Toe and Foot Care

Posted by Nurse Linda in Life After Paralysis on March 28, 2022 # Health

With the changing weather, our bodies need different care. Cold days require protection for warmth, cooler days not so much. Rain requires protection, snow even more so. It seems that we go from season to season this time of year, sometimes in days and sometimes in just hours. Our feet are particularly vulnerable to weather changes because they are the body part that is farthest from the heart, so blood flow can take a moment to adjust. They are also susceptible as there is not much tissue to protect them from temperature changes.

Even though sensation signals may not be fully reaching the brain, the body is still sensing those temperature changes. Typically, if any location of the body is feeling too warm or cold, even minute changes, a message is sent to the brain to enlarge blood vessels so more heat will be removed from circulation or to make blood vessels smaller so less body heat will be lost. If the message cannot reach the brain, this vascular change will not occur, fully or partially.

The other sensory process with temperature change is feeling cold, so you put on more clothing or feeling warm, so you put on lighter clothing. The brain needs to receive messages to make you act. However, your body is still reacting to the change in temperature. Without compensation measures of vascular changes or physical acts of adjusting clothing, your body is left unprotected or overprotected.

Caring for body parts with decreased sensation can be a challenge. When you are not receiving signals that something is in disarray, it is often easy to forget or not worry about them. Hands and fingers are more visible, but feet and toes are way down below eye level and usually out of sight, making them easy to overlook.

One of the easiest things to do to care for your feet and toes is to dress for the weather. However, I still meet individuals who have exposed feet in the cold, rainy, and snowy months with no covering on their feet. Their feet are red, swollen, chapped and perhaps even with blueish toes due to frostbite. Their comment is, oh, I don’t feel it. But this is a perfect example of their body reacting.

Photo of a pair of socksWhen the weather is cool or cold, warm shoes are a necessity. Socks not only help the body maintain heat but protect the shoe from rubbing. Your foot might not rub in your shoe from the active movement of your body, but your body is exposed to external movement from vibration from car travel or powerchair or even bumps as you propel yourself. Braces and orthotics can also rub as you move. You may not have the ability to sweat, but even a small amount of moisture can affect your skin. Socks help absorb that moisture.

Be sure your shoes fit your foot. Feet change over time. The less shoes are worn, the more your feet change. This was one of the lessons learned in the isolation times of COVID. People stayed in and did not put on shoes every day. When they started to go out, they found their shoes no longer fit as their feet had changed.

Have your foot measured periodically as they change over time. If you cannot go to a shoe department with a foot-size measuring tool, have someone trace the outside of your foot while it is hanging down or while you are seated. Then take the drawing to the shoe department to use in the size measuring tool. This will give a fair approximation of your shoe size and, importantly, width. Try on sizes and differing widths, checking for the best fit. There should be adequate room around the circumference of your foot, space between your toes and the front of your foot, and the heel should be seated in the back of the shoe. Check your new shoes for changes in pigmentation anywhere on your foot to look for pressure injury. Check when your feet are in different positions.

Tone (spasticity) has a huge effect on shoes. Getting a foot into a shoe that has tone can cause a spasm or cause the toes to curl, which you may not recognize. Mispositioning of the toes in shoes (curled toes) can lead to continued tone, discomfort, ingrown toenails, skin breakdown, and episodes of autonomic dysreflexia. If this is an issue, check with your healthcare professional to see if further treatment is needed. Purchase shoes that are made to open wide so as to allow you to position the toes within the shoe.

Good hygiene should be provided to your feet to ensure your skin is properly maintained. Wash your feet with a mild soap in warm water and dry thoroughly. This may seem like a simple step, but feet are often just rinsed by people. Old skin cells slough off as your feet move within your socks. Old skin cells may cling to your feet without this friction, leading to dry, flaky skin. The friction of a washcloth will help remove the old skin cells. Too many clingy old skin cells will collect on your feet in the form of calluses.

Callouses usually collect on the most used surfaces of the body, on your feet, especially the heels and balls of the foot. Callouses are hard, dry skin that does not have healthy skin elasticity. These areas do not stretch and have no blood supply. This area clings, replacing healthy, moist, elastic skin. When thick, the callus will crack, creating an opening to the inside of your body. This is a pathway for infection. A cracked callous is also painful, which you may not sense, but your body still reacts to pain.

To reduce a callous takes time. Soak the foot or area of the callous with warm water. You can place your foot in a basin of warm water or wrap a warm, wet towel around your foot to add moisture to the callous. The use of a washcloth is to ‘buff’ the area of the callous. You might not see a slight layer of the callous coming off, but it is. Several daily sessions will be needed before you begin to see healthy skin forming under the callous. As the callous is being reduced, healthy skin is reforming below it. Sudden callous removal with a sharp object can easily cut the foot, creating that bacterial opening or does not allow time for the healthy skin to form, leaving your foot susceptible to skin breakdown.

Toes are extremely important as well. They provide input to the brain about temperature but also a lot of input about balance and particularly body support, even if you do not recognize toes working. Taking care of your toes is an important task.

Trim your toenails straight across to avoid ingrown toenails or exposure to the toenail bed. The toenail protects the toenail bed from infection. When the toenail bed is exposed, an open skin area is now available for infection. You can avoid cracking the toenails if you cut them after bathing, as the nail will be softened from the water. You may need to clean under the edge of the toenail with an ‘orange stick’ or a soft wooden stick made for the job. Be cautious not to go in too deeply, again separating the toenail from the toenail bed. Many individuals will use the services of a podiatrist for nail care.

Check your toenails for fungus under the nail. This may appear on one toe or several. Anyone is susceptible to toenail fungus. However, individuals with diabetes, type I or II, are at a higher risk. Talk to your healthcare professional about treatment for toenail fungus. They may recommend a prescription antifungal cream, polish, or toenail removal. The toenail does grow back. Protection to the toe is needed during this process. Your healthcare professional may recommend an over-the-counter product, but these are not as safe to use with decreased sensation and possible infection for individuals with decreased sensation. Earlier treatment of toenail fungus makes the healing process much quicker and less invasive.

Between your toes, athlete’s foot, a type of fungus can develop. This can be from not drying between the toes well enough. The key sign of athlete’s foot is itching. This may not be felt with sensation issues. Other signs are cracks in the skin between the toes, flakiness, and inflammation. Over-the-counter treatments are available, but some cases are severe and do require prescription treatments. Athlete’s foot is very irritating, which can trigger episodes of autonomic dysreflexia.

With any part of the body, pressure injury can occur. There are many places on the toes and feet where pressure injury can arise. The back of the heel, the bottom of the feet at the heel and ball of the foot, the outer edges of the foot and the tips of the toes, bottom of the toes and top of each of the tiny joints in the toes are places where pressure injury can occur.

Inspection of the feet should be carefully done twice a day at a minimum. Look at all aspects of your feet in the morning as pressure injury can occur in bed, and in the evening from shoes. If it is early after your injury, you will need to check more frequently. Increase frequency of skin checks should occur if you have new shoes or any new equipment that may affect your feet or toes. Any change in pigmentation should be regarded as a pressure injury unless or until another source of the pigment change is found. Do not rub the area as this increases pressure. Stay off the area and do not use the shoe or equipment until the area has been resolved. Be sure to modify the equipment if that is the source of injury.

Feet and toes are important parts of the body but are often overlooked. Careful maintenance is critical to your overall health.

Pediatric Consideration:

Children’s feet can change overnight. Every parent has a tale of buying new shoes only to have them not fit the next week. Be sure you give both of your child’s shoes a quick check for fit each time you put them on. A feel around the shoe will generally give you the information needed.

Tone (spasticity) is especially an issue with children and shoes. They may not be able to tell you something is amiss with their toes or feet due to lack of sensation or their developmental level. Be sure to check to make sure the feet are properly placed within their shoes. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

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The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.