Gout
The Highlights
Gout is an incredibly painful inflammatory joint condition (most commonly affecting the big toe joint) where the body launches an inflammatory response to an excess accumulation of substances called uric acid crystals, either because of dietary intake of their precursors (purines) or an inability to sufficiently filter and excrete uric acid from the body.
Diagnosis can be made by a combination of medical history, physical examination, diagnostic ultrasound (available in our practice), blood tests and examination of joint fluid under a microscope.
Treatment is primarily about medication to manage inflammation and then lower uric acid levels for long-term management. Our practice can also help by protecting the joint through footwear advice, foot orthoses (specialist insoles) and targeted management of joint inflammation with corticosteroid injection therapy.
What is it and what are the symptoms?
Gout is an exceptionally painful inflammatory mono-arthritic (single joint) disease caused by the body's response to high levels of a substance called uric acid. If left untreated, it can lead to frequent joint flares and associate high levels of damage to the affected joint. As the big toe is the most commonly affected joint in the body, we see the results of this disease regularly and can play an important part in managing it.
An acute gout attack comes on suddenly and can last for around a week. It usually only affects one joint at a time (it may also affect soft tissues like tendons). The single most common site for a gout attack is the 1st metatarsal phalangeal joint (the big toe joint). The symptoms of gout are a red, swollen joint and pain...a lot of pain! So much so that people often struggle to sleep and even light pressure can be unbearable (if it's "just a little sore" - you probably don't have gout).
The knock-on effect of multiple gout attacks is fairly significant joint damage and the formation of "tophi" which are large whitish masses that can protrude from the joint often leading to a permanently enlarged, stiff joint and secondary osteoarthritis which may itself need addressing.
Why does it happen?
Compounds called purines are the start of the story - they exist in our own body tissues and also in many of the things we consume - especially for diets high in meat, seafood, alcohol or fructose-containing sweets and drinks (I know, all the good stuff). Purines are broken into uric acid which is filtered through our kidneys and excreted in our urine...however...if we take in too many purines (leading to too much uric acid) and/or if we have a problem processing them because of kidney problems, as well as other risk factors like being male, certain blood pressure drugs like diuretics and genetic factors, we will end up with high concentrations of uric acid in our blood (hyperuricaemia). This uric acid has to go somewhere and that somewhere included being deposited as crystals in our joints' synovial linings.
Sudden changes in our uric acid levels (possibly from a meal rich in purines) or trauma (such as stubbing a toe) may dislodge some of these crystals...and here's where the problems really begin. The crystals occur naturally in dead or dying cells and in the presence of infection which is exactly what immune cells called macrophages think they are dealing with when they encounter these crystals during gout. They respond by signalling to other immune cells to flood the joint and begin releasing huge quantities of inflammatory substances. And before you know it, the gout attack has begun!
What are the treatment options?
Diagnosis, as always, comes first. Your past medical and lifestyle factors combined with the clinical presentation will usually make it straightforward to lead to gout. On top of this, blood tests are usually done by your GP to check the uric acid levels in your blood. The one issue with this is that blood uric acid levels tend to peak a few weeks before there is enough joint crystal deposit to launch an attack. So by the time you show symptoms, your blood levels may have dropped back into normal range. The gold standard test for gout involves arthrocentesis - fluid is remove from the joint with a needle and examined under a microscope to look for the presence of these crystals.
Another useful tool in the diagnosis of gout is diagnostic ultrasound - both during and outside of an attack, gout has unique features detectable with this imaging technology - we are proud to be the only Podiatry clinic in the Scottish Borders able to offer this service in-house.
Once gout is diagnosed, medication is begun. Anti-inflammatories (most often Naproxen or Colchicine) are used during an acute attack to relieve symptoms and then medication to help manage hyperuricaemia in the long-term is used - Allopurinol being the most common here. It is very important any medication you take to treat gout is done so under the guidance of your GP: some over-the-counter anti-inflammatories like aspirin should be avoided because although the decrease inflammation they also decrease the kidneys' ability to remove uric acid from the blood.
Outside of oral medication, our clinic can offer localised, targeted therapy in the form of corticosteroid injections directly to the problem joint. This can be very helpful in settling symptoms and lowering the inflammation which may otherwise lead to permanent joint damage. We can also address ongoing joint issues with footwear advice and can provide foot orthoses (specialist insoles) designed to protect the joint from mechanical irritation going forward.
