Nail Braces for Ingrown Toenails: Process, Types and Medical Benefits

What lies behind it

The nail organ of the human foot is a complex anatomical structure. The solid nail plate, scientifically referred to as lamina unguis, consists of tightly joined keratin layers. It rests on the highly sensitive and heavily vascularised nail bed and is enclosed laterally by the skin folds of the nail wall. The space between the lateral edge of the nail plate and the skin tissue is called the nail sulcus or sulcus unguis.

An ingrown toenail, medically termed unguis incarnatus, occurs when the lateral nail border presses into or pierces the surrounding soft tissue of the nail sulcus. This is to be distinguished from the pincer nail, unguis convolutus. In a pincer nail, the nail plate curves strongly transverse to its direction of growth, leading to immense pressure in the nail sulcus without an open wound necessarily being present. However, both conditions cause considerable pain and limit weight-bearing capacity when walking.

As soon as the hard keratin plate breaches the epithelial barrier of the skin, the body reacts as it would to a foreign body. The immune system activates an inflammatory cascade. This results in local hyperaemia, meaning increased blood flow, as well as oedema formation. If this mechanical stimulus persists, the body forms vascular substitute tissue. This so-called granulation tissue, colloquially often referred to as hypergranulation, proliferates over the nail border and further increases the pressure load.

Typical signs

The clinical presentation of an ingrown toenail progresses through different stages. In the first stage, affected individuals complain of localized pressure pain at the lateral nail wall. The nail sulcus is slightly reddened and swollen, yet no visible secretion or open wound area is present. The symptoms occur primarily in closed footwear or during direct palpation.

In the second stage, the inflammation intensifies noticeably. The skin barrier is breached, and watery or purulent fluid exudes from the nail sulcus. The area is highly sensitive, throbbing, and warm. Bacterial secondary colonization, usually by staphylococci or streptococci, significantly worsens the inflammatory symptoms in this phase.

In the third stage, chronic inflammation develops with marked formation of granulation tissue. The damaged skin attempts to close the lesion, but due to the ongoing mechanical stimulus, it proliferates over the nail plate. The tissue tends to bleed easily at the slightest touch.

The case of Mr M., a 42-year-old warehouse worker, serves as an illustration. Due to wearing heavy safety shoes daily and a damp shoe climate, an unguis incarnatus stage II developed on his right hallux, which had a hallux valgus tendency. Cutting down the corner of the nail himself resulted in a deep-seated nail spike, a so-called spicule, which had bored deep into the tissue. Only professional remediation within the scope of a podologische Komplexbehandlung (comprehensive podiatric treatment) and the insertion of a nail brace brought lasting relief.

Similar complaints can also be caused by other alterations. A subungual exostosis, a benign bony outgrowth beneath the nail bed, often mimics the pressure pain of an ingrown nail. Likewise, a clavus durus, a hard corn located deep within the nail sulcus, can be extremely painful without the nail plate itself being ingrown. A careful podiatric differential diagnosis is therefore essential.

Everyday causes

The reasons for ingrown toenails are varied and usually result from a combination of anatomical predispositions and external influences. The most common trigger in daily practice is incorrect trimming of the toenails. If the nail borders are cut rounded deep into the lateral nail sulcus, a sharp keratin spur often remains in the concealed posterior third. As the nail plate grows forward, this spur pushes into the soft tissue like a chisel.

Inappropriate footwear also plays a central role. Shoes that are too tight, pointed, or too shallow in the toe area press the toes together and force the nail wall against the hard nail edge. Increased moisture in the shoe, caused for example by excessive perspiration or poor breathability in work shoes, also softens the skin in the nail sulcus. Macerated tissue loses its resilience and is damaged much more easily by the keratin plate.

Foot deformities and structural misalignments alter load distribution during walking. A hallux valgus, splayfoot, or flat arched foot causes the big toe to bear excessive load on its medial border during toe-off. This lateral ground pressure continuously pushes the tissue of the nail wall against the nail plate.

Genetic factors must not be underestimated. Some people inherit enlarged nail walls or a natural tendency towards heavily curved, highly arched nail plates. Underlying conditions such as diabetes mellitus, rheumatic diseases, or circulatory disorders also alter the nail structure and reduce tissue regeneration.

When medical evaluation is necessary

Podiatric treatment with a nail brace is an effective and low-pain method. However, there are clinical scenarios that strictly require prior or accompanying medical diagnosis and therapy. Particularly when signs of systemic spread of inflammation are present, a physician must be consulted immediately.

Warning signs of a more severe infection include rapidly spreading redness across the entire toe or dorsum of the foot, throbbing pain at rest, a local sensation of heat, and the occurrence of fever or chills. A red streak running from the toe towards the heart indicates lymphangitis. In such cases, there is a risk of cellulitis or spread to the bone, known as osteomyelitis.

Special caution applies to at-risk patient groups. These include individuals with diabetes mellitus, particularly when peripheral arterial disease (PAD) or diabetic polyneuropathy is present. With reduced pain perception and impaired wound healing, minimal tissue damage left untreated can lead to deep ulcers.

Patients undergoing immunosuppressive therapy or chemotherapy, or those with severe coagulation disorders, should also have any changes to the nail sulcus evaluated by a doctor. In stage III with severe hypergranulation and purulent exudation, podiatrists work closely within an interdisciplinary network alongside dermatologists, surgeons, or general practitioners to ensure adequate wound care.

What podiatric treatment can achieve

The podiatric nail brace technique, professionally termed orthonyxia, utilizes physical leverage and tensile forces to gradually correct the deformed nail organ. The term derives from the Greek: orthos stands for straight and onyx for nail. The aim of the treatment is to gently lift the ingrown or curved nail at the borders, relieve pressure from the sulcus, and allow the tissue to heal. In the long term, the brace helps the nail bed return to its original, flatter shape.

In practice, various types of braces are used, selected individually according to anatomy, nail thickness, degree of inflammation, and nail sulcus depth:

• Wire braces: These consist of medical-grade spring steel wire and are custom-bent for the patient. Well-known examples include the Ross Fraser brace or the 3-piece VHO-Osthold brace. They attach under the lateral nail borders using small hooks. By twisting a central loop, a precisely adjustable tensile force is applied to the nail plate. Wire braces offer high stability and are exceptionally well suited for severely deformed or thick nails.
• Adhesive braces: These consist of elastic plastic or glass-fibre reinforced material, such as the BS brace or Onyclip. They are glued transversely onto the cleaned and degreased nail plate. Through the curved brace's tendency to return to its original straight shape, it generates a continuous restoring force that lifts the nail borders. Adhesive braces are particularly suited for thin, brittle nails, for children, or for a very sensitive nail sulcus.
• Combination braces: Systems such as the 3TO brace, Podofix, or Combiped combine elements of wire and adhesive techniques. Typically, a hook is engaged on one side, while the other side is glued to the nail or tensioned by twisting. They can be adapted very flexibly to unilaterally ingrown nails.

The treatment process in a podiatry practice follows a strict hygiene and therapy protocol. First, the affected foot is thoroughly inspected and disinfected. The podiatrist carefully cleans the nail sulcus using fine instruments such as an excavator to remove hyperkeratosis, skin dander, or small nail spikes. If necessary, a sterile non-woven tamponade, such as Copoline, is placed beneath the nail border to immediately relieve pressure on the tissue.

Subsequently, the chosen nail brace is fitted. In the case of a wire brace, the practitioner bends the steel wire to the exact millimetre according to the individual nail contour. After hooking the ends in place, the tension is adjusted and verified incrementally. The brace is secured with a light-curing resin composite to prevent slipping and to cover sharp edges. This allows patients to immediately return to wearing their usual footwear and resume daily activities without restrictions.

Orthonyxia treatment is a lengthy process that requires patience. A toenail grows slowly, averaging approximately 1 to 1.5 millimetres per month. The total duration of therapy is therefore usually between 6 and 18 months, depending on the degree of deformation and individual nail growth. At regular intervals of roughly 4 to 6 weeks, the brace must be checked, released, repositioned further back towards the matrix, and retensioned. This procedure is referred to as reactivating the brace.

Statutory health insurance funds have recognized the medical benefit of orthonyxia. Since 2022, nail brace treatment has been firmly anchored as a prescribable service in the German Heilmittel-Richtlinie (remedies directive). General practitioners, dermatologists, or orthopaedists can issue a prescription for podiatric nail brace treatments when indicated. Following approval, the costs are largely covered by health insurance. Unless exempt, the patient pays only the statutory co-payment of 10 euros per prescription plus 10 per cent of the treatment costs. Detailed information on billing can be found on our page about prices and billing.

What you can do yourself

Alongside professional care in the podiatry practice, your everyday habits are crucial to the success of the treatment. Through proper care and attention, you directly contribute to preventing inflammation and supporting the correction process of the nail brace.

1. Always trim toenails straight across. The nail edges should sit flush with the tip of the toe and should not be shortened below the level of the lateral nail wall.
2. Use a fine emery board or glass file to smooth the edges. File exclusively in one direction to prevent splintering of the keratin layers.
3. Limit foot baths to a maximum of 3 to 5 minutes at a water temperature of no more than 37 degrees Celsius. Prolonged soaking softens the skin in the nail sulcus and promotes the penetration of nail borders and pathogens.
4. When selecting footwear, ensure a sufficiently wide toe box. Toes must have adequate space in both length and width without pressing against the toe cap or sides.
5. Use antiseptic sprays or caring oils only after consulting your treating podiatrist to avoid unnecessarily disrupting the skin microbiome.

Common mistakes

In podiatric practice, we regularly observe well-intentioned but counterproductive measures that drastically worsen the condition of ingrown nails. Understanding these mistakes helps to preserve nail health over the long term.

• The V-cut myth: The widespread advice to cut a V-shaped notch into the centre of the free nail edge so that the nail allegedly contracts is scientifically unfounded. The nail plate grows exclusively forward from the matrix. A V-cut does not reduce lateral pressure in the nail sulcus in any way, but it weakens the stability of the keratin plate.
• Bathroom surgery: Trimming around the painful nail sulcus yourself using unsterile nail scissors, clippers, or razor blades almost always leads to deep injuries. Usually, an invisible, sharp keratin spur remains behind, maintaining inflammation deep within the tissue.
• Excessive foot baths: Soaking feet for hours in soapy solutions or curd soap causes the tissue to swell. Macerated skin loses its natural protective function, giving bacteria free rein and allowing inflammation to thrive.
• Ignoring early symptoms: Waiting at the first signs of pressure pain often leads to the formation of granulation tissue. The earlier professional pressure relief is provided, the faster pressure-free healing occurs.
• Wearing tight hosiery: Not only shoes, but also socks that are too tight or shrunken exert continuous pressure on the nail wall and push the tissue against the nail plate.

Current evidence and medical perspective

The efficacy of orthonyxia as a conservative therapeutic procedure for ingrown nails is well documented in dermatological and podiatric literature. For many decades, wedge resection, known as Emmert's procedure, was the standard surgical treatment for ingrown toenails. In this surgical procedure, a lateral nail wedge, including the corresponding matrix area, is excised. However, the surgical method is associated with postoperative pain, prolonged recovery times, and a risk of wound healing complications.

Clinical comparative studies demonstrate that the recurrence rate of ingrown nails following surgical wedge resections alone without chemical matrix cauterisation lies between 10 and 30 per cent [1]. Cicatricial tissue remodelling in the nail sulcus permanently alters the anatomy, which complicates treatment should symptoms recur.

In contrast, treatment with nail correction braces achieves high success rates while preserving maximum tissue [2]. Studies show that when wire or adhesive braces are professionally applied in stages I and II, permanent flattening of the nail plate and complete resolution of symptoms can be achieved in over 85 per cent of patients [3].

A key advantage of orthonyxia lies in immediate pain reduction. Studies on subjective pain perception on the Visual Analogue Scale (VAS) show a significant decrease in pain intensity within 24 to 48 hours after application of the correction brace [4]. Relieving pressure on the inflamed tissue enables patients to return immediately to their usual work capacity and daily activities without requiring sick leave.

International guidelines for treating unguis incarnatus therefore primarily recommend conservative measures such as nail brace therapy before invasive surgical interventions are considered [5]. Especially for at-risk groups such as diabetic patients, brace-based correction represents the procedure of choice due to the minimal risk of infection and tissue trauma.

Treatment in Memmingen

At our podiatry practice FREITAG® Podologie GmbH at Kempterstr. 25 in Memmingen, we place great emphasis on sound and precise treatment of nail problems. Owner Helga Maria Freitag has been a state-recognised podiatrist since July 2025 and qualified as a sectoral practitioner in podiatry since March 2026. With her specialization, she offers patients from Unterallgäu, the entire Allgäu region, and Upper Swabia a high degree of professional expertise.

In our modern facilities, we combine medical expertise with a calm atmosphere. The highest standards of hygiene and instrument reprocessing are second nature to us, ensuring your visit is as safe and pleasant as possible. Learn more about our philosophy on the page about our practice or gain an overview of our services.

If you suffer from pain caused by an ingrown or curved toenail, do not hesitate to seek professional support. The practice team is readily available to provide individual consultation and therapy planning. You can reach us by telephone or directly through the contact options on our contact page.