Today on the Doc On The Run Podcast, we’re talking about whether or not a a painful red big toe joint means a runner has gout.
I was recently doing a telemedicine visit with a runner who wanted a second opinion because she was having pain in her big toe joint, and she was actually worried that she had a condition known as gout.
Gout is something that can be extremely painful and it does often affect the big toe joint. And it certainly will disrupt your running, if you get gout. But that is not the only thing that causes painful, red, big toe joints. And your story can actually help you figure out which one of those things it might be, whether it’s gout or something else.
Gout certainly can cause your big toe joint to become red, hot, swollen and painful.
But gout is only one of three different conditions that might cause big toe joint pain. The pattern of redness around the big toe joint can help you decide which condition might be causing the problem if you are a runner.
There are really three common causes of pain in the big toe joint, if you’re a runner. Now, if you get gout, if you think you have gout, or you suspect that your doctor is worried you have gout, there are a couple of ways that you can tell.
Now, first of all, the worst, least reliable test for gout is to actually draw a blood sample. Because when you are a runner and you get gout, what happens is, you actually get these crystals that form in the joint and they’re sharp and they cause pain. It’s as simple as that.
The reason you get those crystals is because they become deposited in the tissue in the big toe joint. But then they’re not in your bloodstream anymore. So if we draw some blood right after you have an attack of gout, right after it becomes painful, a lot of times, the serum test for the uric acid, the amount of it in your bloodstream, well, it looks normal. But the uric acid isn’t in your bloodstream anymore, it’s in the joint in the form of gout.
Now, the thing is, is that it can be very painful. But the people who have gout typically have a pretty simple story. They say the same kind of things. Like, they went for a run and they forgot to take their water. They know that they’re dehydrated. They know they did a longer run than they should have, and they didn’t drink water, they didn’t take water.
They did something that put them at risk of dehydration, because when the amount of water in your system goes down, the concentration of those things like uric acid goes up by comparison. So when you get dehydrated, you’re more likely to have an attack of gout.
The other thing is that, it’s very, very painful, first of all. We’re actually taught in medical school that the classic description of gout is a red, hot, painful, swollen big toe joint. And the patient complains that they literally cannot have the bedsheets touching the foot because it’s so painful. Now, that is very different then most of the causes of big toe joint pain in runners. But when somebody says, “I literally couldn’t even sleep with the bedsheets on it,” well, that certainly suggests gout.
Also, it’s not just the big toe joint. You don’t see one little tiny area that’s red. The whole forefoot, and certainly centered around the big toe joint, but a lot of times, the whole big toe and a whole lot of the rest of the foot is actually red, inflamed and swollen. And it is extremely tender to the touch. And good for you, as a runner, this is not really that common. It can happen, but it’s not as common as the other causes that we’re going to talk about.
Now, the second one is actually a thing called bursitis. And so, if you are a runner and you have a bunion deformity, if your big toe slopes over toward your second toe, and you have the metatarsal bone sticking out a little bit at the inside of your foot in what we call a bunion deformity, there is a little fluid-filled sac on the outside of that bone toward the arch side of your foot on what we call the medial side of your big toe joint. When this little fluid-filled sac gets irritated and inflamed, you developed a condition called bursitis. So that bursa or the sac under the skin gets inflamed. It becomes very painful. And it swells up.
A lot of these patients who have bunions that get this kind of bursitis because they bought the wrong pair of running shoes, or they didn’t lace them tight enough and their foot was sliding around and it irritated the bursa, they will often say that they know they have bunions, but it really doesn’t bother them, but it seemed like their bunion got bigger overnight. And in that case, it’s just the bursa sitting on top of that bump that actually swelled up a little bit and made the bunion look a lot worse.
When you have bursitis, it’s usually a spot about the size of a nickel, maybe, sitting on the inside, what we call the dorsal medial part of the metatarsal phalangeal joint, or that joint at the base of the big toe. And it becomes very red. It’s very tender. But it’s pretty well delineated. It looks red. It looks red in one spot, not the entire big toe joint. But that is just bursitis. That’s definitely not gout. Gout, it’s the whole area swells up and becomes red. But bursas, there are a lot more localized because it’s just the sac that’s inflamed.
And the third reason I see people who get a pain in the big toe joint when they’re runners are people that have a condition called hallux rigidus. Now, hallux means big toe. Rigid means it doesn’t move. And so hallux rigidus is where your big toe is really not as flexible as it should be. And it’s the opposite of a bunion deformity in many, many ways.
But basically, the toe jams when you’re running in unstable shoes, or if you’re running up and downhill, and particularly if you’re running in really flexible shoes, it can get inflamed because you’re jamming the big toe joint. And sometimes, if you do this over and over where you’re doing some really aggressive runs in shoes that are maybe just a little bit too flexible, then the skin actually becomes inflamed because the joint capsule underneath it is also inflamed.
But in this case, it looks like an area or a wide line that goes right across the top of the joint line at the base of the big toe. That’s the metatarsal phalangeal joint. And so, if you have this localized stripe of redness across the base of the big toe, that’s usually a sign of capsulitis or inflammation within the joint at the base of the big toe. And that also does not look like gout.
But those are the three things that really cause redness in the big toe joint in runners, bursitis, capsulitis and gout. They’re all very different and they’re treated completely differently. So the first step, of course, to figuring out how to get it better is make sure you understand which one is really covering your condition.
So in this telemedicine visit, it was very easy to take a look at this lady’s foot, have her move it around, poke on it, talk about all the things to get it better. And it’s easy to figure out. But it’s a good question, because if you have the wrong treatment and you do the right things for that treatment, well, then if you don’t know which condition you’re treating, it’s not going to get better.
So if you treat hallux rigidus the same way you treat bunions, it won’t get better. If you treat gout the same way you would treat hallux rigidus, it’s not going to get better. And if you treat hallux rigidus the same way you treat gout, it’s also not going to get better. So make sure you figure out which one is really causing the trouble and which ones you can continue to train with, so you can keep getting better and maintain your running fitness. That’s really the key.
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