Mortons Neuroma and its affect on the Distance Runner!

Mortons Neuroma

A relatively common injury in the forefoot is a condition called Morton’s neuroma. Let’s take a quick look at how it might affect the distance runner:

Anatomy

The interdigital nerves between the metatarsals provide sensory feedback. These nerves do not provide movement (motor) to this area hence their innervation is primarily to the skin, giving tingling and acute sensory pain. The most common area is between the third and fourth metatarsals however, it can occur between the first and second or second and third metatarsals. The metatarsal heads are covered with layer subcutaneous fat (padding) to reduce compressive load.


Fig 1. A build up of fibrous tissue around the interdigital nerve can cause pain and compression of the nerve, limiting mobility.                                                       

Cause

Morton’s neuroma most commonly comes on after a period of loading to this area or after being placed in a prolonged stretch position (think of gardening or tiling the bathroom floor!) In this position your toes go into an extended position placing the interdigital nerve on stretch. This position ‘irritates’ the nerve, setting off an inflammatory cascade. Further compression through this area is commonly associated with poor foot biomechanics. In this scenario the forefoot fails to re-supinate on take off. This places increased pronation and compressive force between the metatarsal heads. After a number of insults, scar tissue tends to gather around the nerve, causing thickening and decreased mobility.

Signs and symptoms

Morton’s neuroma often presents with acute local pain on weight bearing made worse by stretching with the toes in an extended position. It is often described as a burning or sharp neural pain, sometimes referring into the toes. It may warm up initially however it tends to worsen throughout the run.

Treatment

Treatment about this area needs to address and modify any factors of causation (if they can be identified). Most commonly, Dr. DiPretoro will look to modify any foot abnormalities such as increased pronation, poorly fitting shoes, poor glute control further up the chain. Decreased ability of the great toe (hallux) to go into extension places further load on the area. Clinically we find passive great toe extension of 60 degrees to be adequate. This allows the forefoot to supinate on toe-off, decreasing compressive forces. 

Fig 2. Local corticosteroid injection to the nerve. The injection is aimed at 'bathing' the nerve with cortisone.

It is very difficult to manually address the soft tissue fibrosis around the area. If there is limited mobility about the forefoot joint mobilisation may help. Often donut padding around the area is enough to de-load the forefoot and help spread load across the metatarsal heads. Further treatment may involve mobilising the nerve. In chronic cases cortisone to the affected area can provide short-term relief. In recalcitrant cases excision of the offending tissue may be performed.

Fig 3. Recalcitrant cases may need to resort to surgery.Conservative treatment should be explored first. 

Differential Diagnoses

Less commonly there may be inflammation of the bursa that lie within the interdigital space. The cause is similar, an increase in toe extension as may occur with an increase in speed work or hill running. Pain originating from the bursa is usually painless with passive ranges of motion however particularly painful with active range of motion. Bursal pain does not warm up and increases with increased loads. In these cases the initial treatment is similar with regards to causation. Further to this, cortisone is effective at decreasing inflammation within the bursa. 

Fig 4. The arrows show the close proximity of the nerve and the bursa demonstrating a possible co-existence. An inflamed bursa may place extra pressure on the adjacent nerve.

The possible side effects of corticosteroid injection (particularly repeated at the same site) are atrophy and degeneration of the fat pad. This can lead to increased load through the boney and tendinous architecture through the forefoot. 

Prognosis

Morton’s neuroma can be quite difficult to treat, especially if caught late. Once thickening starts to occur around the nerve, it becomes more likely to become irritated again causing further tissue thickening. This creates a vicious cycle. This is one of those injuries that can flare up quite quickly and then lay dormant for a few months before returning. Make your appointment with Advanced Foot & Ankle Center if you are experiencing any of the symptoms!

A Runner's Achilles Heel

Preventing Achilles injuries

A common and sometimes chronic grievance, Achilles tendinopathies can be, both literally and figuratively, a runner's Achilles heel. The media's constant chatter about Achilles injuries only serves to highlight their prevalence. Reporters recently speculated that Usain Bolt's loss to Tyson Gay at the Diamond League Meet in Stockholm was the result of a slow recovery from an Achilles injury. David Beckham's highly publicized Achilles rupture prevented him from playing in this summer's World Cup. Even Alex Wong, a contestant on this season's So You Think You Can Dance, had his rug-cutting dreams dashed by an Achilles laceration.

While these types of injuries occur among soccer players, dancers and everyone in between, runners are perhaps the likeliest candidates. Handling up to 12 times your body weight, that tendon has a big job. Achilles tendinopathies, which include acute tendinitis and the more chronic tendinosis, account for nearly 11 percent of running injuries. As many of these injuries result from training errors, experts agree that education about proper training and rehabilitation is the key to combating them.

Physiology of the Achilles

"The Achilles is the strongest and largest tendon in the body. It's a very important structure," says Claude Pierre-Jerome of Emory University, a leading researcheron the foot and lower leg. Joining at the Achilles is the gastrocnemius and the soleus muscles, which both come from the upper part of the lower leg. The Achilles tendon then attaches to the calcaneus on the back of the heel.

In addition to getting used a lot, the Achilles receives poor blood supply, which makes it particularly susceptible to injury and, once injured, is slow to heal. While tendon injuries can occur on the entire length of the Achilles, the blood supply is most lacking 2-6 centimeters above the insertion point, leading to the greatest percentage of injuries in that area.

The Achilles tendon carries a lot of load and, when you're running, the load increases. If the tendon isn't healthy and the load is increased, it causes injuries. All tendons, bones and muscles need cyclical loading to work properly, but sometimes the loading exceeds what the tissue has adapted to.

While the Achilles can tear or rupture completely, most of the overuse injuries associated with running are less acute.  When it comes to Achilles pathology, most runners will suffer from either tendinitis or tendinosis.  Tendinitis is when there is acute inflammation. The tendon itself is surrounded by a sheath and that becomes inflamed.  Tendinosis is more chronic and runners tend to just run through it for months, if not years. That's where you get degeneration of the tendon itself.  Regardless of the diagnosis, the culprit that causes these ailments is usually identical: training errors.

So Much Load, So Little Time

Most experts agree that overtraining or incorrect training, improper footwear and certain types of terrain lead to most Achilles tendinopathies. Unfortunately , Running is one of the main activities that leads to Achilles tendon injuries.

Typically these Achilles injuries are caused by building up mileage or intensity too quickly, or doing too many hills.  When you do too much too soon, things start breaking down. Speedwork and hill training are commonly identified causes that spring from training. While these are necessary aspects of any good training plan, injuries come from jumping into them too soon or too fast.

Your own biomechanics (determined by genetics) can play a role, but causes can also be traced to shoes and terrain.  Some people wear shoes that aren't appropriate for running and that puts an extra load on the tendon, which then causes injuries.

Dr. DiPretoro has seen many patients with Achilles injuries who wear shoes with too much cushioning and not enough support. He explains that a highly cushioned heel allows your feet to sink down too far, while your calf muscle is simultaneously contracting.  Then you have the tendon being pulled in two directions. It's being yanked down at the same time the muscle is pulling it upwards and it over stretches.

Similarly, overly soft surfaces that cause the tendon to work harder, like sand, have been said to cause Achilles injuries. Also, the crowning affect of many roads that can lead to imbalances when runners are always on one side.

Road to Recovery

We hope runners will take care of these injuries early on when they first start having pain. In those cases, it can be treated with rest, ice and elevation to start with.  Even a few weeks of gentle treatment and decreased mileage can get a runner over a mild case of tendinitis.

In all cases, the first line of defense is understanding the pathology.  Your personal running history, the length of time you've had the injury and the other activities in which you are involved can all be important factors in determining a treatment plan.

First and foremost, we have to calm down the symptoms before we can be aggressive with any stretching and strengthening.  Unless you are having significant pain with every walking step, we usually prefer not to cut out training, but to cut it down.  This is the very reason for the 10 percent rule—avoiding mileage increases from week to week that exceed 10 percent is one way to curb Achilles injuries. Experts agree that cutting back on mileage, avoiding hills and staying away from speedwork for a few weeks can sometimes be enough.

As the rehabilitation progresses, there are a number of different exercises that have been shown to be beneficial. For chronic Achilles tendinosis, in particular, eccentric training is often prescribed once the runner is asymptomatic. To do this, stand on a ledge or platform with your heels off the back and do a toe raise with both feet; come back down using only the affected side. While this may not work for many patients, research suggests that it is helpful to some runners. Do not  allow your heel to go down too far off the platform, thereby overstretching the Achilles. It is meant to be a light strengthening exercise.

Keeping the calf muscles healthy will also help to rehab an ailing Achilles and prevent further issues. Besides the heart, the calf muscle is the hardest working muscle in the body. It's taking stress and applying stress with every single footstep.   Most doctors and PTs will recommend fairly gentle stretching. Runners  should stretch the calves by placing hands against a wall with one leg extended straight back with the knee straight and the other leg forward with the knee bent. The straight leg will stretch the gastrocnemius and the bent knee leg will stretch the soleus. Since these are the muscles that eventually connect with the Achilles, their flexibility leads to less stress on the tendon.

Upon following your Podiatrists' orders regarding icing, training modifications and stretching and strengthening routines, you will also want to check your footwear. Put simply, choose a shoe that is right for your foot type. Adding in heel raises and orthotics may also help calm the symptoms. We usually suggests a ¼-inch heel lift in a runner's shoes, saying that such lifts can decrease the stress on the tendon by 10–15 percent. Additionally, lifts can be built into orthotics, which also help cut down on three-dimensional torque.

If you react quickly, it could take as little as three weeks to heal.  However, if you react slowly, it could take three months, six months or longer.  In the interim, substitute some of those running miles for biking and swimming. Through crosstraining, you will continue to bank cardiovascular fitness without further irritating the tendon. In the end, smart and methodical training will help you avoid making your Achilles heel, your Achilles heel.

What are ingrown toenails? What are the symptoms?

What are ingrown toenails? What are the symptoms?

Symptoms of ingrown toenails are sore, often painful, nail folds with various degrees of redness, swelling, and sometimes clear or yellow drainage. Frequently, ingrown toenails resolve without medical treatment. Complicated cases may require treatment by a your Podiatrist, Dr. Raymond A. DiPretoro, Jr..Ingrown toenails are a very common problem affecting primarily the great toenail. They are caused by sideways growth of the nail edge into the skin of the toe. The abnormal extension of the toenail pushes into the surrounding skin causing discomfort. Normal toenail growth should be vertical or outward toward the tip of the toe. The medical term for ingrown toenail is onychocryptosis.

What causes ingrown toenails?

Are some people more prone to ingrown toenails? The sideways growing portion of nail acts like a foreign body and pokes into or pinches off a small piece of skin at the outer edge of the toe. This may cause a break in the skin, causing inflammation and possibly infection. The inflammation often causes more thickening of the nail skin fold, further exacerbating the problem. The protruding piece of nail keeps pushing into the skin, causing further injury and pain.

Some people are simply more prone to ingrown toenails. Some risk factors include

• athletic adolescents and children,
• tight or narrow shoes (poorly fitted shoes),
• repeat injury or trauma to feet,
• poor foot hygiene,
• poor posture and gait,
• congenital foot deformity,
• congenital toenail malformation,
• very long toes,
• naturally short nails,
• obesity,
• diabetes,
• toenail infections,
• fungal nail disease,
• prior nail surgery,
• abnormal nail growths,
• arthritis, and
• excessive foot sweating.

Ingrown Toenails!!

Ingrown Toenail

• Overview
  • Alternative Names
  • Causes
  • Exams and Tests
  • Treatment
  • Outlook (Prognosis)
  • Possible Complications
  • When to Contact a Medical Professional
  • Prevention
• 
  

Illustrations

• Ingrown Toenail

An ingrown toenail occurs when the edge of the nail grows down and into the skin of the toe. There may be pain, redness, and swelling around the nail.

Alternative Names

Onychocryptosis; Unguis incarnatus; Nail avlusion; Matrix excision

Causes

An ingrown toenail can result from a number of things, but poorly fitting shoes and toenails that are not trimmed properly are the most common causes. The skin along the edge of a toenail may become red and infected. The great toe is usually affected, but any toenail can become ingrown.

Ingrown toenails may occur when extra pressure is placed on your toe. Most commonly, this pressure is caused by shoes that are too tight or too loose. If you walk often or participate in athletics, a shoe that is even a little tight can cause this problem. Some deformities of the foot or toes can also place extra pressure on the toe.

Nails that are not trimmed properly can also cause ingrown toenails.

• When your toenails are trimmed too short or the edges are rounded rather than cut straight across, the nail may curl downward and grow into the skin.
• Poor eyesight and physical inability to reach the toe easily, as well as having thick nails, can make improper trimming of the nails more likely.
• Picking or tearing at the corners of the nails can also cause an ingrown toenail.

Some people are born with nails that are curved and tend to grow downward. Others have toenails that are too large for their toes. Stubbing your toe or other injuries can also lead to an ingrown toenail.

Exams and Tests

An examination of the foot will show the following:

• Skin along the edge of the nail will appear to be growing over the nail, or the nail may seem to be growing underneath the skin.
• Skin may be swollen, firm, red, or tender to touch. At times, there may be a small amount of pus present.

Tests or x-rays are usually not needed.

Treatment

If you have diabetes, nerve damage in the leg or foot, poor blood circulation to your foot, or an infection around the nail, go to your Podiatrist right away. Do NOT try to treat this problem at home.

To treat an ingrown nail at home:

• Soak the foot in warm water 3 to 4 times a day if possible. Keep the toe dry, otherwise.
• Gently massage over the inflamed skin.
• Place a small piece of cotton or dental floss under the nail. Wet the cotton with water or antiseptic.

You may trim the toenail one time, if needed. When trimming your toenails:

• Consider briefly soaking your foot in warm water to soften the nail.
• Use a clean, sharp trimmer.
• Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not try to cut out the ingrown portion of the nail yourself. This will only make the problem worse.

Consider wearing sandals until the problem has gone away. Over-the-counter medications that are placed over the ingrown toenail may help some with the pain but do not treat the problem.

If this does not work and the ingrown nail gets worse, see your foot specialist Dr. Raymond A. DiPretoro, Jr..

If your ingrown nail does not heal or keeps coming back, your doctor may remove part of the nail.

• Numbing medicine is first injected into the toe.
• Using scissors, your doctor then cuts along the edge of the nail where the skin is growing over. This portion of the nail is then removed. This is called a partial nail avulsion.
• It will take 2 to 4 months for the nail to regrow.

Sometimes your Podiatrist will use a chemical, electrical current, or another small surgical cut to destroy or remove the area from which a new nail may grow.

If the toe is infected, your Podiatrist may prescribe antibiotics.

Outlook (Prognosis)

Treatment will generally control the infection and relieve pain. However, the condition is likely to return if measures to prevent it are not taken. Good foot care is important to prevent recurrence.

This condition may become serious in people with diabetes, poor circulation, and nerve problems (peripheral neuropathies).

Back to TopPossible Complications

In severe cases, the infection may spread through the toe and into the bone.

When to Contact Your Podiatrist

Call your Podiatrist, Dr. Raymond A. DiPretoro, Jr.  if you:

• Are unable to trim an ingrown toenail
• Have severe pain, redness, swelling, or fever

If you have diabetes, nerve damage in the leg or foot, poor blood circulation to your foot, or an infection around the nail, your risk for complications is higher. If you have diabetes, see your Podiatrist at Advanced Foot & Ankle Center!

Prevention

Wear shoes that fit properly. Shoes that you wear every day should have plenty of room around your toes. Shoes that you wear for walking briskly or for running should have plenty of room also, but not be too loose.

When trimming your toenails:

• Considering briefly soaking your foot in warm water to soften the nail.
• Use a clean, sharp nail trimmer.
• Trim toenails straight across the top. Do not taper or round the corners or trim too short.
• Do not pick or tear at the nails.

Keep the feet clean and dry. People with diabetes should have routine foot exams and nail care.

Achilles Tendinitis in Runners: Symptoms, Causes, Prevention & Treatment!

Achilles Tendinitis

The Achilles is the large tendon connecting the two major calf muscles--the gastrocnemius and soleus--to the back of the heel bone. Under too much stress, the tendon tightens and is forced to work too hard. This causes it to become inflamed (that's Achilles tendinitis), and, over time, can produce a covering of scar tissue, which is less flexible than the tendon. If the inflamed Achilles continues to be stressed, it can tear or rupture.

Identifying symptoms of Achilles tendinitis

Achilles tendinitis is characterized by dull or sharp pain anywhere along the back of the tendon, but usually close to the heel. Other signs you might have Achilles tendinitis include limited ankle flexibility, redness or heat over the painful area, a nodule (a lumpy buildup of scar tissue) that can be felt on the tendon, or a cracking sound (scar tissue rubbing against the tendon) when the ankle moves.

 

Causes of Achilles tendinitis

Tight or fatigued calf muscles, which transfer too much of the burden of running to the Achilles, can be brought on by not stretching the calves properly, increasing mileage too quickly or simply overtraining. Excessive hill running or speedwork, both of which stress the Achilles more than other types of running, can also cause tendinitis. Inflexible running shoes, which force the Achilles to twist, cause some cases. Runners who overpronate (their feet rotate too far inward on impact) are most susceptible to Achilles tendinitis.

 

Prevention and treatment of Achilles tendinitis

If you start experiencing Achilles pain, stop running. Take aspirin or ibuprofen, and ice the area for 15 to 20 minutes several times a day until the inflammation subsides. Self-massage may also help. 

 

Once the nodule is gone, stretch the calf muscles. Don't start running again until you can do toe raises without pain. Next, move on to skipping rope, then jumping jacks, and then gradually begin running again. You should be back to easy running in six to eight weeks.

 

If injury doesn't respond to self-treatment in two weeks, see your Podiatrist, Dr. Raymond A. DiPretoro, Jr..  Surgery to scrape scar tissue off the tendon is a last resort.

 

Try these alternative exercises: Swimming, pool running and bicycling (in low gear). Stay away from weight-bearing exercises.

 

To prevent the recurrence of Achilles tendinitis, strengthen and stretch the muscles in your feet calves and shins. A good way to do this: Sit on the floor with a weight taped or strapped to the front of one foot. Bend the knee at a 90-degree angle, with your heel resting on the floor; then lift the weight by pulling the toes toward you. Lower, and repeat. You can also do toe raises to help strengthen your calves.

 

Another great stretch for the Achilles is also the simplest. Stand on the balls of your feet on stairs, a curb or a low rung of a ladder, with your legs straight. Drop both heels down and hold for a count of 10. To increase the intensity of the stretch, keep one foot flat and lower the other heel. Then switch legs.

 

Wear motion-control shoes or orthotics that your Podiatrist can make for you to combat overpronation, and don't run in worn-out shoes. Ease into any running program. Avoid hill work, and incorporate rest into your training schedule.

 

Gout and Your Feet

Definition and Causes

Gout is a type of arthritis that is caused by the accumulation of uric acid in the body and the joint fluid (hyperuricemia).  The build-up of uric acid commonly happens when the body does not process well certain proteins, which occur naturally in our diets, called purines (PURE-EENS).

The actual accumulation of uric acid results when the body does not eliminate uric acid through the kidneys and urine, or when the body produces too much uric acid.  It is a hereditary tendency to accumulate uric acid.  This hereditary tendency may skip an individual or a generation and reappear in the children of someone without any signs of gout.  Gout is most prevalent in males between the ages of 50 and 60, although there are occurrences in females and in younger males.

Symptoms

The onset of gout is signalled by a sudden onset of pain in one or more joints, commonly in the joint of the big toe of the foot.  Redness, swelling, and warmth over the joint accompany the pain.  Often the patient does not remember injuring the joint before the pain begins.  Many patients report that they first notice the pain in the middle of the night or upon rising in the morning.

The symptoms occur most often in the big toe joint; however any joint may be affected.  Other typical areas of pain are the instep of the foot, the ankle, or the knee.  When the foot is affected, it is difficult and painful to wear shoes and to move the joint or stand on the foot.

Gout usually starts with a sudden onset of intense pain in one or more joints, usually the big toe joint of the foot.  The pain is accompanied by redness, swelling and warmth over the joint.  Typically, the patient does not recall injuring the joint before the pain started.  Many patients say they first noticed pain in the middle of the night or upon arising in the morning.

Diagnosis

Diagnosis of gout is based on personal and family history along with and examination by the doctor that often finds the common symptoms of gout and makes a clear diagnosis.  Uric acid levels are often determined by performing blood tests, and uric acid crystals can be found by examining joint fluid.  Both bones and joints are examined through x-rays to rule our abnormal changes due to gout.

Treatment

The first step for treating gout is obtaining a correct diagnosis.  An acute attack of gout is most often managed through oral anti-inflammatory medications.  Over-the-counter medications may reduce symptoms of gout; however they are rarely effective in treating the acute pain, swelling, and inflammation.  When the symptoms of gout occur in the toe, relief is often found by elevating the foot, avoiding standing and walking, and wearing loose slippers until consulting a podiatric physician.

Controlling gout is commonly achieved with prescribed medication, when there is an acute symptom and for on-going treatment.  It is important that your doctor to determine whether producing too much uric acid or not eliminating it properly is responsible in order to determine the effective medication to treat the gout.

If the symptoms of gout continue despite medical treatment, if deposits of uric acid crystals in a joint are excessive, or if arthritic pain is continual, surgery may be required to treat the gout by removing the crystals (tophi) and repairing the joint.  By not considering surgery when necessary may cause permanent arthritis of the joint(s).

Prevention

Foods high in purines can elevate uric acid levels and cause an acute attack of gout.  Such foods include red meats, shellfish, beer, red wine, and salt.  Certain medications such as diuretics (water pills), often prescribed to control high blood pressure or reduce swelling, may be responsible for acute attacks of gout.  Gout may also be caused by stress, infection, and trauma.

The chance of an attack of gout can be reduced or the severity of an attack can be lessened by consuming 6-8 glasses of water daily, eating an appropriate diet, and evaluating current medications.  Regular visits to a podiatric physician will also reduce the chances of an attack if you have a personal of family history of gout.

What Is Gout? What Causes Gout?

The word gout comes from Latin gutta and old French gote meaning "a drop". Several hundred years ago gout was thought to be caused by drops of viscous humors that seeped from blood into the joints. In fact, this supposition was not that far from the truth. When a patient experiences the symptoms of a gout attack uric acid has been accumulating in his blood, and uric acid deposits have been forming in the joints. 

Gout is a complex disorder, it is more prevalent among men, and afflicts women more commonly after the menopause. Men have higher uric acid levels in their blood than women.

In 2011, the American College of Rheumatology announced that 8 million Americans have gout - nearly 6% of men and 2% of women.

According to Medilexicon's medical dictionary, Gout is:

"A disorder of purine metabolism, occurring especially in men, characterized by a raised but variable blood uric acid level and severe recurrent acute arthritis of sudden onset resulting from deposition of crystals of sodium urate in connective tissues and articular cartilage; most cases are inherited, resulting from a variety of abnormalities of purine metabolism.

The familial aggregation is for the most part galtonian with a threshold of expression determined by the solubility of uric acid. However, gout is also a feature of the Lesch-Nyhan syndrome, an X-linked disorder [MIM*308000]."

What are the symptoms of gout?

Signs and symptoms of gout are generally acute - they come on suddenly without warning. A significant proportion of patients experience them at night.

• Severe pain in the joints - The patient may experience pain in his ankles, hands, wrists, knees or feet. More commonly the big toe is affected (podagra). Many patients describe the affected areas as warm/hot. The fluid sacs that cushion tissue (bursae) may become inflamed (bursitis) - when this happens in the elbow it is called olcranon bursitis, while in the knee prepatellar bursitis.


• Gradually goes away - A bout can last for over a week if left untreated - and then gradually goes away during the following week or two.


• Itchy and peeling skin later - As the gout subsides the skin around the affected area may be itchy and peel. By the end of it the patient feels fine.


• Redness and inflammation - The sufferer will most likely have tender, red and swollen joint(s) in the areas that experienced the most pain.


• Red/purplish skin - The affected area may become red or purplish, making the patient think he has an infection.


• Fever - Some patients have an elevated temperature.


• Less flexibility - The affected joint may be harder to use, the patient has limited movement.


• No symptoms - Some patients experience no symptoms. In these cases it may develop into chronic gout.


• Nodules - The gout may first appear as tophi (nodules) in the elbows, hands, or ears.

Gout presenting in the metatarsal-phalangeal joint of the big toe

What causes gout?

The levels of uric acid in your blood rise until the level becomes excessive (hyperuricemia), causing urate crystals to build up around the joints. This causes inflammation and severe pain when a gout attack happens. 

When the human body breaks down chemicals called purines it produces uric acid. Purines can be found naturally in your body, as well as in food, such as organ meats, anchovies, asparagus, mushrooms and herring. 

Most of the time uric acid dissolves and goes into the urine via the kidneys. However, if the body is producing too much uric acid, or if the kidneys are not excreting enough uric acid, it builds up. The accumulation results in sharp urate crystals which look like needles. They accumulate in the joints or surrounding tissue and cause pain, inflammation and swelling. 

Surprisingly, hyperuricemia is commonly found in many people who never develop gout. Scientists are not completely sure what causes hyperuricemia. There is definitely a genetic factor because a person who has close relatives with hyperuricemia is more likely to develop it himself. 

The following have been known to bring about a gout attack and may be contributory causes of gout:

• obesity
• heavy alcohol consumption, especially beer
• a diet high in purine foods, such as seafood and meat, and meat organs
• extremely low calorie diets
• regular aspirin use
• regular niacin use
• drinks high in fructose linked to gout risk - females who regularly consume beverages with a high fructose content are 74% more likely to develop gout, compared to women who consume such drinks no more than once a month, researchers from Boston University School of Medicine reported in JAMA (November 2010 issue).
• regular use of diuretic medicines
• medicines taken by transplant patients, such as cyclosporine
• fast weight loss
• chronic kidney disease
• hypertension (high blood pressure)
• psoriasis
• tumors
• myeloma
• hemolytic anemia
• lead poisoning
• hypothyroidism
• surgery
• Kelley-Seegmiller syndrome
• Lesch-Nyhan syndrome

When should you see a doctor?

If you have a sudden and intense pain in a joint get in touch with your doctor. If you do not treat it, the gout can gradually get worse over time. If you also have a temperature, and the joint is hot and/or inflamed, get medical attention as soon as possible - it could mean you have an infection.

How to test for gout?

After examining you, your doctor may carry our either or both these tests:

• Blood test - to measure your levels of uric acid. This test is not definitive as some people with high uric acid levels never have gout symptoms; while others who have gout symptoms do not have high levels of uric acid in their blood.
• Joint fluid test - a needle is used to collect fluid from the affected joint. The liquid is then examined under a microscope to see whether urate crystals are present.

What are the complications of gout?

Gout does not commonly cause any further problems. However, some are possible:

• Recurrent gout - while some people just get one attack, and never experience another one again, others may have recurrent attacks. There are drugs which help reduce the number of recurrent attacks, or even eliminate them.
• Advanced gout - If the gout is not treated urate crystals may form under the skin in nodules, they are known as tophi. They may become swollen and tender whenever the patient has a gout attack, but are not painful otherwise.
• Kidney stones - Urate crystals can accumulate in the urinary tract of a patient who suffers from gout. This causes kidneys stones. There are drugs which can lower the chances of developing kidney stones.
• Damage to joints - if the tophi (nodules) become inflamed the joints could become damaged.
• Gout might spread - The gout could spread to other joints.

Treatments for Gout

1) Medication

Gout is usually treated with medications, these include:

• NSAIDs (nonsteroidal anti-inflammatory drugs) - these help combat inflammation and pain. Ibuprofen and naproxen are NSAIDs. There is an increased risk of stomach pain, ulcers and bleeding for some patients who take this drug - the higher the dosage, the higher the risk.
• Colchicine - an effective drug for gout. However, a number of patients might experience diarrhea, vomiting and/or nausea. Colchicine is often given to patients who are unable to take NSAIDs.
• Steroids - these may help combat inflammation and relieve pain. The patient may receive the medication orally or it could be injected right into the joint. Some patients who take steroids may experience a thinning of bones, poor wound healing, while others find that their immune systems become weaker and it is harder to fight off infections. Steroids are usually given to patients who are unable to take either colchicines or NSAIDs.
• Uloric (febuxostat), a drug that lowers levels of uric acid in the blood, was approved by the US FDA in February 2009, for the treatment of hyperuricemia and chronic gout.

2) Self Help

These measures may help ease the pain and swelling:

• Raise and rest your limb.
• Some people use a splint to immobilize the joint.
• Do not do vigorous exercise.
• Keep the joint cool, apply an ice pack or bag of frozen vegetables wrapped in a towel. Do not apply directly to your skin without a towel as this could damage your skin. Allow the temperature of the affected area to return to normal before repeating this.
• Do not cover the joint.

How to prevent gout

1) Medications

There are some medicines which can reduce your risk of future gout attacks. These are usually taken after an attack is over:

• Reducing the production of uric acid - Allupurinol reduces the amount of uric acid your body produces, which in turn lowers your chances of having an attack recurrence. Some patients who take this medication may have a rash, and/or a low blood count.
• Removing uric acid more effectively - Probenecid helps your kidneys eliminate uric acid more effectively, thus lowering your blood uric acid levels, which in turn reduces your chances of recurrence of an attack. Some patients may develop a rash when taking this medication, while others may have stomach pains, and a very small number may develop kidney stones.

2) Nutrition

Although diets have not been proven to reduce a person's risk of gout, this is due to a lack of studies rather than the existence of studies that prove diet is ineffective. It would make sense not to consume too many foods that are high in purines, such as red meat, meat organs, and seafood. Reducing your consumption of alcoholic drinks may also be beneficial. Some people suggest you should consume more low-fat dairy products, while others mention a good intake of whole-grain breads is beneficial. If you drink plenty of water you might dilute the amount of uric acid in your blood, some say. 

A study published in September 2012, in the journal Arthritis & Rheumatism, suggested that eating cherries could reduce the risk of gout attacks by 35%.