What is Gout?

Gout is a form of arthritis, characterized by an acute onset of extreme pain. Gout attacks most commonly occur in the foot and ankle, in particular at the first metatarsophalangeal joint, the joint that connects the great toe to the foot. Gout also appears in the ankle, and can theoretically occur in any joint of the foot.

During an acute attack, the affected joint will appear red and swollen, and it will be hot to touch. It will also be extremely painful to touch. The simple touch of a bed sheet or even a slight breeze can cause an immense amount of pain. Evaluation by a doctor will be used to rule out other possibilities such as a fracture, infection, or other forms of arthritis. X-rays may be taken to visualize the effected joint as well. There are generally not any changes seen on x-ray with the first gout attack, but distinct changes may be seen with repetitive attacks. These changes include bony erosions seen around the joint, with the appearance of bone that has been chewed away. This is referred to as Martel’s sign.

An excess of uric acid in the body causes a gout attack. Uric acid is a byproduct of many foods; in particular it found in high quantity in red meats, lobster, and beer. Because of its association with overindulgence of rich foods, it has been historically referred to as “the disease of kings”. The high volume of uric acid crystallizes at the level of the joints, causing a tophus to form. The crystallization most commonly happens overnight. Some believe that this is due to a drop in body temperature, particularly in the feet, while sleeping.

A high level of uric acid in the body is a condition known as hyperuricemia. The excessive uric acid may come from several different sources. It may be dietary, as in the overconsumption of red meat, beer, and seafood. Hyperuricemia may also be associated with diabetes mellitus, hypertension, psoriasis, or congenital conditions such as Lesch-Nyhan syndrome. Excessive uric acid levels can also be caused by the use of some diuretics, particularly during their early use.

The treatment of gout is twofold; it must address both the acute painful phase as well as controlling the hyperuricemia. Initially, patients may be given colchicine or indomethacin to alleviate pain. After the acute attack has subsided, the underlying hyperuricemia may be addressed with allopurinol a drug that blocks the enzyme that creates uric acid in the body.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Hallux Limitus and Hallux Rigidus

Hallux limitus and hallux rigidus are two terms that are used to describe the progressive loss of motion that is seen in the first metatarsophalangeal joint. For normal function of the big toe, a range of motion of between 50 and 90 degrees is required. In hallux limitus, the range of motion is decreased. In hallux rigidus, there is little to no motion at all at the first metatarsophalangeal (MTP) joint.

The first MTP joint plays a critical role in normal gait. It is the area of greatest propulsion during the gait cycle, and plays a large role in balance. When the range of motion at the first MTP joint (located at the base of the big toe) is lost, significant secondary symptoms can occur, such as calluses across the bottoms of the feet.

Hallux limitus (and later, hallux rigidus) is a specific form of osteoarthritis localized to the first MTP joint. Therefore, the signs and symptoms are similar to that of common arthritis. This includes pain and stiffness in the joint when it is pushed upwards, such as when walking, running and squatting. Swelling and inflammation may be seen as well, particularly on the top of the foot around the joint. In particular, damp and cold weather may make the symptoms worse.

Later findings that are consistent with hallux rigidus include continuous pain in the joint, even when at rest. A person with hallux rigidus may have a visual bump on the top of their foot over the joint. This bump is actually a bone growth known as an osteophyte that can be seen on x-ray, and is common in osteoarthritis. Another common complaint is difficulty wearing shoes, particularly shoes that are tight in the toes, such as high heels.

When the joint becomes too painful to walk on, a limp may be apparent. The attempt to keep weight off the joint can lead to problems with other areas of the foot that are not meant to bear the weight that the big toe is designed for. Knee, hip, back and neck pain are also common conditions associated with hallux limitus and hallux rigidus.

Hallux limitus and hallux rigidus can be treated by either conservative or aggressive treatments, or a combination of both. Conservative treatment relies on stabilizing the foot, taking weight off of the big toe, and alleviating some of the pain associated with the condition. Stabilization of the foot is often achieved with a custom orthotic device or other form of padding. Symptoms may be alleviated with anti-inflammatory medications (NSAIDs), icing, rest, and padding.

More aggressive treatment is focused on the surgical management of hallux limitus/rigidus. The joint can commonly be fused, which takes away motion at the joint and alleviates the pain associated with the motion. Another option may be to use an implant, which can bring motion back to the joint. There are a number of different factors that go into the surgical decision making, so talk to your doctor about the options.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.Winter Haven, FL 33881
Phone: 863-299-4551
www.FLFootandAnkle.com

Hammer time? Hammertoes!

Hammertoes are a common condition that is treated by podiatrists. When discussing hammertoes, it is important to discuss exactly which joints of the toes are affected, and how they are misaligned. The picture above depicts the three classic types of hammer digits, each of which has an effect on one or more of the three joints of the little toes on the foot.

In mallet toe, only the distal interphalangeal joint is affected. The interphalangeal joints are the joints within each toe. All of the toes besides the big toe have two interphalangeal joints. The big toe has one. Mallet toe is characterized by a toe that is straight until the last “knuckle” joint of the toe, where it is pointed downwards.

In claw toe, all three of the joints of the lesser digits are affected. The metatarsophalangeal joint, the joint that connects the toe to the forefoot, is deviated upwards, while the two interphalangeal joints are deviated downwards. This creates a claw-like appearance, as is seen in the bottom diagram of the drawing.

The most common form of hammer digits is depicted in the middle diagram. This is the classic form of hammertoes. In this form, the metatarsophalangeal joint is deviated upwards, the proximal interphalangeal joint (the one closer to the middle of the foot) is deviated downwards, and the distal interphalangeal joint (the one further down the toe) may be either normal or deviated slightly upwards.

Besides the aesthetic changes to the toes, hammertoes can be a source of pain for many people. When the joints of the toe are misaligned, it forces the toes to take up more space in a shoe. This can often lead to corns on the tops of the toes, as they are rubbing against the top of a shoe.

Additionally, hammertoes are often pointed towards each other, which cause the toes themselves to rub against the other toes. This can also cause corns and calluses to form, as well as abrasions in between the toes.

Hammertoes are caused by a loss of muscle stability and balance that is formed by the muscles of the foot. The flexors on the back of the leg and the extensors on the front of the leg serve to counterbalance each other on the toes, thereby keeping the toes straight. When the balance is lost from things like loss of function of one muscle or strengthening of another muscle, the toes can become deformed. This problem is often seen in women who wear high heeled shoes.

When treating hammertoes, claw toes, or mallet toes, a podiatrist may use one of two approaches. The conservative approach would be to treat the corns and calluses formed by the toes rubbing against either each other or the shoe. This may be done by burning or shaving off the dead skin causing the pain, as well as modifying the shoe gear to accommodate the misaligned toes.

The other route is to correct the misalignment of the toes through surgery. Several different methods are used depending on the extent of the deformity – only your surgeon will be able to decide which the proper method to use is.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com