San Francisco Podiatry Video


Wednesday, May 5, 2010

Do I Have Gout in the Big Toe Joint

Gout is one of the most painful conditions I see as a Podiatrist in San Francisco. Usually gout attacks the big toe joint. The question is, how do you tell if you are having an attack of gout in the foot?

When gout happens the first thing you will notice is pain, swelling and redness around the joint. In the foot this is most often the base of the big toe in the joint podiatrists call the "metatarsaophalangeal joint." Gout can happen in any of the joints in the foot, but usually it the big toe joint.

When gout develops, you get uric acid crystals forming and being deposited in the joint itself. If untreated, the crystals may continue to form and lead to the buildup of a chalky paste-like substance called tophi. You can see the huge lump on the bottom of the big toe joint in the picture above. All of that is uric acid crystals in the joint.

Because these sharp needle-shaped crystals end up in the joint, it can be incredibly painful to move the joint. Every time you move the big toe, it is like having a thousand little needles poking the inside of the joint. This of course hurts.

In response, your body reacts with inflammation. That is where the classic pain swelling and redness comes in. The foot will be warm to the touch, red and very painful. Many gout sufferers will say they can't even have a bed sheet touching the foot because it is so painful.

The biggest problem with trying to tell if you actually have gout is that gout mimics two other conditions: infectious arthritis and Charcot. Charcot arthropathy is an emergency that can look like gout, but is actually more serious. It is most common in people with diabetes. Infectious arthritis is where bacteria (instead of uric acid) is invading the joint. Both of these are emergencies. With either, it is important to start treatment right away to prevent further damage and the potential for losing the foot to an amputation.

Many people who have had multiple attacks of gout can seem to tell when it is coming on. However, if you have never been diagnosed with gout, it is important to see a foot specialists who can make sure you don't have a more serious condition.

The most accurate way for your podiatrist to diagnose gout is through a small procedure called joint aspiration. In this way, the uric acid crystals in the joint can easily be identified. More importantly, your foot doctor can rule out a bacterial infection. Blood tests and x-rays may give clues that you have had gout, but can be unreliable if used alone to diagnose gout.

Once you have been diagnosed with gout, your podiatrist will likely make recommendations on modifying your diet to prevent it from happening again. You can view our recommendations on a Gout Diet here. If you are given a prescription to treat the gout, you will be given written instructions that you should follow closely.

Dr. Christopher Segler was selected in 2010 as one of "America's Top Podiatrists." He has a podiatry house calls practice in the San Francisco Bay Area. To learn more about gout, visit the Gout page on our website. If you have gout and need pain relief right away, he makes podiatry emergency house calls 24/7. If you think you might have gout and would like to speak directly with him to ask a question, you can call him (415) 308 0833.

Saturday, May 1, 2010

NSAIDs: Why Runners Should Think Twice - by San Francisco Running Podiatrist

Ibuprofen is often referred to as "vitamin I" by marathon runners and triathletes. I have spotted ibuprofen tablets in the road on nearly every marathon or Ironman triathlon I have entered. Usually the tablets have been dropped and sprinkled on the asphalt just before an aid station, presumably by some miserably sore athlete hoping to kill the pain and keep on running. But just because its popular, doesn't mean its a good idea.

Non-steroidal anti-inflammatory drugs (NSAID's) are the most commonly consumed over-the-counter medication. The anti-inflammatory drugs includes aspirin, Motrin (ibuprofen), Aleve (naproxen) and others. Because these seemingly harmless drugs can relieve minor aches and pains while also decreasing inflammation they are very popular among endurance athletes.

But there are actually two very good reasons why you might want to think twice before popping those pills.
1. NSAIDs slow tissue healing.
2. NSAIDs can damage your kidneys.

I have had dozens of running buddies tell me that they routinely take 600-800mg of ibuprofen after long runs or intervals. This is a common tactic to decrease inflammation and attempt to prevent delayed-onset muscle soreness. There is no doubt that this can work, but at a price.


The very first phase of any wounded tissue healing is the "inflammatory phase." By taking a medication that interferes with inflammation you can actually decrease the tissue healing that takes place after your workouts. This really seems counterproductive.

If you think about how hard you work to stay on pace that last couple of miles during your hard workouts, it would seem you would want the maximum recovery benefit as well. There are a number of studies that show NSAIDs can decrease the effectiveness of the recovery process, and in effect, your workouts.

As long ago as 1986 a study showed that NSAIDs appeared to interfere with recovery from muscle strains. Your hard run workouts (particularly intervals, mile repeats and progression runs) are nothing more than controlled induction of muscles strains. Of course, when your muscles respond to these workouts, they heal and increase your muscular strength and fitness. Interfere with this process and you don't get the maximum bang for your workout buck.

Twenty years later, another study showed that NSAIDs also impaired strength and interfered with tendon-to-bone healing. This is important for any runner or triathlete with tendonitis. Achilles tendon injuries, peroneal tenditis, and posterior tibial tendonitis all have the potential to completely halt your marathon training. If you have any tendon pain, you definitely need to heal as quickly as possible. You have to treat the problem by seeing a running specialized podiatrist and not just covering up the pain.


Your kidneys are metabolic waste-removal machines. They filter the blood and help you get rid of any waste by-products. They also clear NSAIDs.

When you exercise hard, your blood flow is diverted from your internal organs to your hard working muscle groups. Runners know this best in terms of the limited capacity to eat while running. Because of the reduced blood flow to your digestive track, you might get a gastric revolt if you eat too much during a strenuous run. The same sort of decreased organ blood flow happens in the kidneys, but you don't get any warning such as nausea when you tax your stomach.

Studies from New Zealand and England have shown that during sustained exercise NSAIDs can decrease renal (kidney) function and increase the risk of developing acute renal failure. To make matters worse, consider that many marathon runners and aching triathletes will take OTC pills (which are 200 mg each) at a prescription strength (600-800 mg). Taking big doses when your you are exercising further increases the risk of kidney overload and kidney damage.

While NSAIDs are great drugs for the right circumstances, they should be respected. As hard as marathon training and speed workouts are, you want to make certain that you get the best recovery and the most strength gain possible from those workouts. During the race, you must realize that running at your limit is going to hurt. Fight the temptation to relieve the pain with ibuprofen during the race. Otherwise you might find yourself wearing a hospital gown under that finisher medal.

Dr. Christopher Segler is a multiple Ironman finisher and marathon runner. When not busy seeing athletes in his podiatry house call practice, you can find him riding through Nicasio Valley, running in Golden Gate Park, or doing mile repeats at Kezar Stadium. If you think you have tendonitis or any running related foot pain, he will come right to your Bay Area home or San Francisco office to help get you back on the road to recovery as quickly as possible. (415) 308-0833.