Gout - Gouty Arthritis

Gout:

Gout is a medical condition, a metabolic disease in which crystals of Uric acid (Monosodium urate) gets deposited in joints and tissues. These crystals are the by-product of body’s Protein degradation.

Causes:

The proteins that we consume in our diet get digested and undergo various steps of degradation in our body. Uric acid is produced during this process is usually excreted from intestine and kidneys.

High levels of Uric acid can be produced due to

Intake of protein rich diet- high purine dietAbnormalities in chemical pathways that leads to excessive production of uric acidCertain drugs like Aspirin (Salicylates), Diuretics (Kidney drugs) interfere with the excretion of uric acid thereby raising its level in blood.

The body’s own overproduction of uric acid is an inherited condition and is present from birth.

Symptoms :

Uric acid is deposited in the form of crystals (Monosodium urate) in joints and tendon. This result in intense irritation, inflammation and pain in the joints and tendon tissues. The joint becomes hot, red and swollen.

Classically the big toe joint of the foot is affected, but ankles, knees, elbows and joints of hand and feet can be involved. Large joints like hip and shoulder joints tend to be spared.

Predisposing factors:

Men are more likely to be affected than women.The commonest age for the first attack is between 30 and 60.

Risk factors include.

A high alcohol intake. Alcohol by itself  does not cause gout, but it will stimulate gout attacks in those who are affectedA protein rich diet.Certain races, like Maoris and Polynesian- who have higher blood levels of uric acid are more susceptible to goutObesity,Conditions that cause high cell turnover, such as polycythaemia (increased red cells), lymphomas and various other cancers can increase blood uric acid levels.A family history of gout,Drugs like Diuretics (drugs increasing urine flow) or low dose salicylates,Kidney diseases,

Some percentage of patients suffering from Gout can have renal colic due to deposition on uric acid crystals in the kidneys.

Diagnosis:

History and complaints

Sudden onset of severe pain, swelling and redness of joint in great to of the foot.Sometimes swelling of joints of foot, ankles and handsHistory of similar episodes in the past.

Examination:

Red, tender, swelling of joint of great toe or other involved joints.Long standing cases uric acid crystals deposit in tendons, tissues appear as swellings called Gout tophi. More common around the elbow, wrists, finger and toe joints and sometimes on the earlobe.

Investigations:

Blood tests: Raised blood uric acid levelsDoubtful cases: Fluid examination from Gout swelling for Uric acid crystals.X rays: in long standing cases shows joint destruction

Treatment:

Acute attack:

Acute attack of gout is characterised by hot, swollen, red and painful joint of great to of foot.

Non-steroidal anti-inflammatory drugs in acute attacks help in reducing the pain and swelling. They should be given in high doses initially.Colchicine is one of the oldest known drugs and can be taken during acute painful phase.New drugs are available that can be given during acute attacks which can reduce blood levels of Uric acid.

Drug treatment:

Drugs in the treatment of gout are given to control the levels of uric acid in blood and to prevent long term complications. Drug dosage should be adjusted according to the levels of uric acid in the blood.

Allopurinol is one of the oldest and common drug used to control the levels of uric acid in blood. This drug inhibits xanthine oxidase which converts xanthine into uric acid.Probenicid and Sulphinpyrazone – Promotes excretion of uric acid through kidneys.

Prevention:

Once you are diagnosed with Gout, you’re a patient of gout for your life.

Avoid Protein rich diet – High Purine foodsAvoid Dehydration: especially in hot weathersAvoid unaccustomed strenuous exercise.Care should be taken in patients on long term diuretics and low dose aspirin.

Regular medications to control the uric acid levels by the advice of physician or orthopedician.

Complications of untreated Gout:

Long term complications of uncontrolled gout can cause

Joint damage (Arthritis),Formation of gout tophi (swellings around the joint) andRare complication of chronic kidney disease.

HEEL AND FOOT PAIN

HEEL & FOOT PAIN

Heel pain is an extremely common complaint, and there are several common causes.

Plantar Fasciitis:  It is the most common condition that causes heel pain. Plantar fasciitis is due to irritation and inflammation of the tight tissue that forms the arch of the foot. The most common symptom is pain under the heel after a period of rest, i.e. severe pain and inability to walk in the morning after getting up from sleep. The same might happen after sitting for a long time and then trying to walk. Interestingly the pain gets better after a few steps though it may not go away completely.  Again, the pain may get worse with prolonged walking and standing. X ray may show a bony spur which may develop in long standing cases of heel pain due to plantar fasciitis, but it may not cause the symptoms.

Posterior Heel Pain:  Posterior heel pain causes symptoms behind the foot, rather than underneath. Posterior heel pain causes include Achilles tendinitis and retrocalcaneal bursitis. These patients may also develop bony growth behind the heel bone and when they are large may lead to rupture of Achilles tendon. Patients may have difficulty to walk comfortably on the affected side and pain that occurs at night or while resting.

Treatment Options:

Not all of these treatments are appropriate for every condition, but they may be helpful in your situation.

1.Rest - Avoiding the precipitating activity; for example, take a few day off jogging or prolonged standing/walking.  Rest can reduce the severity of pain and will allow the inflammation to begin to cool down.

2.Ice Packs - Icing will help to diminish some of the symptoms and control the heel pain. Icing is especially helpful after an acute exacerbation of symptoms.

3.Exercises and Stretches - Are designed to relax the tissues that surround the heel bone. Some simple exercises performed in the morning and evening, often help patients feel better quickly.

4.Anti-Inflammatory Medications - Help to both control heel pain and decrease inflammation.

5.Shoe Inserts - Are often the key to successful treatment of heel pain. The shoe inserts often permit patients to continue their routine activities without heel pain.

6.Injection therapy - In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain.

7.Removable walking cast - May be used to keep your foot immobile for a few weeks to allow it to rest and heal and is used only for severe cases.

8.Night splint - Wearing a night splint allows you to maintain an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients.

9.Weight reduction – It helps to reduce stress on foot and heel and thus help to reduce the severity of pain.

If, after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered.

Healthy Joint Club says:

Not being able to take first step out of bed in the morning can be frightening. More over severe pain from the heel may force you to restrict several day time activities. Except for a handful of cases and some uncommon conditions, most cases improve with treatment and time. Even though the time taken for the recovery may vary from person to person there is a natural tendency for these conditions to get better spontaneously.

STRETCHING EXERCISES

     

1.PLANTAR FASCIA STRETCH:

Sit in a chair and cross one foot over your other knee. Grab the base of your toes and pull them back toward your leg until you feel a comfortable stretch. Hold for 10 seconds and repeat 5 to 10 times.

2.ACHILLES STRETCH:

Stand on forefoot at the edge of stair, reach the step below with your heel, until you feel the stretch in the arch of the foot. Hold this position for 10 seconds and repeat 5 to 10 times.          

3.HEEL RAISE:

Stand behind the chair or any support and raise your body up onto your toes and hold for 5 seconds. Then slowly lower down yourself. Repeat 5 to 10 times.

4.TOWEL PICK:

Drop a towel on the ground and pick up the towel with your toes. Release and repeat 5 to 10 times.

5.FROZEN CAN ROLL:

Take a frozen juice can or tin, roll your feet on the can from front to back. Do it for 3 to 5 minutes.

6.TOWEL STRETCH:

Loop a towel around your toes and pull the foot towards your body keeping your leg straight. Hold this for 10 seconds and relax. Repeat 5 to 10 times.

Dr.A.Mohan Krishna
M.S.Ortho.,MCh orth (U.K)
Consultant Orthopedic surgeon,
Apollo Hospital
Appointments
Cell: 9247258989
         9441184590
email: bonesandjointsclinic@gmail.com
online appointments: 
www.drmohankrishna.com
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