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 musculoskeletal condition of the foot and ankle such as a bone, muscle or tendon injury. However, the inflammation and extreme pain is caused by an acute gout attack. While gout is more common among men, doctors have noted a growing trend towards a younger age of diagnosis in both men and women in Singapore.1
Patients who present with gout-related problems range from 18- to 20- year-olds with high levels of uric acid, those in their 20s to 40s with active flareups and those above 40 for long-term effects of gout erosion on their joints.
Left untreated, gout attacks will become more frequent over time. Uric acid deposits continue to build up between each attack without having an active effect on the patient, a process known as intercritical gout. Gout typically affects select areas of the body, particularly the foot or big toe, with over 90% of cases involving the big toe joint.
Gout is caused by having too much uric acid in the bloodstream, a condition known as hyperuricemia. This means the primary cause for gout in most patients is their diet and/or lifestyle.
The average Singaporean is protein-heavy which increases the likelihood of a gout attack as the body produces more uric acid to break 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 concertation of purines.
On top of being a source of uric acid, alcohol 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.
Middle age male patients are the most typical to present with 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 the lowered levels of oestrogen reduces the ability to remove uric acid from the urine tract, women are still less likely to suffer from acute gout attacks when compared to men. The family factor should not be underestimated as approximately 18% of patients have a family history of gout.
Risk Factors for Gout include –
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.
Acute gout attacks are characterized by a rapid onset of pain in the affected joint. These 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.
Symptoms of a gout attack can include –
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 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. In some instances, an attack may not subside entirely, especially if the patient’s uric acid levels are consistently high.
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 may require additional blood tests and a joint aspiration.
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 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% a person’s body weight in pressure daily, erosions can quickly advance developing secondary, very 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.
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. 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 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.