When the side of toenail hurts but its not ingrown, the pain can be overwhelming—literally—if it is a case of excruciating pain on the side of a toenail. Many patients don’t realize that they are not only experiencing an ingrown toenail issue. In fact, for many patients there can be pain on the side of a toenail for a variety of reasons, all of which are entirely unrelated to the toenail needing to grow out of the skin (which is the classic ingrown nail problem).
Knowing the true cause can be important as the treatment varies dramatically—so read on for the most common etiologies of pain on the side of a toenail, how to differentiate them, what things you can do about it at home, and when to see a podiatrist for treatment.
Why Side of Toenail Hurts Not Ingrown
Pain at the nail edge doesn’t necessarily signify that the nail is dig into the periungual skin. The true ingrown toenail is when the free, sharp margin or edge of a nail actually cuts into the periungual tissue and elicits a wound response. The side of a toenail may be painful when the nail itself is healthy but the irritated tissue, periungual fold or nail bed itself is the true area of pain.
However, it is real, and making the distinction truly important. If, however, you push on the skin along side of your nail, and it is tender, but there is no sign of any of the nail edge sitting embedded in flesh, something else is up. Inflammation or infection often presents with pain, redness or swelling focused on the skin fold and not the nail itself.
Likewise, if the pain is worse after a marathon or long day in close fitting footwear, this suggests a mechanical insult, not a structural problem with the nail. Anterolateral side nail pain is more common than most of us appreciate.
Common Causes When Side of Toenail Hurts
Many conditions can cause pain along the edge of the toenail without actual nail ingrowth. Common examples are fungal infections, repeated trauma, footwear that is too tight and thickened skin in the nail groove. Each has a slightly different presentation and its beneficial to know the subtleties to eliminate the possibilities.
Paronychia and Skin Inflammation
Paronychia is an infection of the periungual skin—and may resemble an ingrowing toenail (onychocryptosis) without being one. Acute paronychia develops rapidly, often following a minor skin break, vigorous nail cutting, or an inflamed hangnail. The tissues on either side of the nail are inflamed, erythematous, edematous and tender.
A pustule may be seen just below the surface of the skin. Chronic paronychia occur more slowly, and is more common in those with wet feet for long periods, or for those with diabetes. This is caused more commonly by fungal organisms rather than bacteria.
The nail fold is constantly inflamed, and may become thickened, and the nail may become discoloured or show evidence of lifting at the base. It is not painful as acutely, but the pain is continuous and purulent.
Pressure, Curved Nails, and Callus Buildup
Certain toe nails are arched naturally, not to the extent that it is obvious when looking down at your foot but sufficient enough that as you walk, the edges of the nail bear against the groove of the nail bed. This feature is sometimes referred to as a pincer nail/involuted nail. It does not pierce the skin but causes a considerable amount of mechanical pressure which, when persistent for a length of time, can give rise to localised discomfort.
Onychophosis is another underrecognized aetiology. This describes a collection of hardened, calloused skin within the nail groove. In the absence of true ingrowth this thickened tissue gradually results in a collection of hyperkeratotic tissue in the space between the nail edge and the periungual skin, pinching and painful.
Tight footwear compound this rapidly. This can be safely excised by the podiatrist simply and relatively painlessly: a good quick fix!
Symptoms That Help Identify the Cause
The subtle nuances in nature of the pain you notice tell you a lot. Pain that is throbbing and not relieved by analgesics, increases overnight and is associated with swelling points towards infection. A dull, pressure type pain that peaks after physical activity such as running, walking on hilly terrain or long hours spent on feet indicates a more mechanical or structural abnormality.
Discoloration of the nail, in the form of a yellowish or brownish stain spreading concentrically from the margin is also characteristic of fungal rather than in-grown pathology. Subungual hematoma (bruising under the nail) can also be painful along the margin, more so if the foot has been dropped on, or after strenuous downhill walking. The blood accumulated under the nail exerts a pressure radiating from the center.
What Makes It Different From an Ingrown Toenail
In reality when you look at the nail it will be apparent that the edge of the nail has broken or cut into the skin, the skin next to the nail is generally inflamed and may be broken and weeping and there will be a definite point of entry a sharp corner pressing into soft tissue and this is where the pain is felt. If the nail isn’t ingrown, the tenderness will usually be scattered and spread out. The skin may be swollen or inflamed over a larger surface than a single point of tenderness.
If you gently run your finger through the groove, you should not feel a nail edge pushed into the flesh. This simple check can help you decide whether to manage the condition yourself or seek treatment.
Home Care and When to Get Treatment
Less severe cases of lateral toenail pain can be remedied with more straightforward approaches. Immersing the foot in warm water (not scolding) for 15 to 20 minutes helps soften the skin around the toe and also temporarily alleviates the immediate pain. Transitioning to wider shoes with more room alleviates the mechanical stressors at work that aggravate the toe on a daily basis.
Proper hygiene (keeping the toe dry, especially after soaking the toe) can prevent secondary infection from occurring. In my opinion, keeping the nail edges squared rather than rounded is possibly the single best maintenance habit we can promote. It gets rid of the primary mechanical trigger of both ingrown nails and pressure-induced groove pain.
Signs You Should See a Doctor
Some symptoms cannot be tolerated and need to be seen by a doctor, for example pus drainage from the nail fold, red streaking up the toe or foot, fever or the presence of severe pain that does not improve with over-the-counter pain medication. These should be seen by a medical professional as soon as possible. Particular caution needs to be taken by people with diabetes or poor circulation, as even the smallest nail and skin conditions can worsen rapidly.
How to Prevent Side Toenail Pain
Prevention is easy once the triggers are understood. Keep the toenails trimmed every 4–6 weeks. Keep them trim and straight across (avoid coining or very short cuts at the corners).
Wear shoes with large enough toe box that your toes are not compressed together; sweat controlling socks will also slow down the softening of the skin. Let your feet dry after every workout before you re-close the shoes; examine nail grooves regularly so you may avoid thicker and painful callus buildup.