Is It Possible That I Have Gout?
Gout can cause patients a significant amount of pain; however every time there is pain in the big toe with lack of trauma to the area, patients automatically assume “its gotta be gout!” However, there are certain characteristics of this arthritic disease that set it apart from other big toe pain or joint pain.
What Is Gout?
Gout is actually an arthritic condition where the body has an increased level of uric acid in the blood. Uric acid is the by-product of the breakdown of certain foods. The increased concentration of uric acid can either be from your body’s over excretion, or your body’s over production, of uric acid with the body’s decreased excretion through the kidneys. So a patient is either considered an “over producer” or an “under excretor.” Either way, the levels of uric acid increase in the blood and collect in certain joints. Gout can occur in any joint in the body where the uric acid collects and then crystals form. In the foot, the most common joint for this collection is the big toe joint. However, our doctors occasionally see gout in the other joints of the foot, including the ankle.
What Causes Gout?
Many foods and even alcohol consumption have been linked to gout. Diet concerns such as increase in red meat consumption or wine or other foods that produce uric acid upon metabolization. Some medications can even have increased uric acid as a side effect, thus causing accumulation and a gouty flare up.
How Is Gout Diagnosed?
A patient may describe the pain in the big toe joint so severe that now only can they not walk, but even the bed sheet or a sock touching their foot causes pain. They may present with a hot, swollen, red big toe joint at the base of the toe. However it is important to understand that although the big toe joint may be the most common joint to be affected, gout can occur in other joints in the foot. The most common way to diagnose gout is by clinical findings. Although there is a blood test that can be taken to measure uric acid levels in the blood, very often in an acute attack, the levels are actually normal. The doctor can confirm gout by actually collecting synovial fluid, or joint fluid, by an aspiration with a needle. This procedure can be done in the office and often will be performed under local anesthesia. A small sample is taken and sent to the lab, where there is verification of the presence or absence of gout crystals. On the surface, the gout crystals are referred to as gouty “tophi.” The tophi look white and solid, almost like cottage cheese. When a radiograph, or X-ray, is taken of the foot, a person with a history of gout may have changes to the head of the first metatarsal consistent with gout such as subchondral cysts or the absence of bone at the head which may appear as a “rat bite” or deficiency in the bone.
What Else Could It Be?
If there is lack of trauma to the affected area, but still presents as a hot swollen joint, it could be a septic joint. A septic joint is an infection that is in the joint caused by bacteria causing the inflammatory response. Another explanation is that it could be pseudo-gout. Pseudo-gout occurs when there are crystals present in the joint, they are made up of calcium pyrophosphate, and not due to tophi formation from increase in uric acid.
How Do You Treat It?
There are various treatments for an acute gout attack. First and foremost, the doctor wants to make sure that the patient is out of pain. There area various ways to do this, from oral medications to injection into the affected joint. For oral medication, there various NSAIDs (non steroidal anti inflammatories) but the most common is indomethacin. Although this is the most traditional, any NSAID can be used. One must always be cautious of renal function when taking NSAIDs, and because of this, oral NSAIDs cannot be used as a long term treatment. Another oral medication that can be used is oral steroids. A common steroid is prednisone, which is usually started at a high dose such as 60mg and tapered down. Oral steroids should be used with caution, as side effects include increase in blood glucose and increase in insulin use. Intra articular cortisone injection and also provide relief, but in a diabetic patient, blood sugars should still be monitored. No other medication that can be used is colchicine. Colchicine interrupts steps in the pathway to inflammation due to gout, although the pathway is not completely understood. Side effects of this medication include nausea and GI upset, and this may be a rate limiting step.
How Do You Prevent Gout?
In order to prevent a gout attack, the best way is to take medications that will in effect decrease uric acid levels in the blood. It is important to work with the patient’s primary care physician or rheumatologist (arthritis specialist) to find out which medications are the most effective if the patient is determined to be an over producer or under excretor. In addition, there may be dietary changes that are recommended. Other tests may be run, such as a 24 hour urine collection which measures uric acid excreted. Your PCP or rheumatologist will take all of this information and work with your podiatrist in order to help prevent another gout attack.
If you have big toe joint pain in the lack of trauma, consider an episode of gout. It is important to consider that it could be a gout attack. See your podiatrist at Prairie Path Foot and Ankle Clinic in one of the acute/emergency spots, and have your foot examined, radiographs taken, and a treatment plan discussed.