purine nucleoside phosphorylase deficiency - Turf Toe
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Turf Toe

Turf toe gets no respect. Let's take a closer look at the causes of turf toe and see how to treat it more effectively. Turf toe is actually a form of hallux limitus. Hallux limitus is classically described as pain and progressive decrease in the range of motion of the first metatarsal phalangeal joint (MPJ). The onset of hallux limitus is due to the following:


Uric acid is filtered out of the body by the kidneys. It is then excreted in urine. When too much uric acid is produced by the liver, the kidneys are not able to remove it all, and it builds up in the blood stream. This build up of uric acid in the blood stream is known as hyperuricemia. Over time the uric acid crystallizes and ends up settling in joint spaces. White blood cells eventually mistake the crystals as a foreign invader to the body, and gather into the joints as well to attack the crystals. This causes inflammation, ie: swelling, redness, and the typical gout pain.


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 -Injury to the joint -Exposure to lead -Diet. Foods that contain large amounts of purine include red meat, creamy sauces, scallops, anchovies, beans, liver and heavy creamy sauces. -Medication. Aspirin, levodopa and several other medicines can interfere with the kidneys ability to remove uric acid from the body. -Excess body weight.

If you've suffered from a gout attack or two now is the time to take action to stop the attacks in their tracks and discover effective preventative steps before your uric acid levels get out of hand.

The list of high purine food is actually quite long thus it is very important for gout patients to be wary of the food they consume daily. Some of the common beverages, which gout patients should avoid, include coffee, tea, cocoa and even chocolate. Some of these beverages are already part and parcel of ones daily life that it is seriously a bit different to imagine having to abstain drinking them. If you think it is really no big deal to indulge in it once in awhile, you will really have to think twice. Is the pain from a possible gout attack really going to be worth it from your indulgence?

When treating turf toe be sure to recognize the fact that there is no nerve innervation in articular cartilage. Pain associated with stage one turf toe (hallux limitus) is either synovial pain or bone pain. If we recognize that painful stage one turf toe (hallux limitus) may be due to bone pain, we then realize that turf toe should be treated aggressively to insure the long term viability of the joint.

Treatments include anti-inflammatories, corticosteroids. These medications can help alleviate symptoms in as little as a week. Before taking any medications for gout, you need to discuss the potential side effects with your doctor. Certain medications can cause severe gastrointestinal and cardiovascular side effects.

What is gout? Gout is a type of arthritis. It is caused by the buildup of uric acid in your joints. It can affect the foot, heel, ankle, elbow, wrist or hand. Most often though, it affects the big toe. Gout is a reoccurring problem that comes and goes. It usually comes on without warning, and then goes away after 7-10 days.

Preventing gout The best medication for gout is prevention. A healthy lifestyle decreases your chances for getting gout. Maintaining a proper weight, and limiting alcohol intake will help. Dehydration is also know to increase the formation of urate crystals. Drinking a lot of water daily will help "flush" uric acid from the blood stream. It is recommended that you drink six to eight glasses of water each day. Also, try to avoid foods high in purine such as alcohol, red meat, sardines, beans, rich sauces, scallops, liver and dried peas.

Until recently, gout and sleep apnea have been treated separately. However, many sleep apnea patients who implement treatments for that condition find that their gout improves at the same time.

Most notably, though, is that gout attacks are the most common while asleep, indicating that sleep has an impact on gout attacks and sleep disturbances and conditions may also influence the causes of gout attacks.

So, if you're suffering from gout, you may want to check to make sure that you are not also suffering from sleep apnea, as it may be one of the causes of gout aggravations in your body. Then you will be able to look into both sleep apnea treatments and remedies for the gout itself. Speak to your physician about undergoing a sleep study to determine if you have sleep apnea or not.

References: Lombardi, C.M., Silhanek, A.D., Connolly, F.G., Dennis, L.N., Keslonsky, A.J. First Metatarsophalangeal Arthrodesis for Treatment of Hallux Rigidus: A Retrospective Study. J. Foot Surg. 40:3, 137-143, 2001


Differential Diagnosis: The differential diagnosis of turf toe includes; Arthitis Fracture Gout Joint infection Joint or bone tumor Synovitis

About the author:
Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle
surgeon. Dr. Oster is also board certified in pedorthics. Dr.
Oster is medical director of href=http://www.myfootshop.comMyfootshop.com and is
in active practice in Granville, Ohio.

Turf toe caused by a direct injury to the joint may or may not be obvious. Athletes may not remember an incident of pain since they're often distracted by the event or game in which they're involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

Diet and gout Most often, your diet will determine if you get gout. However, heredity is also a factor. About 18% of people with gout find that it runs in their families.

Ronconi, P., Monachino, P., Baleanu, P.M.,Favilli, G. Distal Oblique Osteotomy of the First Metatarsal for the Correction of Hallux Limitus and Rigidus Deformity. J. Foot Surg. 39:3, 154-160, 2000

Treatment Doctors can prescribe several drugs. These drugs work to decrease the amount of uric acid in joints. This helps to reduce the symptoms and frequency of attacks. If not treated, serious permanent damage can occur. This can lead to permanent disability.

Treatment of turf toe varies with the type of healthcare provider and includes the use of rest, shoe modifications, orthotics, steroid injections and surgery. The success of non-surgical care will vary with the degree of injury, the rate at which the injury is healing and how much osteoarthritis has occurred. We see varying degrees of success with orthotics that promote plantarflexion of the first ray, effectively treating metatarsus primus elevatus and peroneus longus dysfunction. Simple arch supports can make a significant difference in the symptoms of turf toe. Should our patient not respond to conservative care in a reasonable time period, we are not reluctant to suggest surgical revision to address the problem whether it be revisions of the joint defect, shortening of a long first metatarsal or structural revision of metatarsus primus elevatus. As mentioned before, the clinical appearance of dorsal lipping or visible radiographic changes are suggestive of moderately advanced osteoarthritis, a condition that is only repaired by joint revision or replacement.

It is seriously important for people with gout to bear in mind the types of food items that are harmful and beneficial to their gout conditions. Since you now have a better knowledge of the food types that should be consumed, it might be a good habit of what to buy and what not to buy when you do your grocery shopping the next time.


Anatomy: The great toe joint, or first metatarsal joint consists of two bones. The proximal bone is the first metatarsal and the distal is called the proximal phalanx or hallux. These two bone move against each other in an up and down motion through what we refer to as the sagital plane. Biomechanics: The motion of the great toe joint is dependant upon the plantarflexion of the first metatasal. If the first metatarsal is limitied in its' ability to plantarflex, the joint will jam resulting in funtional hallux limitus, which as we know is one of the causes of turf toe.

This article was written by Scott Mogul, editor for Healthy Skin Guide and Quick Care. For additional information about gout and gout treatment, please visit www.healthy-skin-guide.com

Even though choosing the correct food to consume is important for people with gout, drinking plenty of water is also essential. Drinking lots of water will help the body to remove the excessive uric acid in the body through the urinal system. Exercising regularly will also help gout patients to improve their overall gout conditions.

The second list of food gout patients should avoid includes gizzard, kidney, seafood, heart, gravy and red meats. Alcohol should also be place in the list of food to be avoided. Any form of alcohol including wine or beer can trigger attacks of gout. It is significant to memorize the list of food to avoid as it can help to reduce the amount of gout attacks controlling drugs one will have to take.

But before we go any further, we need to understand that the terms turf toe and hallux limitus aren't really synonymous. The fundamental difference between the two terms is the patient population that they affect. Turf toe is a term used in athletic circles referring to any injury of the great toe joint. Consequently, discussions about turf toe will focus on the first two causes of hallux limitus mentioned above; functional hallux limitus and direct physical injury. On the other hand, when we discuss hallux limitus, we're actually referring to a broader, 'non-athletic' patient population and need to include all three causes of hallux limitus.

What causes gout? Uric acid is naturally produced by the liver, and is found in the blood stream. Uric acid is a by-product of certain products, especially those containing purine. Foods that are known to contain large concentrations of purine include: sardines, anchovies, liver, brains, dried peas and beans.

The treatments for sleep apnea include preventative actions, such as avoiding sleeping on one's back. When sleeping on the back, the airway can become constricted and is more likely to close, causing the oxygen levels in the blood to be lower than in other sleeping positions. Therefore, changing the way you sleep can help to prevent gout attacks simply by increasing the overall blood oxygen level. Other sleep apnea treatments can include a pressurized CPAP mask or surgery.

 
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Nomenclature: First MPJ - the big toe joint Metatarsus primus elevatus - a functional or structural position of the first metatarsal First metatarsal - the foot bone making up the proximal portion of the big toe joint Hallux - the great toe


Symptoms: Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to increase their activity. It may not occur during the first athletic season, or the second, but when it does begin to cause pain, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step. Turf toe caused by a direct injury to the joint may or may not be obvious. Athletes may not remember an incident of pain since they're often distracted by the event or game in which they're involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

Gout, which is a common form of arthritis especially among man of age 40 to 50, is caused by the deposits of excess uric acid in the bloodstream on the joint connections area. By avoiding food that will cause the body to generate more uric acid than necessary in the body is very critical. Food items containing high purine level is found to increase the production of uric acid in the human body. It is essential for people with gout to avoid such food completely.

By restricting your diet and only sticking to food that are low in purine levels will definitely help to reduce complications associated with gout and the need for medication to help control the pain due to an gout attack. To completely be free of the tortures of gout, one will have to bear in mind all the above mention method and pointers.

Alcohol can interfere with the removal of uric acid from the body. Regular consumption of alcohol increases the likelihood of getting gout. Other risk factors include:

Diagnosing gout A physician can usually diagnose gout very easily. A physical examination as well as certain tests are used to measure the amount of uric acid in the blood. Sometimes a sample of fluid is taken from the joints and tested for the presence of urate crystals.

Unger, K., Rahimi, F., Bareither, D., Muehleman, C. The Relationship Between Articular Cartilage Degeneration and Bone Changes of the First Metatarsophalangeal Joint. J. Foot Surg. 39:1 24-33, 2000

Symptoms of gout The main symptom of gout is severe pain. If the gout is in the feet, it can be so severe that the sufferer cannot stand. Inflamed skin around the joint can be red and shiny, and over the course of time can get worse. Over the course of time, the frequency of attacks will increase, and the attacks will last longer. If left untreated, more and more joints will be effected and stone-like deposits can build up in the joints. This is known as tophi, and can lead to permanent disability.

The reason for this link is believed to be the reduction in blood oxygen during apnea episodes, causing cell disintegration in the body and the generation of uric acid in the bloodstream. The cause of gout is, after all, the presence of uric acid crystals in the joints. Furthermore, during apnea there is an increase in the carbon dioxide percentage within the blood, making the blood's acidity level higher and increasing the risk of uric acid precipitation as monosodium urate. This can collect in the joints and can even lead to an increased risk of developing kidney stones.

Other conditions - synovitis, crystal deposition diseases such as gout, systemic arthritis, external physical influences such as Dupytren's contracture, etc.

Functional hallux limitus - biomechanical function that results in metatarsus primus elevatus and subsequent repetitive jamming of the first MPJ. Direct physical injury - injury to the articular cartilage or subchondral bone. These injuries may be due impaction injuries or hyperextension/flexion of the first MPJ.

Think of turf toe (hallux limitus) as an isolated case of osteoarthritis limited to the first MPJ. Whether the injury is acute or due to repetitive loading, the result is a load that is applied to the subchondral bone that is greater than what the bone can tolerate. As the injury progresses, a series of micro fractures will develop in the subchondral bone. The typical soft spongy character of the metaphyseal bone changes to become brittle and hard. The result is that the articular cartilage looses its' underlying support and becomes susceptible to damage. Juxtachondral eburnation, osteophytes, lipping, spurring; call them what you like, but what you see on your x-ray is the slow progressive destruction of the joint.

Is the onset of turf toe always the same? Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to increase their activity. It may not occur during the first athletic season, or the second, but when it does begin to cause pain, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step.

Who gets gout Although it is sometimes referred to as "rich mans disease", anyone can get it. About 5% of all cases of arthritis are actually gout. It is much more common in men than women, and usually develops in men in their late 30's or early 40's. Women usually develop gout later in life, in their 50's or 60's. Medical experts believe that estrogen protects women against hyperuricemia. During menopause when estrogen levels decrease, women lost this protection and uric crystals can start to accumulate in joints.

Other links between sleep apnea and gout include show up in the fact that not only are primary gout sufferers demographically the same as the primary sleep apnea sufferers (middle-aged, overweight men), but sleep apnea and gout are also both much more common among women who have been through menopause. Also, both gout and sleep apnea are associated with people who have a larger neck circumference.

This effect is very similar to what happens within the cells when excess alcohol is consumed. And it should be noted that drinking alcohol can cause sleep apnea to become more pronounced. Therefore, gout sufferers with sleep apnea have two major reasons to avoid drinking alcohol.

What's the actual physical change that takes place in the joint with turf toe? As an easy analogy, consider the changes that takes place when an apple falls from a height and is damaged. The skin of the apple appears intact but the underlying pulp is damaged. In the case of turf toe (hallux limitus), think of the skin of the apple as the cartilage of the joint and the damaged pulp of the apple is the subchondral bone. Mild cases of turf toe (hallux limitus), result in little damage to the subchondral bone and will merely exhibit signs of inflammatory change within the joint. Most authors would refer to these cases as stage one turf toe (hallux limitus). More severe cases result in damage to the joint surface, the subchondral bone or both. These are the stage two and three cases of turf toe (hallux limitus) that show visible change on x-ray. As the subchondral bone becomes increasingly damaged, it will create an uneven supporting surface for the cartilage. An increase in activity results in uneven loading of the joint due to the compression injury of the subchondral bone.

The third and somehow the list which most people consider as the most healthy choice is simply a bit hard to comprehend why it should be avoided by gout patients. Peas, spinach, lentils and beans are vegetables that should be avoided if one is diagnosed with gout.

No matter the final remedy, improvements to a patients sleep apnea problem ensures that blood oxygen levels remain high, minimizing uric acid and monosodium urate precipitation and therefore gout flare ups.

People always have the mentality that as long as one does not eat junk food, one can be considered to have a healthy diet. Actually a diet that is considered healthy to one might be unhealthy to another person, it can be quite subjective in this context. Gout patients are usually advice to go on a special diet, which will help to alleviate the pain cause by gout attacks. This diet will require one to avoid food that will increase the uric acid in the body. The list of food to avoid will also include certain food, which are considered healthy by most standards and definitions.

There are many different potential triggers for gout that you should be aware of if you suffer from the condition. One of the potential triggers that we've been asked about recently is sleep apnea. It may seem as though these two conditions are completely unrelated, but in reality, they are connected. The connection was first noticed when sleep apnea patients received treatment for their disorder and they noticed their gout symptoms simultaneously improved.

Skyjoe is a well-known author, website publisher and owner of http://www.mygeneralknowledge.com. ??Skyjoe. All rights reserved. This article may be freely distributed as long as it remains unaltered inclusive of the active links and the copyright notice. No alteration is allowed without express written permission from the author.


 
 
     
 
 





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