Gout, or 痛风, is a relatively common joint inflammation which often occurs in a short period of time. Many patients present with a suspected musculoskeletal condition of the foot and ankle such as bone, muscle or tendon injury but quickly find that there is an underlying musculoskeletal or biomechanical concern, but the overlying inflammation and extreme pain is an acute gout attack. Gout is not confined to the elderly.
Over time the gout attacks will become more frequent. Between each attack, the uric acid deposits continue to build up without having an active effect on the patient. This is known as intercritical gout. Gout typically affects select areas of the body, and sufferers typically experience gout pain in the foot or big toe. Over 90% of cases involve the big toe joint.
That is why podiatrists become quite experienced in dealing with this inflammatory joint condition. Gout can be quite debilitating due to the excruciatingly painful flare-ups, and in the long term can limit activity and lower quality of life.
There is little information on the prevalence of gout in Singapore but, from a local Singaporean Chinese Health Study it is estimated that 4.1% of 52,322 had gout, and the mean age at diagnosis was 54.7 years old. At East Coast Podiatry, we statistically see gout-related problems in much younger patients, ranging from 18 years old with high uric acid, 20-40’s with active flare-ups and 40+ years old for long-term effects of gout erosions on their joints. Middle age male patients are the most typical to present with such gout-related foot problems. Gout is more likely to affect those who have other diseases such as hypertension, hyperlipidaemia, renal failure, ischaemic heart disease and diabetes. Obesity is a major contributing factor.
Although the incidence of gout increases after menopause as oestrogen loses its ability to effectively remove uric acid from the urine tract, women are still less likely to suffer from acute gout attacks when compared to men. There is a family history element to take into consideration, it is estimated that 18% of patients with gout have a family history of gout.
Diet and lifestyle in short. Gout results from hyperuricemia. That is, from too much uric acid in the bloodstream.
The generalised diet of a Singaporean is noted to include more protein, higher purine and meat based foods. Protein-based diets, especially those with a very high purine concertation (organ meats, venison, sausages, bacon, seafood and shellfish) will increase the likelihood of a gout attack as the body produces uric acid to break down these purine-containing foods.
Alcohol affects uric acid metabolism by slowing down the excretion of uric acid from the kidneys by causing dehydration which then deposits the crystals in the joints.
A more sedentary lifestyle with richer foods and more alcohol intake leads to obesity and high uric acid build up.
Obesity, excessive weight gain, especially in youth, moderate to heavy alcohol intake, high blood pressure, and abnormal kidney function are among the risk factors for developing gout. Certain drugs and diseases can also cause elevated levels of uric acid. Also, there is an increased prevalence of abnormally low thyroid hormone levels (hypothyroidism) in patients with gout.
The secondary effects of gout then come into play with patients developing often severe bone erosions from the chronic uric acid build up and crystal deposition into the joints. As the feet can take up to 300% a person’s body weight in pressure daily (specifically the big toe joint), erosions can quickly advance developing secondary, very painful arthritis (wear and tear of the joints).
Acute gout attacks are characterized by a rapid onset of pain in the affected joint, typically one joint at a time followed by warmth, swelling, reddish discolouration, and the marked tenderness. The maximal intensity of symptoms is usually within 8-12 hours of presentation with excruciating pain and disability. The small joints at the base of the big toe are the most common site for an attack. Other joints that can be affected include the ankles, knees, wrists, fingers, and elbows.
In some people, the acute pain is so intense that even a bed sheet touching the toe causes severe pain. These painful attacks usually subside within two weeks but frequently require a minimum of anti-inflammatory treatment to ease the pain. In some instances, an attack may not subside entirely, especially if the persons uric acid levels are consistently high.
Sometimes acute arthritis of the first toe joint (big toe) is the first manifestation in 50% of gout sufferers. Elderly women with renal impairment and who are on hypertension medication (thiazide diuretics) may present with polyarticular gout (multiple joints affected) and form gout tophi earlier.
Acute attacks may be precipitated by sudden fluctuations in uric acid levels brought on by acute alcohol ingestion, stress, starvation, rapid weight loss and the introduction of uric acid-lowering drugs.
Podiatrists routinely encounter gout in their daily practice.
Gout is considered when a patient reports a history of repeated attacks of painful arthritis, especially at the base of the toes or in the ankles and knees. Patients would undergo clinical evaluation and thorough history taking to determine if gout is the cause of their pain and foot/ankle problem, clinical imaging such as diagnostic ultrasound or x-ray may be taken to give a clear visualisation of the underlying problem. Patients are often asked to further follow up with a Rheumatologist who would routinely send for blood tests and a joint aspiration (if needed).
Podiatrists use various non-invasive clinical modalities/therapies to reduce the immediate pain and inflammation of gout attacks. Medications given by your GP or Rheumatologists help to manage the internal cause of gout that is high uric acid levels, to prevent further attacks and complications such as gouty arthritis, kidney stones and tophi in the soft tissues.
Leaving gout attacks to subside in their own time, leaving uric acid crystals to accumulate within a joint or living with higher uric acid levels is what triggers gouty attacks. A rheumatologist can manage gout with proper medications and podiatrists are key in offloading and reducing localised inflammation.
An abnormality in handling uric acid and crystallization of these compounds in joints can cause attacks of painful arthritis, kidney stones, and blockage of the kidney filtering tubules with uric acid crystals, leading to kidney failure.
Gout is a disease and it progresses. Ultimately, uric acid deposition leads to the formation of renal stones and renal damage. Studies show that the most common joint involvement in that study was the 1st toe joint (51%), ankles (46%), knees (4%). Gout tophi are reported to be observed to be more common.
Long-term gout affects the kidneys and advances into tophaceous gout with recurrent and more frequent flare-ups. However, many patients don’t realize that gout is not just crystals causing temporary inflammation; gout can also permanently affect the bones and result in joint deterioration and destruction. Imagine an apple being eaten from the inside out by worms. The apple is your bone and joints; the worms are gout-induced erosion.
If joint damage has already taken place, then medications alone will not resolve the problem. There may even be knock-on effects of a joint compromised by gout, causing secondary musculoskeletal pains in other areas of the foot and ankle. Podiatrists can address the resulting joint pain and deformity by adjusting the foot biomechanics, using shoe modifications and custom orthotic insoles for long-term relief.
Gout treatment in Singapore has several phases. The first step is deal with the pain and inflammation. Patients should rest and use an ice pack for acute inflammation. As the initial flare-up subsides, a warm-to-cold contrast therapy can help to flush out the joint.
The second step is to seek treatment. If the patient has already done so, they should continue to follow the advice and treatment regime prescribed by their healthcare professional.
A podiatrist is able to help with reducing localised swelling and inflammation through clinical therapies and for non-acute attacks (chronic gout). Podiatrists are specialists at offloading the joints of the feet to reduce the joint wear and tear from increased erosions/OA build up.
Education is a key to empowering the patient, podiatrists will advise patients comprehensively on their condition and give long-term care advice to help to significantly manage their gout.