Diagnosis Usually Starts with Listening

Although an ingrown toenail often appears obvious, making the correct diagnosis involves much more than simply looking at the nail.

The consultation usually begins with understanding your history.

Important questions include:

  • When did the pain begin?
  • Has it happened before?
  • Have you had previous nail surgery?
  • Have antibiotics been prescribed?
  • Has there been drainage or infection?
  • What treatments have already been attempted?
  • What makes the symptoms worse?

These answers often provide valuable clues regarding the underlying cause.

Examination of the Toe

The physical examination focuses on identifying exactly why the nail is irritating the surrounding tissue.

Your clinician will assess:

  • The shape of the nail.
  • Nail thickness.
  • Curvature of the nail.
  • Swelling of the nail folds.
  • Presence of hypergranulation tissue.
  • Signs of infection.
  • Previous surgical scars.
  • Tenderness.
  • Drainage.
  • Skin quality.

The aim is to determine whether the problem is straightforward or whether there are additional contributing factors.

Looking Beyond the Nail

An experienced assessment also considers why the problem developed in the first place.

Potential contributing factors include:

  • Tight footwear.
  • Nail-cutting technique.
  • Repeated trauma.
  • Sporting activities.
  • Foot mechanics.
  • Nail deformity.
  • Previous surgery.
  • Medical conditions.

Addressing these factors may reduce the risk of recurrence.

Do You Need an X-ray?

Most ingrown toenails do not require imaging.

However, imaging may occasionally be considered when:

  • There is concern about a retained foreign body.
  • A bone abnormality is suspected.
  • Long-standing infection raises concern about deeper involvement.
  • Trauma has occurred.
  • Other diagnoses need to be excluded.

These situations are relatively uncommon.

Is Ultrasound Needed?

Ultrasound is not routinely required for diagnosing a simple ingrown toenail.

Unlike many of the chronic heel pain conditions I treat, diagnosis of an ingrown toenail is primarily based on clinical examination.

Occasionally, ultrasound may assist if there is uncertainty regarding an underlying soft tissue mass or another pathology, but this is uncommon.

Assessing Previous Surgery

Patients who have undergone previous nail surgery require particularly careful examination.

The clinician looks for:

  • Residual nail spicules.
  • Regrowth from remaining nail matrix.
  • Abnormal scar tissue.
  • Persistent curvature.
  • Incomplete previous procedures.

This information helps determine whether revision surgery is likely to be beneficial.

Evidence Update

Clinical diagnosis remains the gold standard for ingrown toenails. Imaging is reserved for selected situations where complications or alternative diagnoses are suspected.

Patient Tip

Bring details of any previous procedures or antibiotic treatments to your consultation. This information can be very helpful when planning the most appropriate treatment.