Ask the Doctors September 2019 Issue

Ask The Doctors: September 2019

Q: I've read that gout is not caused by food or alcohol. I've also seen lists of foods and alcohol that are gout triggers. Having suffered gout attacks I know that certain foods and beer do cause problems. So what is correct?


Arthritis Advisor Editor-in-Chief Steven Maschke, MD, Department of Orthopaedic Surgery, Cleveland Clinic Orthopaedic & Rheumatologic Institute.

A: This can be confusing. While certain foods and alcohol can trigger gout attacks, they don't cause the disease. Gout results from excessive amounts of uric acid in the body. Uric acid is a natural chemical, which is a byproduct of old cells dying off. For most people, the body has an efficient system for eliminating uric acid, mostly in urine.

If not enough uric acid is excreted (a function of the kidneys) it can build up in the bloodstream and cause hyperuricemia. Some people, but not all, who have hyperuricemia will develop gout. In people with gout, uric acid leaves the bloodstream and travels to joints. The deposits of uric acid can intermittently form needle-shaped crystals, which set off an inflammatory response by the body. The result is a red, hot and swollen joint of a gout attack.

The reasons some people have hyperuricemia and develop gout are not understood, but there are known risk factors. An important one is genetics. You can inherit a tendency to not efficiently eliminate uric acid. Other risk factors are being overweight or obese, high blood pressure, kidney disease or taking certain medications, such as diuretics.

The role of food relates to their purine content because purines break down in the body to uric acid. Foods high in purines, including organ meats (such as liver and kidney), red meat and some seafood (such as shellfish, anchovies and sardines), and alcohol may raise uric acid levels. Alcohol also reduces the amount of uric acid removed by the kidneys. These changes are small, and not enough to cause gout in someone with otherwise normal uric acid levels. For a person who has gout, sudden changes in uric acid levels, which can occur if you binge drink alcohol (especially beer) or eat high-purine food, can destabilize uric acid deposits and trigger a gout attack.

Q: In the article on hammertoes in the July 2019 issue, you mention exercises to strengthen the muscles in the toes. What are the exercises?

A: Hammertoes are the abnormal curling of the toes. The end of the toe bends down and the middle joint sticks up. Hammertoes usually affect the second toe, but they can also occur in the third, fourth or fifth toes. They are generally caused by an imbalance among muscles, tendons and ligaments.

At first, the toe maintains some flexibility. Over time, it may become a rigid deformity. As long as there is still some flexibility in the toe, exercises can help alleviate any pain they might be causing. Georgeanne Botek, DPM, Section Head of Podiatry at Cleveland Clinic, recommends stretching toes to lengthen the tendons in the joints and prevent stiffness. This can be done actively or passively.

For an active stretch, try to move each toe individually. We should be able to move our toes like we can move our fingers. For a passive stretch, manipulate your toes by holding the base of the toe and stretching it lengthwise. Hold it in that position for 10 seconds. Repeat with all your toes.

Splints, such as Yoga ToesŪ, can be used at night to passively stretch toes while you sleep. Other advice is to wear shoes with a wide and deep toe box and use pads on the toe knuckle to prevent rubbing that might lead to corns.

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