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Gout Symptoms

Gout is a common disease and often presents suddenly with a painful joint. The most common and well-recognized symptom is swelling of the joint in the big toe where it joins the foot. This can be extremely painful and enlarged and if not treated the pain will last about 10 days and can cause lasting damage with repeated attacks. The area can be red, hot, inflamed and very painful or tender.


Turf toe gets no respect. Let's take a closer look at the causes of turf toe and see how to treat it more effectively. Turf toe is actually a form of hallux limitus. Hallux limitus is classically described as pain and progressive decrease in the range of motion of the first metatarsal phalangeal joint (MPJ). The onset of hallux limitus is due to the following:


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 But before we go any further, we need to understand that the terms turf toe and hallux limitus aren't really synonymous. The fundamental difference between the two terms is the patient population that they affect. Turf toe is a term used in athletic circles referring to any injury of the great toe joint. Consequently, discussions about turf toe will focus on the first two causes of hallux limitus mentioned above; functional hallux limitus and direct physical injury. On the other hand, when we discuss hallux limitus, we're actually referring to a broader, 'non-athletic' patient population and need to include all three causes of hallux limitus.

Even if an injury is the most common cause of a gout attack, illness, fatigue or worry can also trigger a gout attack. If you have an operation, this might also bring an attack of gout just a few days later.

Treatment of turf toe varies with the type of healthcare provider and includes the use of rest, shoe modifications, orthotics, steroid injections and surgery. The success of non-surgical care will vary with the degree of injury, the rate at which the injury is healing and how much osteoarthritis has occurred. We see varying degrees of success with orthotics that promote plantarflexion of the first ray, effectively treating metatarsus primus elevatus and peroneus longus dysfunction. Simple arch supports can make a significant difference in the symptoms of turf toe. Should our patient not respond to conservative care in a reasonable time period, we are not reluctant to suggest surgical revision to address the problem whether it be revisions of the joint defect, shortening of a long first metatarsal or structural revision of metatarsus primus elevatus. As mentioned before, the clinical appearance of dorsal lipping or visible radiographic changes are suggestive of moderately advanced osteoarthritis, a condition that is only repaired by joint revision or replacement.

Nomenclature: First MPJ - the big toe joint Metatarsus primus elevatus - a functional or structural position of the first metatarsal First metatarsal - the foot bone making up the proximal portion of the big toe joint Hallux - the great toe

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Kidney stones can form due to gout and can cause back pain. Other joints such as the knee, fingers and heel can also be affected. Some people get lumps on the rim of the ear or other parts of the body near joints under the skin and these are called tophi.


Differential Diagnosis: The differential diagnosis of turf toe includes; Arthitis Fracture Gout Joint infection Joint or bone tumor Synovitis

Is the onset of turf toe always the same? Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to increase their activity. It may not occur during the first athletic season, or the second, but when it does begin to cause pain, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step.

What's the actual physical change that takes place in the joint with turf toe? As an easy analogy, consider the changes that takes place when an apple falls from a height and is damaged. The skin of the apple appears intact but the underlying pulp is damaged. In the case of turf toe (hallux limitus), think of the skin of the apple as the cartilage of the joint and the damaged pulp of the apple is the subchondral bone. Mild cases of turf toe (hallux limitus), result in little damage to the subchondral bone and will merely exhibit signs of inflammatory change within the joint. Most authors would refer to these cases as stage one turf toe (hallux limitus). More severe cases result in damage to the joint surface, the subchondral bone or both. These are the stage two and three cases of turf toe (hallux limitus) that show visible change on x-ray. As the subchondral bone becomes increasingly damaged, it will create an uneven supporting surface for the cartilage. An increase in activity results in uneven loading of the joint due to the compression injury of the subchondral bone.

Gout is sometimes called the "disease of kings" because it has long been associated with the wrong kind of excess in food and wine, only the rich and powerful could afford. Gout is one of the most common forms of arthritis (inflammation). Gout is the state resulting from uric acid crystals in the filing of body tissues. Gout is characterized by an overload of uric acid in the body and recurring attacks of inflammation (arthritis). The chronic gout can lead to hard nodule deposits of uric acid in and around the joints, decreased renal function and kidney stones. Gout affects about 1 in 100 people and less than 6 to 7 per cent of older men. Men are more likely to find that women are the drop, but women are becoming more sensitive to the drop after menopause.

Unger, K., Rahimi, F., Bareither, D., Muehleman, C. The Relationship Between Articular Cartilage Degeneration and Bone Changes of the First Metatarsophalangeal Joint. J. Foot Surg. 39:1 24-33, 2000

People may have an elevated uric acid also called hyperuricemia but have no symptoms. Later they may develop acute gouty arthritis where the joint is affected. Almost three fourths of people with gout will develop it in the big toe at some point of time. In between attacks the gout is said to be in an interval or intercritical phase and finally some people get chronic tophaceous (with the tophi) gout.


Anatomy: The great toe joint, or first metatarsal joint consists of two bones. The proximal bone is the first metatarsal and the distal is called the proximal phalanx or hallux. These two bone move against each other in an up and down motion through what we refer to as the sagital plane. Biomechanics: The motion of the great toe joint is dependant upon the plantarflexion of the first metatasal. If the first metatarsal is limitied in its' ability to plantarflex, the joint will jam resulting in funtional hallux limitus, which as we know is one of the causes of turf toe.


Symptoms: Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to increase their activity. It may not occur during the first athletic season, or the second, but when it does begin to cause pain, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step. Turf toe caused by a direct injury to the joint may or may not be obvious. Athletes may not remember an incident of pain since they're often distracted by the event or game in which they're involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

The definite diagnosis or determining if the arthritis is due to gout may involve drawing fluid from the joint and looking for crystals of uric acid.

 
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Other conditions - synovitis, crystal deposition diseases such as gout, systemic arthritis, external physical influences such as Dupytren's contracture, etc.

4. Applying heat helps relax aching muscles, and reduces joint pain and soreness. 5. Applying cold helps to lessen the pain and swelling in a joint.

Urate is the main cause of gout as studies have shown. However, not all people who have high urate levels actually suffer from gout. Even relatives of gout patients can have high urate levels in their blood and still not suffer from gout or have any gout attack in their lives. Diuretics, that are mainly used to treat high pressures of blood or heart problems can increase the levels of urate and thus lead to gout.

There was a myth that said that the cause of gout is too much food and drinks. Nowadays, this myth has proven wrong. However, everybody knows that there is a little truth in every myth. This gout myth makes no exception. If you drink a lot, but mainly wine or beer and if you eat more than you should, then gout attacks are more likely to appear. However, this is not the cause of gout. Studies have shown that people who suffer from gout suffer from a chemical process disorder of their bodies. One of the gout causes can be the build up of urate, that can form crystals in your joints. These are very painful. However, this problem is mostly genetic and almost all people who suffer from it inherited gout from their grandparents or parents. Actually, gout is a family problem.

Left untreated can cause permanent joint gout and kidney damage. You can treat gout with drugs. The first line of treatment should be pain relief. NSAIDs may control inflammation and pain in patients with gout. NSAIDs include over-the-counter options such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others), as well as the most powerful prescription NSAIDs. Corticosteroids, such as prednisone, given in short courses, are powerful anti-inflammatory agents for the treatment of acute gout. The ice can be applied for 20-30 minutes several times a day. Weight reduction may help to lower the risk of recurrent attacks of gout. The best solution is to reduce dietary fat and calorie intake combined with a programme of regular aerobic exercise. Alcohol consumption should be reduced or stopped.

Think of turf toe (hallux limitus) as an isolated case of osteoarthritis limited to the first MPJ. Whether the injury is acute or due to repetitive loading, the result is a load that is applied to the subchondral bone that is greater than what the bone can tolerate. As the injury progresses, a series of micro fractures will develop in the subchondral bone. The typical soft spongy character of the metaphyseal bone changes to become brittle and hard. The result is that the articular cartilage looses its' underlying support and becomes susceptible to damage. Juxtachondral eburnation, osteophytes, lipping, spurring; call them what you like, but what you see on your x-ray is the slow progressive destruction of the joint.

References: Lombardi, C.M., Silhanek, A.D., Connolly, F.G., Dennis, L.N., Keslonsky, A.J. First Metatarsophalangeal Arthrodesis for Treatment of Hallux Rigidus: A Retrospective Study. J. Foot Surg. 40:3, 137-143, 2001

When treating turf toe be sure to recognize the fact that there is no nerve innervation in articular cartilage. Pain associated with stage one turf toe (hallux limitus) is either synovial pain or bone pain. If we recognize that painful stage one turf toe (hallux limitus) may be due to bone pain, we then realize that turf toe should be treated aggressively to insure the long term viability of the joint.

Functional hallux limitus - biomechanical function that results in metatarsus primus elevatus and subsequent repetitive jamming of the first MPJ. Direct physical injury - injury to the articular cartilage or subchondral bone. These injuries may be due impaction injuries or hyperextension/flexion of the first MPJ.

6. Vitamin C, taken in high doses, can help decrease blood uric acid levels.


7 NSAIDS such as indomethacin (Indocin) and naproxen (Naprosyn) are effective anti-inflammatory medications for acute gout.

Gout is a fairly old disease, being around for more than two thousand years. Gout is a disease that affects mostly mean, but women can suffer from gout as well, mostly after menopause. Gout is a very hard rheumatic disease, but out off all this type of diseases, gout probably has the best treatment.

Ronconi, P., Monachino, P., Baleanu, P.M.,Favilli, G. Distal Oblique Osteotomy of the First Metatarsal for the Correction of Hallux Limitus and Rigidus Deformity. J. Foot Surg. 39:3, 154-160, 2000

Gout Treatment and Prevention Tips 1. Drinking alcohol should be reduced or stopped. 2. Try to keep your weight down. 3. Use helpful devices such as a cart to carry your grocery bags.

It occurs more frequently in countries that have a high standard of living. Mostly male over the age of 40. Gout affects up to 500000 (1 to 30) of Canadians. Gout attacks usually the big toe (about 75 percent of initial attacks), but it can also affect other joints such as the ankle, heel, foot, knee, wrist, elbow, fingers, and the spine. The most common sign of gout is a nighttime attack of the swelling, tenderness, redness and pain in your big toe. Gout is strongly associated with obesity, hypertension, hyperlipidemia, and diabetes. Due to genetic factors, the drop tends to run in some families. Gout can be inherited or occur as a complication of another condition. The use of thiazide diuretics used to treat high blood pressure and low dose aspirin may also raise levels of uric acid.

Over the long term there can be deformity of joints and there can be many large lumps under the skin. Nowadays with proper treatment this is less likely. The symptoms can last from three to ten days and often get better even without treatment. The next attack may occur many months or even years later. Usually (and fortunately) only one joint is affected at a time and the symptoms of the swelling and pain start within a day.

Gout is very painful. In fact, this disease is the most painful of all rheumatism or arthritis forms. Gout attacks mainly start during night time and the first gout attack sign is pain in your big toe. This toes becomes swollen, extremely red and painful. However, it is sometimes difficult for doctors to tell you if you are having a gout attack or it is just a simple bunion case. Besides this joint, other joints can also be attacked by gout. The elbow, wrist or knee are some of the other places at risk of a gout attack.

Turf toe caused by a direct injury to the joint may or may not be obvious. Athletes may not remember an incident of pain since they're often distracted by the event or game in which they're involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

About the author:
Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle
surgeon. Dr. Oster is also board certified in pedorthics. Dr.
Oster is medical director of href=http://www.myfootshop.comMyfootshop.com and is
in active practice in Granville, Ohio.


Myrtle Randolph

 
 
     
 
 





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