620 Woodmere Ave, Suite C, Traverse City, MI
Diabetes Foot Care Northern Michigan

Overview

Gout is a form of arthritis that involves the accumulation of urate crystals within a joint. Uric acid is a normal byproduct of the body’s metabolism which is typically removed by the kidneys. Some people either produce too much uric acid or cannot get rid of it fast enough. When this happens, the uric acid can migrate to any joint in the body, most commonly the big toe, where it crystallizes and the body reacts by creating an inflammatory response often leading to sudden, unexplained pain.

Symptoms

  • Intense joint pain without a history of injury
  • A red, warm, swollen joint, most commonly the great toe
  • Limited range of motion of a joint
  • Ongoing joint pain

Causes

Uric acid is a normal byproduct of the body that is formed when purines are broken down. Purines are a type of protein found in certain foods such as meat and seafood, alcohlic beverages, and drinks sweetened with fruit sugar (fructose). Normally, the kidneys will excrete uric acid. However, if the body produces too much uric acid or the kidneys cannot get rid of uric acid fast enough, the uric acid can accumulate in joints which then cause pain and inflammation (swelling) of the joint.

Risk Factors

  • Age
    • Gout tends to present for the first time between the ages of 30 and 50
  • Diet
    • A high purine diet (meat, seafood, alcohol) can predispose you to gout
  • Family History
    • If a family member has a history of gout, you’re more likely to develop gout
  • Gender
    • Men are more likely to suffer from gout
  • Medical Conditions
    • Certain medical conditions such as heart and kidney disease, diabetes, and high blood pressure can increase your chances of developing gout
  • Medications
    • Anti-rejection drugs for transplant patients, thiazide diuretics used to treat high blood pressure, and low dose aspirin can elevate uric acid levels thus increasing the chance of a gout attack
  • Surgery or Trauma
    • Undergoing surgery or suffering an acute injury places increased stress on the body which can predispose a patient to a gout attack

Complications

Gouty Arthritis

  • If not treated properly, urate crystals can lead to irreversible joint damage leaving the patient with limited mobility and severe joint pain.

Recurrent Gout

  • Patients with ongoing high uric acid levels, or those who do not adhere to the “gout diet” can have recurrent gout attacks. Sometimes, these attack are so painful, they require immediate medical attention. Recurrent gout attacks eventually lead to irreversible destruction of a joint.

Kidney Stones

  • Urate crystals may accumulate in the urinary tract forming painful kidney stones which may require surgical intervention

Preventions

  • Stay hydrated
    • The National Academies of Sciences, Engineering, and Medicine recommend approximately 15 cups (3.7 liters) and 11 cups (2.7 liters) of water for men and women respectively each day. We obtain 20% of our water through the food we eat and 80% from the liquids we drink. So, that really means 12 cups of water for men and about 9 cups for women
  • Limit or avoid alcohol intake
  • Limit meat, fish, and poultry if you have a known history of gout
  • Maintain a healthy weight for your height

Diagnosis 

Several different tests are typically performed in order to diagnose gout

  • Before any tests are even done, the doctor asks the patient a very thorough series of questions in order to make the diagnosis and rule out other conditions that may look similar to gout.
  • Joint fluid test
    • This is the gold standard for diagnosing gout. The physician cleans and numbs the skin over the affected joint with a local anesthetic. Once, the area is numb, a needle is placed within the joint and fluid is drawn and sent to the lab where a pathologist checks the fluid for gout crystals. The results usually come back in 24 hours.
  • Blood test
    • The doctor may draw blood to check the patient’s uric acid level. This test can be misleading as not all patients with high uric acid levels have gout, and not everyone experiencing a gout attack has an abnormally high uric acid level at the time of the blood draw.
  • X-Ray
    • An X-ray of the affected joint may be useful to assess for any destructive changes to the joint caused by gout over time verses other possible conditions causing joint pain such as infection (septic arthritis) or fracture (broken bone). 
  • Ultrasound
    • If uric acid crystals become large enough, they may be sign with an ultrasound machine
  • MRI and Dual Energy CT 
    • These imaging modalities are highly sensitive for subtle changes of gout that cannot be appreciated on x-ray. However, these tests are not routinely ordered due to their high cost

Treatment

Preventive Medications

  • There are two classes of medications that help patients with a history of gout:
    • Medications that inhibit uric acid from forming
    • Medications that help the body remove uric acid more effectively
  • These medications are typically prescribed and managed by the patient’s primary care physician

Medications to Treat Gout Attacks

  • Nonsteroidal Anti-inflammatory drugs (NSAIDS)
    • Aleve (Naproxen), Advil (Ibuprofen, Mortin), Mefanamic Acid, Indomethacin
    • These medications help alleviate pain and inflammation during a gout attack and are available over the counter as well as in prescription strength. 
    • These medications may be prescribed by the foot and ankle specialist in conjunction with other medications to treat gout.
    • Consult your doctor before taking NSAIDS as they can have harmful side effects and may interact with other medications.
  • Colchicine
    • This is a prescription medication commonly prescribed by the foot and ankle specialist that helps to decrease the pain and inflammation during a gout attack by preventing the continued deposition of urate crystals within a joint. 
    • Common side effects include nausea, vomiting, and diarrhea 
  • Corticosteroids
    • This is a potent class of anti-inflammatory medications that is often prescribed by the foot and ankle specialist during an acute attack.
    • Common side effects include weight gain, mood changes, elevated blood sugar level, difficulty sleeping. 

Shoe Gear for Gout Patients

  • There are several recommended types of shoes for patients who suffer with foot and ankle pain caused by gout. These shoes provide stability, support, and cushion which can decrease pain and help promote a more normal gait.
    • Recommended Types of Shoes for those with Gout
      • Athletic or running shoes
      • Walking shoes
      • Orthopedic shoes
    • Shoes to avoid
      • Flip flops/Sandals
      • High Heeled shoes
      • Mocassins
      • Slippers

Orthotics/Shoe Inserts for Gout Patients

  • Orthotics, or insoles can be either custom made to the patient’s foot or can be a prefabricated one size fits all medical grade insert. 
  • These devices can help redistribute pressure and restore alignment to the foot and ankle to help decrease pain.
  • Over the counter insoles from pharmacies, shoe stores, or online vendors are typically not recommended as they often do not provide appropriate support and can be excessively expensive.
  • Consulting a foot and ankle specialist regarding the proper type of orthotic for your pain or issue is recommended and typically ends up saving the patient money and frustration in the long run by avoiding improper selection of an insert by the patient or a recommendation from nonmedical persons. 

Surgical Treatment Options for Gout Patients

Several surgical treatment options are available for patients suffering from pain due to gout. 

  • Joint Injection
    • Although considered a procedure and not surgery, your physician may recommend the painful joint be injected with a mixture of a steroid, such as cortisone, and a local anesthetic such as lidocaine. 
    • Steroid injections can be administered for patients having an acute gout attack or those suffering from chronic pain. 
    • These injections can be administered several times a year to help control pain in patients who do not wish to undergo surgery or those who are not surgical candidates
  • Arthrotomy, Synovectomy, or Cheilectomy
    • When a patient suffers from chronic joint pain due to gout but the cartilage within the joint is spared, the surgeon may recommend an arthrotomy and synovectomy, or a “joint clean out”. When uric acid crystals accumulate within the joint, these crystals can be removed and the joint lining can be “cleaned up”. This procedure can decrease pain and improve range of motion of the joint. 
  • Joint Fusion
    • Long term degenerative changes in joints due to gout can destroy cartilage leading to “bone on bone” arthritis. Patients who experience chronic joint pain may wish to pursue fusion, or welding, of the painful joint. Fusion removes the painful arthritic joint by joining two bones together. Many joints, including the ankle, the toes, and many of the small joints in the middle part of the foot can be fused in order to decrease pain and improve patient function.