#ThinkToes: rehab update


Barts-MS rose-tinted-odometer: ★★★ (Toenail yellow on a gloomy Monday morning #92825A)

As a result of my fractured pelvis, I have a very painful right hip with reduced movement; I have particular difficulty bending my hip and rotating my leg outwards at the same time. As a result of this, it has been very difficult to cut my own toenails. The good news is that seven months after my accident I can now manage to get my right leg into position so that I can cut my toenails with relative ease, albeit painfully. Another small win on my way back to a new normal. This small victory is something many of my patients will never be able to experience due to the progressive nature of MS. 

In patients who I  think are vulnerable, I always try to take the time to examine their exposed feet. Unfortunately, because of COVID-19-induced NHS service changes, this is very difficult to use telemedicine.

Poor foot hygiene and uncut toenails are in my experience an integrator of neglect. As the feet are generally hidden from view, people with MS who are neglecting themselves, or are being neglected, tend to neglect their foot hygiene more than other aspects of their grooming. Their poor foot hygiene is not intentional, but simply represents the reality of living with a disability. Poor eyesight, double vision, oscillopsia, weakness, tremor, loss of feeling in the hands, slow movement, incoordination, obesity, etc. are all more common in pwMS and make cutting your own toenails difficult. 

If you are being cared for sometimes the family member or carer doesn’t take this and leave it up to the podiatry service. During the COVID-19 lockdown nail bars and podiatrists have been closed. Therefore I have little doubt that foot hygiene has deteriorated in many people with advanced MS. 

So if you are a carer or a family member of someone with more advanced MS can I suggest you ask your family member if they need some assistance with their foot hygiene. Even better ask them if you can examine their feet. You may be in for a surprise.  

I am convinced poor foot hygiene, similar to poor oral hygiene, is a social determinant of health. People with MS who have bad teeth, poor gum health and poor foot hygiene are more likely to have poorer outcomes. These should be red flags for putting pwMS on the ‘at risk’ register of closer medical and social interventions. Do you agree? 

So if your family member or client with MS can’t manage to look after their own feet please get them down to the local nail bar or podiatrist for a pedicure. 

Conflicts of Interest

Preventive Neurology




General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust and are not meant to be interpreted as personal clinical advice. 

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • “Another small win on my way back to a new normal. This small victory is something many of my patients will never be able to experience due to the progressive nature of MS.”

    Prof G,

    Thanks for this. When you had your accident, I cringed at the severity of the injuries, but was also confident that excellent medical care and your own determination would see you get back to normal eg running again. As you say, MS is a different beast. With the exception of patients who get HSCT early, I can’t see many patients shaking their neuros hand and saying “thanks for giving me a second chance”. I remember seeing my father in law say this to his heart surgeon and it was a joyous event for both. Treatments for all which stop progression (not just relapses) will be the real game changer for both patient and neurologist. I hope you are still practising when such treatments are available.

  • Great thoughts about foot care. Visiting Nurses are particularly skilled at the Gnarly ones. Need good toenail cutters. Epsom Salt soaks before cutting really helps. Oil afterwards. Those big ones can get scary. Feet hide easily and can be embarrassing to the patient. Diabetics too, need a care plan for foot care.

  • Oh no-ooo not a toe photo again! Been a few years since the last one I guess…

    Joking aside, valid point.

    • Who cuts them for you? A podiatrist (medical), a nail bar (cosmetic) or someone close to you (partner/family/friend/carer)? I am told that this is something that is rarely asked about in routine clinical practice.

  • As others have said soften the toenails first.
    Could then use long handled toenail clippers (available online), for those with weakened hand grip or limited mobility.

  • Prof G, surely as a neurologist you don’t have to worry about toenails? Isn’t your time more valuable than that?

    • Yes, if you manage people with MS in the current social environment that exists in the UK you have to worry about these sorts of things. Deprivation, social isolation, poverty, physical and emotional abuse are happening to pwMS in the UK and elsewhere all the time. The physical signs need to be looked for. If we don’t do it we are shirking our responsibilities. Saying this a colleague said to me that it was time for me to stop my clinical practice; his argument was my time was better spent doing research than seeing patients. I disagreed with him; being on the coalface makes the research side of things more meaningful and more urgent.

    • I have also detected several pressure sores/ulcers on the heels of pwMS who are bed or wheelchair-bound by insisting to examine their feet. Unlike uncute toenails, pressure sores are a notifiable disease as they are recognised as a sign of problems with care. Finding a pressure sore causes social services to get involved and is often the trigger for more services to be provided. The message is examining the feet of disabled pwMS is important.

  • Actually nail fungus..is a sign of autoimmune disease…hypothyroid disorder.

    “The thyroid is a small gland located in the neck and is responsible for warming up the body, regulating an immune response, maintaining metabolism and directing growth. Toenails can actually be a sign of bodily problems and fungal toenails can be a byproduct of an imbalance. The reason this connection exists is that the thyroid hormone is what controls the strength of cardiac contractions. So the more robust contractions are, the greater the amount of blood will be supplied to body parts, such as the toes. Thus, when contractions are weaker and provide less blood flow, the toes will receive decreased amounts of oxygen, get cold and allow for an environment favorable to fungus.”


    • Fugal infection of the toenails is very common even in normal people. From an evolutionary perspective, our toes went meant to be kept locked inside sweaty socks and shoes. The best prevention of fungal infection of the feet and toenails is fresh air and sunlight.

  • Given (1) consultants in the NHS are the high earners and (2) that most appointments last only 15 mins, checking in-growing toenails and bunions is not a good use of precious NHS resources. What are you planning to do next? Ear wax removal, nose piercings? Please can you get back to the hard stuff ie addressing progression! What do you want to be remembered for? The doc who cracked MS or the proprietor of a tacky nail bar in south London?

    • It is irrelevant the cost of consultation or of time allotted for a patient encounter.
      The Quality of the Visit,
      The Purpose, is what is important.
      Head to toe assessment takes very little time as you’re asking your usual questions.
      If you never saw the Gnarly nail, it may have been the only sign of self neglect or caregiver neglect or simply a reason for an unsteady gait and decreased mobility. Check their feet. It only takes a second or 1/60th of an minute

  • This article certainly describes the reality of living with MS, the nerve, muscle pain also following 2 calcaneum breaks attributed to RSD as a complication, including further diagnosis of Coeliac disease /Neurological symptoms complicate life, living it without self neglect is difficult with depression, anxiety disorder , osteo arthritis etc etc

By Prof G



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