gout

Author: Dr. Marc Mitnick
Reviewed by: Medical Review Board

WHAT IS GOUT

This is an arthritic condition that occurs primarily on the feet, although it certainly can manifest itself in other parts of the body. It affects about 3% of the population and is predominantly a male disorder with only 5% of the cases affecting females, generally post menopause.

This condition is associated with hyperuricemia which is an increased amount of uric acid crystals circulating through the blood, however, not all people with hyperuricemia experience gout attacks.

Conditions that may be mimic a gout attack include:

Comparison of Gout and Similar Foot Conditions

Condition	Primary Cause	Key Distinguishing Features	Diagnostic Method
Gout	Uric acid crystal buildup (Hyperuricemia)	Sudden, acute onset (often early morning); extreme redness and swelling; commonly in the big toe joint.	Testing synovial (joint) fluid for uric acid crystals.
Cellulitis	Bacterial infection of the skin/tissue	Often features a visible break in the skin or a wound; lacks joint crystals.	Analysis of joint fluid to check for bacteria vs. crystals; WBC/ESR lab work.
Septic Joint	Infection within the joint space	Intense pain and swelling; dangerous to treat with steroids (which worsen infections).	Aspiration and analysis of joint fluid for bacteria.
Osteoarthritis	"Wear and tear" of joint cartilage	Generally a gradual onset of pain; related to activity and long-term use.	Clinical history and X-rays showing joint space narrowing.
Tophus	Chronic accumulation of uric acid	Presents as an irregular lump; can break through skin to release a chalky substance.	Physical examination of the lump's texture and appearance.

Gout Symptoms

Unlike osteoarthritis or the “wear and tear” arthritis we all suffer, the symptoms of excessive uric acid production are different in that it is manifested by an acute onset of severe pain, redness and swelling, many times for no apparent reason.

In gout pain many patients will complain of a sudden onset of pain occurring early in the morning while asleep. The theory behind this is that when sleeping, the feet are elevated and there is a slight diminishment of blood to the feet which in turn decreases the temperature of the feet just enough for the uric acid to crystallize (gout crystals) in the joint of the foot and create pain.

Other factors that may precipitate this attack include:

• local trauma
• foot surgery
• an acute medical illness including diabetes, hypertension, kidney disease, hyperlipidemia
• a high purine (protein) diet, including organ meats, seafood
• high fructose (sugar) diet
• an alcohol binge
• medications such as diuretics (water pills) low dose aspirin and cyclosporins
• chemotherapy
• high body mass index and metabolic syndrome
• genetics

These attacks most commonly occur in the foot, primarily in the big toe joint. The next most common locations are the middle of the foot followed by the ankle joint. They can also occur at the attachment of tendons such as the Achilles tendon into the heel. It is possible to have these attacks in more than one area at the same time.

Below are common sites for the attacks.

What is tophus? In chronic hyperuricemia, even without acute attacks, there can be an accumulation of uric acid, usually in the area of a joint or tendon insertion. The over-production of uric acid crystals may then cause a lump to form under the skin. It will not be smooth, but rather irregular to touch. In some cases it can break through the skin resulting in a white or yellow chalky substance.

DIAGNOSING GOUT

Diagnosis is generally on clinical appearance and the presenting history because it is not uncommon for a patient’s uric acid level to be normal during an attack. in fact, the only way to confirm a diagnosis of gout is to actually test for uric acid crystals in the synovial fluid (joint fluid).

In some instances gouty arthritis may be mistaken for a cellulitis as an infection in the great toe joint will also present with what appears as a red hot swollen joint. The difference is, in a cellulitis there is almost always a local point of open skin where bacteria has invaded and caused an infection.

Analysis of the joint fluid for uric acid crystals vs. bacteria is the treatment of choice in making the proper diagnosis.

Lab work may be helpful to differentiate between the two conditions. This would include a white blood count (wbc), erythrocyte sedimentation rate (esr) and renal function studies.

GOUT REMEDIES

Gout Medicine

Colchicine is the drug of choice in acute attacks and is almost diagnostic for gout if the pain is alleviated by the drug. This drug should not be used in individuals with kidney or liver disease, nor in those on dialysis.

Anti-inflammatory class of drugs may also be used, but it is important to note that they all do not work for this problem. In fact, low doses of aspirin will actually worsen an attack. The two anti-inflammatories I use are Indocin and Naprosyn. Consultation with your foot specialist is essential.

Steroids may be used in individuals who cannot tolerate NSAID's. They can be administered both orally and injected into the joint. When injected your doctor must make absolutely sure that you are suffering from gout and not a septic joint as an injection will only make matters worse.

The pain generally lasts a few days, and then begins to diminish. The problem is when a person experiences multiple attacks over short periods of time. Aside from the pain of the attack, each attack does damage to the affected joint and a person can reach the point where there is so much damage from the repeated attacks, the joint now becomes constantly painful and surgical intervention is usually necessary.

In those individuals experiencing repeated attacks of gout it is necessary to find out why. Generally speaking, it is usually from either the body overproducing too much uric acid or the kidneys excreting too little uric acid. In either event there is too much uric acid circulating throughout the body. Consultation with your family doctor is necessary to determine the cause. There is medication available to treat both causes.

Allopurinol In situations where a person is having attacks on a repeated basis, he or she should be on oral medication to control uric acid production, rather than medication to reduce the inflammation of an individual attack. This way destruction to the joints of the feet and ankle are minimized and of course there is less overall pain.

Uricosurics Where it is determined that the kidneys are under excreting uric acid, this class of medication helps improve the removal of uric acid from the kidneys.

Gout Diet

Diet modification Patients who are prone to attacks should modify their diets in regards to a low purine diet and should abstain from organ meats such as sweetbread, liver, kidney, anchovies, sardines, rich gravy and alcohol.

Recent research has shown that there is a correlation between elevated uric acid levels and excessive intake of fructose (sugar). People who eat way too much sugar in their diets will tend to have elevated uric acid levels.

The significance of this is that even though these individuals may not suffer gout attacks, the elevated uric acid becomes a marker for poor health secondary to poor eating habits. People who eat too much sugar in their daily diets are subject to what is known as metabolic syndrome. This increases their risk of diabetes, hypertension, and stroke just to name a few of the serious problems that can develop.

Gout Natural Remedies

Cherry juice? A simple treatment that has been mentioned in various sources is that of eating cherries or drinking cherry juice on a regular basis. This may diminish the attacks. It is postulated that the anthrocyanins in cherries reduces the amount of uric acid circulating in the blood.

Vitamin C? In an article published in the ARCHIVES OF INTERNAL MEDICINE (2009) it has been suggested that increasing your intake of vitamin C may reduce the incidence of gouty arthritis. click here for the article.

REFERENCES

Mayo Clinic

MedlinePlus

Centers for Disease Control

see related article....arthritis

see related article....cellulitis

Questions I Have Answered From Visitors

Sensitive spot on left foot

by Derrick
Cape Town, South Africa

Hi there,

I have a very sensitive spot on the inner side of my left foot, just behind the big toe joint. It is slightly swollen and red. From the little research I have done I have learnt that this area is called the Thymus Gland area, if it helps at all. At first it sort of in the joint and I thought it might be gout and took the necessary, but now it is on the side of my foot. Sometimes I get a sharp burning pain and then if I try to bend my big toe down all the way, well, let's just say, dictionaries are rewritten. What could the problem be?

Hi Derrick,

Lets first get our anatomy straight. The thymus gland is located in the chest, in front of the heart and just behind the sternum. Now lets talk about your foot.

Gout is certainly an option here as the big toe joint is the most common joint in the body to experience a gout attack. Most attacks occur early in the morning, for no apparent reason. There is no history of trauma nor do most patients relate a lot of activity the day before. The reason these attacks occur first thing in the morning is because while you are sleeping and your feet are elevated, the temperature in your feet cool down a bit and this allows the uric acid to crystallize in the big toe joint and thus you get pain.

The thing about gout attacks is that they are usually self limiting, meaning you have pain for a few days and then it just subsides. Of course, they can recur and if they recur continually they eventually do permanent damage to the joint. If that scenario sounds like your symptoms then you should follow up with your doctor.

The next more common problem that occurs in that joint, that would cause pain and redness would be an inflamed bursal sac. What you will feel on the side of the joint is a spongy area that is slightly red and when you press on it, it will be painful. A bunion by definition is an enlarged bone on the inside of the foot, along with an inflamed bursal sac.

The problem here is that you say when you bend your toe down, you get a lot of pain. This generally will not occur with a bursal sac; a narrow shoe will aggravate an inflamed bursal sac.

So, the next thing to consider is an arthritic inflammation within the joint. I do not know how old you are but if you are 40 years of age or older there is a real possibility that this could be your problem.

Depending on how much pain you are having should determine whether or not to seek medical attention. Sometimes, all of the possibilities mentioned here will quiet themselves down and the foot will no longer hurt, but keep in mind that the problem can easily return.

My best piece of advice to you would be to seek the services of a doctor familiar with foot problems and have he or she offer you a specific diagnosis and then appropriate treatment.

Marc Mitnick DPM
DISCLAIMER

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