What is the Best Way to Diagnose Gout in the Big Toe Joint?

An attack of gout that affects your big toe joint may be one of the most painful conditions you can have in your foot. When gout strikes, you get pain, redness, swelling and extreme tenderness...usually in the big toe joint. If you think you have gout, you probably want to make sure that you get the right diagnosis. Getting the correct diagnosis is important for two reasons.

1. You want to make sure you get the best treatment as quickly as possible.
2. You don't want to have to change your diet and start the dreaded gout diet unless you're absolutely certain that you actually do have gout.

Gout is actually caused by uric acid crystals accumulating in the foot. The crystals actually get deposited as the precipitate out of your bloodstream and become embedded with in the big toe joint, a bursa, or even within the tendons near the joint at the base of the big toe.

There are 5 ways to diagnose gout in the foot
1. Physical exam by a podiatrist
2. X-rays of the foot
3. Blood tests to look for high uric acid levels
4. Joint fluid analysis from the big toe joint
5. Cytology (fluid analysis under a microscope)

This video, posted by San Francisco's Housecall Podiatrist, discusses all of the ways in which your doctor can arrive at a diagnosis of gout. Because gout is a condition in which uric acid crystals actually get deposited in the soft tissues of your foot in your big toe joint, it is important to actually identify those crystals in order to accurately make the diagnosis of gout.

Physical exam (even by a podiatrist) is not 100% accurate simply because gout also mimics other conditions such as an infection in the soft tissues around big toe joint, infectious arthritis of the big toe joint, or even conditions that affect diabetic patients such as Charcot foot, where the foot bones start to break. All of these conditions can present themselves with redness swelling and extreme pain around the big toe joint. Physical exam by itself is just not the best way to diagnose gout.

Foot X-rays are almost always performed in a doctor's office when you have a red hot swollen foot in order to make sure that you don't have a dangerous infection or a fracture in the foot that could be just appearing like it is gout. But x-rays of the foot won't typically show much when an attack of gout has recently started.

Blood tests in order to determine whether or not you are one of the patients that has a high level of uric acid in their bloodstream (and more prone to gout) are not really effective at determining whether or not the pain and swelling around your big toe joint is really caused by the crystals in your joint. In fact, often times these tests are negative, misleading doctors to think that you might not have gout.

A more reliable way to determine whether or not the pain in the big toe joint it's actually caused by count crystals is to perform a joint aspiration where the fluid is removed from the joint to see if there is any chalky white material that looks like collections of gout crystals. This is much more reliable than physical exam, foot x-rays, or even blood tests.

But by far the most reliable way to make the diagnosis of gout is through cytology. This is where your doctor takes the joint fluid that was removed through joint aspiration and then sends it to the pathologist so that they can look for the actual gout crystals under a polarized light microscope. If you do have an attack of gout that is causing the pain in your big toe joint, the pathologist will be able to see needle shaped uric acid crystals within the joint fluid. This is a 100% accurate method of diagnosing gout in the foot.

Dr. Christopher Segler is an award-winning foot and ankle surgeon and sports medicine podiatrist practicing in the San Francisco Bay area. He provides housecalls for people with gout in San Francisco, Marin, Mill Valley, Tiburon, Oakland, Berkeley and Palo Alto. To learn more about the causes and treatment of gout in the big toe joint, visit the gout information page at www.AnkleCenter.com. if you would like to learn about how to get the fastest treatment possible for gout, you can learn more at www.DocOnTheRun.com.

Will orthotics help heel pain when running?

This morning I received an inquiry from a runner in Marin who is training for the Dispea. He asked a common question:

"I have severe left heel pain especially after a 5-8 mile run. I am training for the Dipsea. Advice? Should I consider orthotics?"

Answer:
Custom orthotics can certainly help to alleviate many forms of heel pain including the most common type which is plantar fasciitis. Custom orthotics in fact are one of the best ways to slow do pronation and decrease stress to the large ligament on the bottom of the heel called the plantar fascia. If you over-pronate and repeatedly tug on the plantar fascia as your arch height changes, you get inflammation of the plantar fascia... known as plantar fasciitis.

A long run can place a tremendous stress on the plantar fascia and the heel bone. Most people with plantar fascitis will have pain in the bottom of the heel on days following running. Usually the pain is worse with the first couple of steps when they get up out of bed. They can also get a sharp pain in the heel when they start walking after sitting at a desk for a while.

Custom orthotics are one of the best treatments for this type of running-related heel pain. But that doesn't necessarily mean that it is best to get custom orthotics and keep running. You must get an evaluation with a running focused podiatrist first.

The concern is that you might have something worse than plantar fasciitis. In this case, the runner reports heel pain that is "severe" following long runs. Plantar fasciitis would usually be worse (and more annoying) the day after a long run, but not necessarily severe. It would be important to get x-rays and take a look at the heel bone (calcaneus) to be certain that you are not at risk for stress fracture in the heel bone (calcaneal stress fracture).

It is also possible that there is a cyst in the heel bone that is causing the problem. In the simplest of terms, a calcaneal cyst is a hollow or fluid filled pocket that develops within the heel bone. When running, the walls of the cyst can flex slightly causing pain and inflammation in the heel bone itself. In some cases the heel bone can flex so much that it cracks or fractures. This is actually much worse than a calcaneal stress fracture.

With a quick set of x-rays and an exam by an experienced running podiatrist, heel pain can be effectively treated. With all of the conditions that effect the heel, the sooner the best treatment is chosen and starts, the faster you will finish your goal race, wether it is the Dipsea, the Vineman or the San Francisco Marathon.


Dr. Christopher Segler is an Award Winning Foot & Ankle Surgeon, 5-Time Ironman Finisher and a sports medicine podiatrist who makes house calls for busy runners, triathletes and active professionals in San Francisco, Marin, the East Bay and the Peninsula. If you have a question about running related heel pain, you can call him directly at (415) 308-0833. You can also learn more about custom running orthotics at AnkleCenter.com and DocOnTheRun.com.

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What Should I Do If I Sprain My Ankle?

San Francisco Podiatrist Explains How To Stop The Ankle Pain and Swelling When You Twist Your Ankle

Ankle sprains are the most common sports-related musculoskeletal injury. Unfortunately many patients who roll their ankles head to the Emergency Room to treat the pain, swelling and bruising. The reality is, you can often get ankle pain relief much faster if you don't go to the ER. When deciding which doctor is best for your ankle sprain, you should see a specialist: an ankle expert called a podiatrist (not a Jack-of-all-Trades in the ER).

The best ankle sprain treatment right after the sprain is P.R.I.C.E.

P=Protection
You have to prevent any further injury to the sprained ligaments. An ankle brace or fracture walking boot can let most ankle injuries heal without having to worry about hobbling around on crutches.

R=rest
If you get sick and rest, you get well faster. If you tear your ankle ligaments and rest, they heal faster. Try to get some rest and take it easy for the first 48 hours after a bad ankle sprain.

I=ice
Ice is one of the cheapest and most effective home remedies for an acute ankle sprain. Apply ice to your injured ankle for 10 minutes out of every hour during the first 24 hours after you roll your ankle.

C=compression
Use the elastic bandage given to you by Dr. Segler a your House Call visit. By keeping your ankle wrapped the way he showed you, the swelling will stop and go down as fast as possibly. Your ankle ligaments won't start to heal until the swelling goes away.

E=elevation
Use gravity to your advantage! Prop the injured ankle way up on a pile of pillows. It has to be above your heart to really work well. Keep it elevated for the first 24 hours and the throbbing ankle pain will start to go away. Remember, your ankle ligaments won't start to heal until the swelling goes away.

By following the PRICE method, you can help stop all of the inflammation that causes ankle pain and leads to prolonged healing of the ankle sprain.

You can also view the Ankle Sprain First Aid Video here.

Dr. Christopher Segler is a podiatrist and a true ankle expert. He published the largest research study every conducted on subtle ankle fractures that are often misdiagnosed as ankle sprains. The fact is, ankle injuries often don't get the best treatment in the Emergency Room. Dr. Segler won an award from the American College of Foot and Ankle Surgeons for his ankle injury research which showed that lateral process fractures are 10 times more common than previously thought. These ankle fractures often don't heal properly because they are incorrectly diagnosed by busy ER physicians. Dr. Segler now has a podiatry practice in San Francisco that offers same-day house calls for people in the San Francisco Bay Area who have ankle sprains or other sports medicine -related foot and ankle injuries.

If you rolled your ankle and have a question, you can actually call him directly at 415-308-0833. And yes, you will actually get to speak with an award-winning ankle surgeon. No nurses, students or residents... direct access to a true ankle expert.

Learn More about ankle injuries at the best podiatry site in San Francisco: AnkleCenter.com

July is Most Dangerous Time for Surgery: San Francisco Foot Surgeon Explains

Your chances of dying in a hospital are highest in July. A new study published yesterday in the Journal of General Internal Medicine exposes one of medicine’s dirty little secrets. It has long been known that all medical internships, surgery residencies, and fellowships begin on July 1st every year. Because of this, July may be the riskiest month for you to have foot surgery or any other procedure that might be associated with hospitalization.

This is not complicated. After eight years of sitting in college classrooms and medical school lecture halls, the wet-behind-the-ears medical intern is just plain itching to practice all of those skills he or she has read about. The problem is, they have a lot of learning left to do.

You don’t really want to be the first person when a new foot doctor tries to make a surgical incision on your foot. You don’t want to be a new ankle surgeon’s very first ankle ligament repair surgery. You also don’t want to that new, nervous, over-worked and sleep deprived intern fumbling through a Pharmacy handbook while writing your medication orders at 4:00 a.m.

It is this combination of pressure and inexperience on new doctors in training that produces the “July Effect.” This new study conducted at large teaching hospitals in California (but not in the San Francisco Bay Area) found that fatal medication errors spiked by 10% during the month of July in counties that had teaching hospitals. By contrast there was no increase in medication errors in counties that did not have doctor’s in training. The study concluded that the spike in hospital deaths was in large part associated with the influx of new medical resident doctors in the month of July.

Whether you are considering bunion surgery or back surgery, there are some simple steps you can take to avoid the risks associated with new medical residents.

1) Have surgery in June or August instead of July. The most change in staff happens in July. This is when the medical residents are newest and more likely to make errors. They are also more likely to get in over their heads in surgery.

2) Avoid the teaching hospitals in July. If you have an elective procedure (such as bunion surgery, ankle stabilization surgery, or heel spur surgery) request that the procedure be performed at an outpatient ambulatory surgery center. There will be fewer residents and less chance of a newbie bungling your case.

3) Ask questions! You have a right to understand all of the procedures that will be done, and by whom. Ask if a resident will scrub in your foot surgery. You do have the right to refuse to have doctors-in-training involved in your care. By asking questions about your surgery, postoperative care, rehabilitation and medications, you will force the attending doctor to stop and think. This may decrease your risk of an error that could occur if the doc is hurried.

4) Have an advocate on your side. If you have a concierge type physician caring for you and overseeing your care, it is far more likely that any mistakes will be caught in time. Docs that report to other docs will be more focused and paying closer attention. If you don’t have a concierge-type physician, at least bring a family member who can ask lots of questions and take notes.

5) Choose an “Out-of-Network” Surgeon. Don’t expect concierge care if you have Medicare. This is just math. On June 1, 2010 doctor’s who accept Medicare got a 21% pay cut. They will be moving faster and working harder to pay the light bill. This will quickly trickle down to all “In-Network” Insurance Policies. Most insurance contracts with “In-Network” doctors are based on a percentage of Medicare pay rates. By choosing a doctor who is “Out-of-Network” you will get a doctor who has more time to spend with you, answer your questions, and guard against resident-associated errors.

The more you know about the dangers of medication errors and inexperience associated with the annual medical trainee change-over in July, the more empowered you will be to enter the hospital or operating room and have a successful surgery. But if you have to check into a University Teaching Hospital in July, stay low and keep moving!

Dr. Christopher Segler is a San Francisco based foot surgeon and an award-winning podiatrist. His new patient appointments with foot surgery patients generally take 1-2 hours. He thinks the best medical care is personalized convenient care. He makes house calls and does not allow residents to perform surgery for him. He also takes his patients to reputable outpatient surgery centers. If you have a question about foot surgery, you can call him directly at 415-308-0833. Learn more at San Francisco's Foot Surgery Info Site.