Gout is a relatively common joint inflammation which often occurs in a short period of time. Many patients who experience gout pain in the foot for the first time may think it is caused by a bone, muscle or tendon injury. The inflammation and extreme pain is however the result of an acute gout attack. This condition is more common amongst men, but it is also rising in occurrence in both men and women.
Patients who present with gout-related problems range from 18 years of age with high levels of uric acid, 20-40-year-olds with active flare-ups, and 40-years-and-up with long-term effects of gouty erosion in their joints.
If left untreated, gout attacks will become more frequent over time. 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 affects select areas of the body; sufferers typically experience gout pain in the foot or big toe. Over 90% of cases involve the big toe joint.
What causes gout?
Gout is caused by having too much uric acid in the bloodstream, which is also known as hyperuricemia. This means the primary cause for gout in most patients is their diet and/or lifestyle.
The average Singaporean diet is protein-heavy, which increases the likelihood of a gout attack as the body produces more uric acid while breaking down these purine-containing foods. Those who regularly consume foods such as organ meats, venison, sausages, bacon, seafood, and shellfish, face even greater risk due to the very high concentration of purines.
Alcohol consumption also affects uric acid levels in the body by slowing down the excretion of uric acid from the kidneys due to dehydration. Instead, the crystals are deposited in the joints.
Who suffers from gout?
Middle-aged men are the most typical patients 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.
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 such patients have a family history of gout.
Risk factors for gout include:
- Obesity, excessive weight gain especially in youth.
- Moderate to heavy alcohol intake.
- High blood pressure.
- Abnormal kidney function.
- Certain medication such as diuretics.
- Certain diseases such as Lesch-Nyhan syndrome.
Some studies have also shown that patients with abnormally low or high thyroid hormone levels may develop gout due to the accompanying issues with kidney function.
What is a gout attack?
Acute gout attacks are characterized by a rapid onset of pain in the affected joint. Acute attacks may be precipitated by sudden fluctuations in uric acid levels brought on by a spike in alcohol consumption, stress, starvation, rapid weight loss and the introduction of uric acid-lowering drugs.
Symptoms of a gout attack can include –
- Painful swelling
- Reddish discolouration
The symptoms usually reach maximum intensity within 8-12 hours of presentation and can reach excruciating levels of pain that disable the patient. The small joint at the base of the big toe is 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. In some instances, an attack may not subside entirely, especially if the patient’s uric acid levels are consistently high.
How do I know if I have gout?
Gout is often responsible 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. To confirm the diagnosis, patients will undergo clinical evaluation and a thorough history taking to determine if gout is the true cause of their pain and foot/ankle problem. This can include utilising clinical imaging such as diagnostic ultrasound or x-rays 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 necessary.
What are the long-term effects of leaving gout untreated?
Left unaddressed, gout is a progressive disease. Leaving gout attacks to subside or recover on its own allows uric acid crystals to accumulate within a joint. This will only lead to further attacks in the future. A rheumatologist can manage gout with the appropriate medication and podiatrists are key in offloading and reducing localised inflammation.
Over time the secondary effects of gout can come into play, with patients often developing severe bone erosions from the chronic uric acid build-up and crystal deposition into the joints. As the feet can take up to 300% of a person’s body weight daily, joint erosions can quickly advance developing secondary, painful arthritis.
If joint damage has already taken place, medication alone is insufficient to resolve the problem. There may be knock-on effects of a joint compromised by gout that cause 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.
Ultimately, a failure to properly handle uric acid in the body will result in more than joint damage. Long-term crystallization of these compounds can cause attacks of kidney stones, and blockage of the kidney filtering tubules with uric acid crystals, leading to kidney failure.
Treatment of Gout
Gout treatment in Singapore has several phases. The first step is deal with the pain and inflammation. Patients should stay hydrated, 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. Medication given by your GP or rheumatologist help to manage the internal cause of gout and prevent further attacks and complications such as gouty arthritis, kidney stones and tophi in the soft tissues, but will not address the joint or bone damage already caused by gout.
A podiatrist will use various non-invasive clinical modalities/ therapies to reduce the immediate pain and inflammation of gout attacks. Once the immediate effects of the attack has subsided, the podiatrist can offload the joints of the feet to reduce the joint wear and tear from osteoarthritis and advise patients comprehensively with long-term care advice on managing their condition.