Tuesday, February 20, 2024

Gout Or Stress Fracture In Foot

How Is Gout Diagnosed

Do I Have A Stress Fracture? Podiatrist Dr. Jairo Cruz

In a clear-cut case, a primary care physician can make the diagnosis of gout with a high level of confidence. However, often there are two or more possible causes for an inflamed toe or other joint, which mimics some of the symptoms of gout, so tests to identify the presence of uric acid is performed.

Since the treatment for gout is lifelong, its very important to make a definitive diagnosis. Ideally, the diagnosis is made by identifying uric acid crystals in joint fluid or in a mass of uric acid . These can be seen by putting a drop of fluid on a slide and examining it using a polarizing microscope, which takes advantage of the way uric acid crystals bend light. A non-rheumatologist, when possible, can remove fluid from the joint by aspirating it with a small needle and send it to a lab for analysis. A rheumatologist is likely to have a polarizing attachment on their microscope at their office. Gout crystals have a needle-like shape, and are either yellow or blue, depending on how they are arranged on the slide .

Figure 11: Uric Acid Crystals Under Polarizing Light Microscopy

There are many circumstances where, however ideal it would be, no fluid or other specimen is available to examine, but a diagnosis of gout needs to be made. A set of criteria has been established to help make the diagnosis of gout in this setting .2

Table 1: Diagnosing gout when no crystal identification is possible

Ideally, 6 of 10 features will be present of the following:

What Is Turf Toe

Turf toe, or hyperextension, is when you bend your big toe too far toward the top of your foot. It can cause a sprain of your toe or your ligaments surrounding it. Turf toe is a kind of metatarsophalangeal joint sprain, which means that at least one of your joints connecting your toe to the rest of your foot is injured.

Turf toe can happen during any sport or activity when your forefoot is on the ground with your heel up, and then you are pushed into a position of hyperextension of your toe. It most often occurs among football players on artificial grass. This is because the turf is harder and not as shock absorbent. Turf shoes also often have less protection in the forefoot because they tend to be more flexible.

Treatment for turf toe depends on the severity of the injury, which ranges from grade 1 to 3:

  • Grade 1. Treatment for grade 1 turf toe involves the RICE method, which can be done at home, along with taking nonsteroidal anti-inflammatory drugs . You can return to sports once you can tolerate this level of activity.
  • Grade 2. Grade 2 treatment focuses on improving your symptoms, which may include wearing a walking boot and partial weight-bearing. An MRI may be done to get a better idea of the extent of your injury.
  • Grade 3. Grade 3 injuries may require 8 or more weeks of recovery and immobilization, and sometimes even surgery.
  • joint pain or stiffness
  • being unable to move your toe typically
  • redness, discoloration, or swelling around your toe and joint

How Can An Attack Of Gout Be Treated

The management of an acute attack of gout is very different from the prevention of subsequent attacks.

Treatments used for prevention, such as allopurinol can actually make things worse if given during an attack, and so need to be held back until the attack has resolved for several weeks.

There are a number of measures that can help resolve an attack of gout. See Table 2 for summary of treatment strategies for acute gout. One principle is that treatment for an attack of gout should be instituted quickly, since quick treatment can often be rewarded with a quick improvement.

If an attack of gout is allowed to last more than a day or so before treatment is started, the response to treatment may be much slower.

Table 2: Medications to treat acute attacks of gout

  • Nonsteroidal anti-inflammatory drugs or COX-2 inhibitorsExamples of : Naproxen 500mg twice daily, indomethacin 25mg three times daily. Example of COX-2 inhibitor: celecoxib 200mg twice a day. Possible side-effects: Elevation of blood pressure, ankle swelling, upset stomach, ulcer . Use with caution if kidney or liver problems.
  • Anti-Inflammatory corticosteroidsExamples of : Prednisone 40mg first day, 30mg 2nd day, 20mg third day, 10mg fourth day. Possible side-effects: Elevation of blood pressure, elevation of blood sugar, mood changes. Short-term use, as in gout, generally much better tolerated than long-term use. Use with caution if diabetic.
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    Which Joints Are Involved In Gouty Arthritis And Why Is It Most Common In The Foot

    As with all other known types of arthritis, Gout has particular joints it tends to attack, and the foot is its most common location. Gout especially favors the bunion joint, known as the first metatarsophalangeal joint , but the ankle, midfoot and knee are also common locations, as is the bursa that overlies the elbow.

    The bunion joint is the first joint involved in 75% of patients and is ultimately involved in over 90% of those with this condition. . It is thought that this joint is especially involved in gout because it is the joint that receives the highest pounds per square inch of pressure when walking or running.

    Late in gout, if untreated, multiple joints can be involved, including the fingers and wrists. The shoulder joint is very rarely involved by gout and the same is true of the hip.

    Figure 5: Location of Gout Attacks

    How Do I Know If I Have A Stress Fracture

    Podiatric Associates Foot &  Ankle Center

    Normally, the body can sufficiently heal these microfractures, leading to a stronger bone that will accommodate these higher forces in the future. However, when forces on the foot are such that the bodys healing response cannot keep up, a stress reaction can develop. Eventually, if the forces continue, the bone structure can fail, and a stress fracture will occur. An individuals lack of sufficient biology to heal microfractures can also contribute or lead to stress fractures. If you have any of the following symptoms, you may have a stress fracture:

    • Pain that you feel most when youre active this pain gets more intense over the course of activity but improves with rest. Some people describe the pain of a stress fracture as deep soreness that gradually becomes debilitating or excruciating as you continue to move. The pain builds over time, eventually making the activity difficult if not impossible. When you rest, the pain subsides, but it will likely return when you resume activity.
    • Swelling around the site of the injury
    • Tenderness

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    The Role Of Diet In Gout Prevention

    Dietary control may be sufficient in a patient with mildly elevated uric acid, for example, 7.0 mg/dL

    For those with a higher level, for example, 10.0 mg/dL, diet alone will not usually prevent gout. For the latter, even a very strict diet only reduces the blood uric acid by about 1 mg/dL- not enough, in general, to keep uric acid from precipitating in the joints. The cutoff where patients with gout seem to dramatically reduce their number of attacks is when their uric acid level is taken below 6.0 mg/dL.4

    Lisfrank Or Midfoot Injury

    The middle of the foot is known as the Lisfrank area or midfoot. This area is made up of a group of small bones that help form the foots arch.

    If one of the midfoot bones is broken or a tendon is inflamed or torn, it may cause pain, swelling, bruising, and redness on the top of the foot.

    Midfoot injuries can be caused by accidents, such as a heavy object landing on the foot.

    Not all midfoot injuries are due to dropping something or getting the foot stepped on, however. They often occur when someone falls with the foot flexed downward, pulling or straining tendons or fracturing bones.

    A hairline or stress fracture can also happen in this area due to overuse, such as from long periods of running or high-impact activity.

    Midfoot injuries can be mild to severe, depending on how many tendons or bones are injured. Mild tendon injuries may only require RICE until the tendon has healed.

    Severe injuries and bone fractures may require a cast, physical therapy, or surgery.

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    What Are The Risk Factors For Developing A Stress Fracture

    Some people are more likely than others to develop stress fractures. Some of the risk factors include the following:

    • Playing high-impact sports, such as basketball
    • Being female, especially if you have a very low body mass index
    • Suddenly increasing your activity level by a lot
    • Having other foot problems, such as flat feet or high arches
    • Not getting enough calcium
    • Not getting enough vitamin D
    • Having bone density problems
    • Having previous stress fractures
    • Wearing worn-out shoes

    Many of these problems are issues we can look into to let you know if youre at risk for developing a stress fracture.

    How Can A Stress Fracture Be Prevented

    What Causes Pain On Top Of The Foot?

    These steps can help prevent a stress fracture:

    • Once you feel pain, stop exercising. Only return to exercise if you are pain-free.
    • See your doctor as soon as possible if you have a persistent area of concern or discomfort.
    • Use the correct sports equipment.
    • Wear the proper running shoes. Running shoes should be replaced every 300 miles.
    • Add new physical activities .
    • Start new sports activities slowly and gradually increase the time, speed and distance.
    • When restarting a sport or activity, reduce your intensity by 50%. Follow the 10% rule no increases of more than 10% per week.
  • Make sure to properly warm up and cool down before activities.
  • Practice strength training to help prevent early muscle fatigue, and to help prevent the loss of bone density that comes with aging.
  • Follow a healthy diet full of calcium and vitamin D foods that will keep your bones strong. A sports nutritionist can be helpful if you are extremely active and have a history of stress fractures.
  • If you decide to increase your activity level, ask your doctor for a recommendation of how much to add and when to add it.
  • Optimize your bone health. If you have a known history of osteopenia or osteoporosis, discuss with your doctor how to medically manage these conditions. For an active person, treatment is best before an injury occurs. A stress fracture with a weak bone is harder to heal.
  • If pain or swelling returns, stop the activity and rest for a few days. If pain continues, see your doctor.
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    Pain Top Of Foot When Walking : 7 Causes

    Question: what causes sharp pain top of foot when walking or running?

    According to the CDC, at 20, the average weight of US men and women are 195.7 and 168.5 poundsrespectively. This weight is carried by your joints with your feet feeling most of the pressure.

    Your feet perform an enormous task by carrying your entire body weight. Therefore, any injury to your ankle and foot is likely to affect your daily routine.

    For sportsmen and women, running and walking fast for long distances may also trigger top of the foot pain. This mainly happens if you arent using correctly fitted running shoes. Tight shoes, when worn for a long time, can cause undue pressure on your foot bones resulting in pain.

    Heres the thing Your ankle is made up of bones, cartilages, and ligaments. The bones are hard structures that form the joint while the cartilages hold bones together. Foot tendons are as well important. Tendons attach your muscles to bones.

    During movement of your foot, your muscles contracts, pulls the tendons, which in turn allows movement to take place. These tendons run just under your skin and can get easily traumatized.

    As a result, wearing tight-fitting shoes may cause excessive tension in your foot tendons leading to inflammation. When the foot tendons get inflamed, it causes you to feel pain. The most commonly affected are the Extensor tendons and Tibialis Anterior tendons.

    Other causes of upper foot pain are

  • Stress fracture
  • Deformed toe
  • Symptoms And Signs Of Gout In Foot

    An attack of gout is often sudden. Symptoms:

    • It may present with excruciatingly painful swelling of joints in the big toe, it is known as Podagra. The joint may be stiff and appear red or purple, very swollen, and tender to even light touch. Other gout sites include the instep, wrist, ankle, fingers, and knee.
    • Skin may peel and itch as healing begins.
    • An attack often begins at night the acute phase lasts up to 12 hours. If untreated, the inflammation may last up to two weeks. In 10 percent of people, acute episodes present in more than one joint.
    • Kidney stones precede the onset of gout in 14 percent of patients.
    • Chronic gout may develop, and it may affect more than one joint, mimicking rheumatoid arthritis.
    • Tophi are soft tissue swellings caused by urate buildup in chronic gout. They may be found in the ear, fingers, toes, kneecap, and elbow.

    Some people have a single attack of gout, others are affected intermittently, often when they have overindulged or experienced dehydration.


    Its rare for complications of gout to develop, but they do happen and can include severe degenerative arthritis, secondary infections, kidney stones and kidney damage, nerve or spinal cord impingement, and joint fractures.

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    Signs Of A Stress Fracture

    To avoid worsening a stress fracture, its important to allow your bone time to heal, which means you need to recognize the signs that theres a fracture in the first place.

    The first symptom to look out for is pain, which typically flares during and immediately after activity and then subsides when youre at rest.

    In addition to the pain, you may experience some swelling in the area, as well as tenderness to the touch and visible bruising, though bruising doesnt always develop.

    How Is A Stress Fracture Diagnosed


    Your doctor may need to do several tests to see if you have a stress fracture and the severity of the fracture. These tests can include:

    • Physical examination: During your first visit, your doctor will do a physical exam and discuss your risk factors for developing a stress fracture. When discussing risk factors, you will be asked about:
    • Your medical history.
    • Your activities.
    • Any medications you might be taking.
  • X-Rays: Your doctor may order an X-Ray to look for a fracture. However, a stress fracture can be difficult to see on an X-Ray because the bone often appears normal and the small cracks cant be seen on the image. X-rays actually miss about of stress fractures. X-Rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-Rays. With a high index of suspicion for a stress fracture, your doctor may recommend an imaging test that is more sensitive than an X-Ray and will pick up a stress reaction even before it may become a stress fracture. These tests can include:
  • Magnetic resonance imaging .
  • Bone Scan.
  • Bone scan: A bone scan may be used to see stress fractures that cannot be seen on an X-Ray. During a bone scan, a tracer is injected into your bloodstream. The tracer collects in the bone and settles in the areas where the bone is being repaired. The area that is affected by a stress fracture will appear darker on the bone scan that an uninjured area.
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    What Causes A Stress Fracture

    Stress fractures are caused by repetitive impacts sustained over time, combined with fatigued muscles that become unable to absorb the stress and shock of each impact. But there are other factors, such as how often you exercise, how long you exercise, and your level of exercise intensity.

    All these affect how much stress you put on your lower leg muscles and feet. You do not have to be athletic to suffer a stress fracture in your foot.

    Older women are more susceptible to osteoporosis and other diseases that weaken bones. Even normal household activities can create stress fractures.

    Other causes of stress fractures in the foot include:

    • Type of footwear
    • Osteopenia/osteoporosis

    What To Do If You Think You Have Pain Due To Gout

    The good news is that there are effective medications to treat gout, Dr. FitzGerald says. In some mild cases, gout can be self-managed with lifestyle changes, such as weight loss if needed and eating fewer high-purine foods .

    However, many people with gout should be on a preventive medication to lower uric acid levels and stop flares from occurring. According to the 2020 gout treatment guidelines from the American College of Rheumatology, uric acid-lowering medication is recommended for people who:

    • Have two or more gout flares a year
    • Have gout tophi
    • Have evidence on X-rays of joint damage due to gout

    The guidelines, of which Dr. FitzGerald is a coauthor, recommend a treat-to-target strategy, which means treating gout with medication until a target uric acid level is reached.

    Unfortunately, gaps in quality care for gout continue to persist and many patients do not take uric acid-lowering medication, which can leave people suffering the intense and persistent pain of gout without relief. This is why it is important to seek medical care if you experience pain that you think could be gout, Dr. FitzGerald stresses.

    Gout can be diagnosed several ways, including:

    • Removing fluid from the joint to identify urate crystals.
    • Using ultrasound to identify several common characteristics of gout, such as collections of crystals in or around joints.
    • Using dual-energy CT to detect urate crystal deposits in cases that are more advanced.

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    Gout In Foot: Causes And Risk Factors

    In about 90 percent of hyperuricaemia cases, there is impaired renal excretion in about 10 percent, there is a problem with overproduction.

    • Urate overproduction can be linked to lifestyle factors and certain diseases such as bone marrow cancers, psoriasis, and hemolytic anemia. Lifestyle factors include being overweight and ingesting excess amount of fructose or alcohol.
    • Renal impairment has multiple causes, including gene mutations, hypertension, diuretic drugs, lead exposure, and cyclosporine immunosuppressive therapy.
    • Gender and age. Men are twice as likely to develop gout as women. In men, the risk rises with age. Gout is uncommon in younger women but the incidence increases dramatically after menopause, due to falling estrogen.
    • Western diet. There is solid evidence from the Health Professional Follow-up Study of a link between gout and purine-rich foods. See gout diet.
    • Medications. Diuretics, antihypertensives, niacin, aspirin, chemotherapy and immunosuppressive drugs increase the risk of gout.
    • Other conditions. Certain conditions carry an increased risk of gout including: Recent joint injury or surgery, cardiovascular disease, chronic pulmonary disease, anemia, psoriasis, renal disease, blood cancers, and metabolic syndrome.

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