other symptoms like redness, drainage, puffiness, or discoloration.

Oftentimes, an evaluation by a medical professional is all that is needed to properly diagnose the issue. While noninvasive treatments like footwear modifications and medications are usually effective treatments, some toenail pain may require surgical intervention.

Mayeaux EJ, Carter C, Murphy TE. Ingrown toenail management. American Family Physician. 2019;100(3):158-164.

Westerberg DP, Voyack MJ. Onychomycosis: current trends in diagnosis and treatment. American Family Physician. 2013;88(11):762-770.

American Osteopathic College of Dermatology. Subungual hematoma.

By Tim Petrie, DPT, OCSTim Petrie, DPT, OCS, is a board-certified orthopedic specialist who has practiced as a physical therapist for more than a decade.