Common Foot and Ankle Disorders



The term "gout" originates from the French word "goute", the word's primary origin in the Latin word "gutta" meaning literally "drop of liquid". The "liquid" so-called is actually a "dead" substance contained in the blood that can deposit in a joint and/or other parts of the body if too much of the uric acid accumulates in the blood. We know of gout as most commonly causing redness and swelling in the Big Toe joint.

Gout occurs most often in men - due in largest part to poor diet and alcohol use - though gout is also very common in women as well as in men who take a certain type of diuretic ("water pill").

The "gutta", the drop of dead substance, is a breakdown product of food metabolism called uric acid - in purest form a white powder of small sharp crystals. Within the body it forms a white "chalky" liquid paste that can form into "drops". Under normal circumstances, our bodies' flush-out/excrete most of the breakdown products - the "poisons" - of food metabolism, either through the kidneys (then on into the urine), or through the liver (then on into the bowels). Uric acid in particular is excreted/gotten-rid-of through the kidneys and on into the urine. But, when there is too much uric acid in the blood, or when certain drugs stop the excretion of uric acid, it builds-up and begins to "fall-out" of the blood, depositing in certain areas in our bodies, most often in the arthritic joint(s) of the feet.

When those deposits build-up over time, they become known as "tophus", a hard condensed accumulation of uric acid in the body.

For reasons that have to do with arthritic inflammation and associated increased circulation, and probably even gravity, the joints of the feet, in particular the big toe joint, are the most common places for this white powder to go. This is because the big toe joint is usually the first joint to become damaged in the foot. Once damaged, the joint tissues become inflamed due to an increase circulation from the blood flow that comes-in to heal the damaged joint tissue. It is that inflammation that serves as a kind of "magnet" causing the uric acid to deposit in those inflamed tissues.

Some of the other places that uric acid can deposit include the joints of the hand, wrist, elbow and knees. Even the kidneys themselves can become "storage houses" for uric acid, turning into kidney stones. In rare instances a tophus can even form under the skin - one of the most unusual places being the lobes of the ear of boxers.

Diet and Drugs

As mentioned, men are the best "candidates" for gout. Men tend to damage their big toe joints because of sports and work demands. And men tend to have the poorest diets and drink more alcohol than women. Hence, a bad joint (which alcohol makes all the more inflamed because it increases circulation and the inflammation that is already in the joint tissues) together with a poor diet, make men the most susceptible to gout.

The other, and probably now the most common way in which both men, and women, become candidates for gout, is when they use "thiazide" diuretics such as Lasix, furosemide, Hygroton, hydrochlorothiazide, Dyazide (to give a few of the most common names) to control high blood pressure and fluid retention. Unfortunately these drugs are considered very important for helping to control high blood pressure in particular. So, do not stop taking your prescribed diuretic without consulting your doctor who prescribed it. To counteract the effects of that diuretic if it is contributing to an increased in blood uric acid, you may need to take another drug or alter your diet so as to reduce the chance of getting gout or in order to keep it from coming back.

What happens to the Joint that gets a gout attack?

The joint that gets an attack of the gout is "predisposed", already "upset" (inflamed) and arthritic, even if it never bothered you before the first gout attack. When it gets "attacked", the uric acid crystals deposit inside and around the joint tissues causing the body to reject the uric acid, which in-turn causes a much bigger increase in inflammation. AND, the uric acid crystals which have sharp knife-like edges cut the joint tissues in which they are deposited, causing then more damage and even more inflammation.

If gout happens more than once, and the uric acid imbalance is not recognized and treated, then over time the uric acid deposits will build-up causing joint tissues to become weak, and causing the cartilage to wear away. Those patients who get many attacks will eventually develop large deposits of uric acid that develop into visible accumulations of gout - a tophus - that often break through the skin and must then be surgically removed.


Treatment is divided-up into, 1) localized treatment, i.e. the treatment of the gouty joint, 2) surgical treatment for those joints in which uric acid has destroyed joints or caused the formation of "tophus", and most importantly, 3) "systemic" treatment, i.e. the treatment of the high uric acid levels in the blood.

Localized Treatment

Localized treatment for an acute attack, i.e. one of the first times that a joint becomes attacked and before uric acid has just started to build-up in the joint, involves an injection of local anesthetic mixed with cortisone. The cortisone injection helps to control inflammation which causes terrible pain, increased swelling, and even more damage the joint and joint tissues. Breaking the pain cycle and controlling the inflammation are essential.

In addition to an injection, doctors often prescribe an aspirin-type medication after the injection, such as ibuprofen/Advil (if patients are allowed to take such medicines) which can help with any residual pain that the injection may not help control.

Historically, "colchicine" and "Indocin" have been prescribed for acute attacks of gout in the joints. While these treatments are not wrong, they work too slowly and do not help very well with the severe pain. And, the drug colchicine usually causes diarrhea, a very unwelcome side-effect.

Surgical Treatment

"The end of the road" for gouty joints, those joints in which there is the build-up of uric acid and the development of tophus, the joints must be surgically removed and often replaced, and the uric acid build-up removed as well. And, before surgery is performed on these areas, high uric acid levels in the blood must be brought under control. This is because GOUT ATTACKS CAN EVEN HAPPEN AT SURGERY SITES IN THE FOOT.

Systemic Treatment

Besides controlling the terrible pain and inflammation associated with a gout attack, the most important treatment is recognition and treatment of high uric acid levels.

If diet is the cause (e.g. eating too much fatty food, liver, kidneys, shrimp, and even such vegetables as Brussels sprouts), it must be addressed.

Alcohol is also an issue. Alcohol causes arthritic joints to become even more inflamed, hence becoming even stronger "magnets" for uric acid.

If water pills (thiazide diuretics) are prescribed by your doctor, you must work with her/him to determine if other medicines can be used to just as effectively to treat your high blood pressure and/or fluid retention. If changing your diet does not help to reduce the uric acid levels and/or it is determined that you much take the diuretic medication, your doctor can prescribe the medicine "allopurinol/Zyloprim" in order to lower blood levels of uric acid.