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Monday, January 1, 2018

When High Uric Acid Effects Decision Making: Email Advice

This email was sent to me in November 2017, so I am behind in my correspondence. Hopefully, the new year will bring organization!!

Happy New Year to all. Let us bring love to the world and hope. 

Hey dr blake

     I'm a 33 yr old male from Canada!

     I read your blogs numerous times and I'm trying to find something/someone to compare myself to during this whole ordeal I'm dealing with but can't seem to find a similar case to base mine off.

     Long story short, my foot pain started 2 years ago. I thought it was gout because it came and it went within a week but the pain was agonizing. It was the big toe area and it went away. 
Dr Blake's comment: Gout can affect the foot like this. Agonizing pain, then gone. Referred pain from the low back can also to this. But get your uric acid checked, if you are high normal, or high in general, get advice on lowering. My post on gout is attached. 

     Fast forward 2 years same pain but it lasted a lot longer like a full month of intense pain. I visited a podiatrist and it sort of moved around in my foot and was hard to diagnose. It went from big toe area to cuboid syndrome back to big toe. Finally, he sent me to go do xrays.
Dr Blake's comment: This is definitely gout. Gout can affect joints that are damaged, so xrays and MRI can tell you if you are dealing with gout and something else. You are not giving us a history of falls, too much running, etc. that would cause an injury. Please comment if you are leaving something out. I have had plenty of patients develop gout after an injury caused more circulation to a joint. Were you having swelling or redness that typically goes with gout? You can have gout without the redness, but at least there is swelling. 

     It was revealed that I have a bipartite fibular sesamoid yet my podiatrist said it's too jagged to be bipartite and that radiologist is full of crap and wear a boot for a couple of weeks. 
Dr Blake's comment; This is the sesamoid dilemma. Bipartite versus fracture, or fracture/sprain across the bipartite. Golden Rule of Foot: You can fracture both a normal sesamoid and a bipartite sesamoid, so get an MRI, or treat as a fracture with 3 months in the removable boot with an off weight-bearing pad to float and protect the sesamoid. 

     I wore it for about 3-4 weeks and nothing!! Finally, I decided to try and self-diagnose because I'm always left alone when something happens lol and I asked my dad for gout pills to try and see if it will do anything. Oddly enough it did! I didn’t expect it to but it helped my intense pain overnight.  I went to GP and told him yet he wasn’t convinced even though I did have high uric acid levels in blood and sent me to go do an MRI.
Dr Blake's comment: Now we are getting somewhere. When you hurt something, like a sesamoid, and especially with the high level of pain you have had, you get inflammatory and neuropathic pain, along with mechanical pain. First of all, the boot was on too short of time. Was the boot padded? The gout medicine is anti-inflammatory and should help the even non-gout inflammatory pain. What is the plan to get the uric acid down? We need a solid plan or the symptoms will keep coming. 
    MRI came back and said “ diffuse elevated bone edema and suspected lateral fibular sesamoid fracture unless it shows otherwise in xray”. Already that makes no sense because isn't MRI supposed to be conclusive?
Dr Blake's comment: The MRI is best to show bone edema. Golden Rule of Foot: Bone Edema on MRI shows what bone is in the injured and hopefully healing stage of the injury. A lessening of the bone edema in a repeat MRI documents that healing is actually happening. 

    Xray report says bipartite unless MRI shows otherwise lol anyways based on it being over 3 months of pain and dull and even numbness feeling in my foot, its safe to say its fractured. The xray clearly showed non-union yet on MRI it said non displaced.
Dr Blake's comment: Please take a couple of images of the xrays and MRI slices that show what is going on and email me. You could have too many possibilities. Do you think you were abusing your feet at the time the symptoms started? Golden Rule of Foot: The history of foot abuse typically correlates to fractures seen in the foot. Some of my patients just have been biomechanics and can get an injury like this with transient Vit D deficiency and too many hours in their flip-flops with no foot protection in the cement jungle we live in. 

     Is that a good sign and if so, why doesn't it feel any better than before? I can send you reports if you'd like to take a look? Also, I'll gladly donate or send money for the time given. I know regardless I need to be conservative but I've also been going through this alone with absolutely zero guidance and I'm scared I might have made it worst since my MRI on Oct 31 and since this whole thing started to be honest.
Dr Blake's comment: I am sorry I cannot be definite. It is easy to assume you bruised the sesamoid which sparked the gout attack. It is easy to assume you need months in the removable boot, with anti-inflammatory icing, soaking, perhaps meds, along with a good plan on bringing down the uric acid. Want the uric acid consistently 2.5 points below the high normal value (different with each lab). 

    Its gout it's not gout it's fractured it's not fractured. All I know is that my foot feels super weird like it's been run under boiling water. It's like the circulation is off or something. I have no clue.. anyways thanks for your time!!
Dr Blake's comment: The super weird feeling is your neuropathic pain as you protect yourself. Golden Rule of Foot: Neuropathic symptoms range from complete numbness to weird feeling like spiders running over the foot, to complete pain and everything in between. I hope this will help you. I apologize for the 5 weeks to answer this. Good luck. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.