Fractured Sesamoid presenting as gout?

[Subaru Pilot]

37 yo male, athletic, 10-15+ years of youth/adolescent soccer playing, now an active coach. Regular walking and occasional strength training.

3 weeks ago on a Friday, I noticed a discomfort in my right foot that I couldn’t credit to an acute event. This followed an evening with grilled foods, beer, firepit, etc. It repeat the following evening (Saturday). I continued about my weekend which included a lot of walking after coaching at a soccer tournament. By Monday, my foot had swollen. I was able to get by using ice, rest, elevation, compression and took several ibuprofen and soaked with epsom salts a few times daily. On Wednesday I went to an urgent care where they took an x-ray with negative results. The doctor suggested to follow up with primary care doc regarding possible gout or other inflammatory arthritic condition.

On my step counter (Apple Watch), it suggests I walked 4.5 miles Thursday, 6.8 miles Friday, 4.9 Saturday, and 5.1 Sunday. Following that due to pain, it was under 2 miles for each individual day in total, which was likely short duration.

Saw primary care doc the following week who also suspected gout and had me do blood test. Uric acid levels came back 7.8 but do not have other historical tests to compare to. PCP referred me to podiatrist, who also suspected gout but took another x-ray and saw a bilateral fracture of tibial sesamoid. Rest of bloodwork was okay with no markers towards anything else being abnormal.

We are now on week number 3. I am in a short boot and no longer take ibuprofen since wearing a boot for about a week.

I am confused at this point since my PCP suggested my uric acid was elevated but not out of the high limit to cause alarm. I have not been prescribed any medicine as of yet and would prefer to manage this with diet rather than a pill. I have not consumed any beer since the initial symptoms but I have had a 1 or 2 glasses of wine a couple of times over the 3-week period.

The symptoms of the toe area are improved aside from the pain associated with dorsiflexion of the big toe. The boot immobilizes this so it’s not really an issue unless I do it subconsciously when I am sleeping, etc.

My confusion here is if this is actual gout or if the fractured sesamoid could present as gout like symptoms. I generally eat healthy but I do absolutely love beer, especially IPA variants. I have also not had any red meat (pork, beef, lamb, etc.) and have been eating chicken (white meat), eggs, and low fat dairy. I didn’t eat much dairy before these symptoms started as I’ve learned low fat dairy can reduce your UA levels.

I am taking a generic multivitamin daily, 2 capsules of turmeric daily, and vitamin d3 daily. Since the symptoms started, I have also added 500 mg of vitamin C to the mix as I’ve also read this reduces your UA levels.

What should my next step be here? Should I push to get an MRI done to confirm gout or rule out anything else? The doctors have all been resistant to MRI so far.

[Subaru Pilot]

Sorry, I forgot to mention above, I have no family history of any type of inflammatory arthritic condition including gout. I generally ate healthy before this episode and didn’t eat a lot of red meat, most of my protein was seafood (fish and shellfish) as well as chicken, with occasional pork. Steaks/beef are usually a special occasion for me. It’s been years since I had any type of “fast food” and I would estimate that around 90% of my meals are prepared at home. I avoid sugary treats and desserts and bagged snacks/shelf stable snacks.

Diet wise, I also supplement/have been consuming “Orgain” brand Plant Protein drinks for when I’m in a pinch for work to avoid fast food restaurants. I also unknowingly excluded cow milk dairy products from my diet but didn’t do this on purpose – I drink coffee black and didn’t consume yogurt/ice cream. I read something about B3 possibly elevating your UA levels, so I will check on the ingredients list to find out if it is pushing it a little too high in combination with my multivitamins.

[nobody]

Hi!
Regular doctors do not have the tools to diagnose gout properly and it’s often diagnosed based on a pattern of symptoms over a long time or based on a simple guess. Sometimes doctors simply use gout treatments as a diagnosis tool. An MRI or simply an ultrasound would be useful provided it’s done by a someone with a clue. But what you would ideally want when gout is suspected even though there are other explanations for the symptoms is an analysis of the joint fluid, and you want a skilled hand for that job! So I suggest you see a rheumatologist if at all possible. Not only is that the speciality which is supposed to be most knowledgable about gout but an experienced rheumatologist should be able to recommend someone who knows what they’re doing when it comes to drawing joint fluid from gout sufferers.
Alternatively you could simply wait. Gout typically resolves for a while after the first times you get debilitating symptoms and it will become clearer whether you have typical gout symtptoms or not over time. If you elect to wait, be sure to repeat that uric acid test a few times over the next year even if you feel fine and stop worrying!
Regarding your only uric acid test, it’s high enough to develop gout but low enough that your risk of gout isn’t very high. It wasn’t the best time to get a reliable result anyway. It’s good you were tested at all but I wouldn’t make too much of the result until you get more values to see if that was a typical number for you or not.
Don’t worry too much about your diet or vitamins. It does affect gout but most of the information out there is terrible (including the dietary superstitions peddled by many doctors). You could eat less animal flesh but the main thing I would watch at this stage is supplement-type stuff or novelty foods made with strange ingredients. Plant protein is of course fine to eat in moderation but overeating protein affects uric acid and powder/drinks are easy to abuse. Besides, what else did they put in those drinks you’ve been using?

[Subaru Pilot]

Thanks for your response. I tracked down one of my drinks I throw in my locker for when I’m in a pinch. It’s been helpful when one of my coworkers decides it’s time for a Chick-fil-A run, so I have one of those and be on my way.

I have been drinking them pretty regularly. I haven’t been as aggressive with them since my symptoms started.

Quickly typing the ingredients: water, pea protein, alkalized cocoa, high oleic sunflower oil, sunflower lecithin, trisodium phosphate, tripotassium citrate, gellan gum, monk fruit extract, apple fiber, acai, beet, kale, raspberry, spinach, tomato, banana, blueberry, carrot, and sea salt.

I didn’t consider vitamins & these protein drinks to be a factor, but I will exclude them and see what happens. Again, I’m not vegetarian or vegan, but I do consciously avoid red meats aside from special occasions. Baked chicken or chicken cutlet (breaded) and sauteed in olive oil are my usual go-tos. I avoid vegetable oil and refined flour products. I eat whole grain breads/brown rice or quinoa. I eat a salad every day, dressed with EVOO & red wine vinegar (nothing from a bottle)

Fair point about proteins. I do like eggs, but my total cholesterol numbers were higher than my PCP would prefer, so instead of having 1 egg almost every day I’ve now tuned it down to 2-3 eggs over the course of a week.

I’ll continue to drink at least 8 ounces of low fat or skim milk daily and I’m going to skip the daily multivitamins for now. I started that habit back when Covid lockdowns hit and was concerned over boosting my immune system. I will continue to take the vitamin c 500 mg and I will also continue taking the D3 as my PCP’s instructions are to take the over the counter D3 daily.

Can gout symptoms (swelling) cause the pressure/stress to fracture the sesamoid, or is it possible for the fractured sesamoid to present as gout symptoms?

I do have bruising along the base of the big toe and around the joint above that on the big toe. I can point my toes downward without pain but cannot/won’t flex them so they point upwards, as this caused a tremendous amount of discomfort/pain before I saw the podiatrist.

I’ve seen some other posts on this board and if it happens that I am prescribed allopurinol, I will try to keep the dose as low as possible to avoid side effects. Fingers crossed this is some type of weird reaction to the vitamins and plant protein that I don’t need. I would love to have a nice quality beer in a month for Thanksgiving & Christmas…

Thanks for your reply.

I can’t figure out how to upload the label itself, but you can search for the Orgain Plant Protein, Creamy Chocolate, 11 oz. That’s been what I’ve been having. And I don’t know what the heck I did but my replies have been deleted.

[nobody]

I very much doubt gout swellling could possibly cause fractures, but injuries can trigger gout, in which case it would be easy to overlook the gout and blame the injury for all the symptoms.

There are ingredients you listed which I don’t recognize, which means they could conceivably be a problem. I only consume things I don’t understand occasionally or in small amounts, especially if they aren’t commonly found in food. It’s not only the effects on uric acid gout sufferers need to be concerned about but diuretics among other things.
An egg a day is totally fine. Eggs are only protein-rich relative to their size, and chicken eggs are pretty small. Don’t worry about that unless you know for a fact it materially impacts your cholesterol (more likely it’s other things you’re eating… or failing to eat for that matter). You should be looking at the total amount of proteins you eat anyway, not particular foods. And most proper foods (as opposed to sweets and whatnot) contain proteins. People do normally not need to count proteins but if you’re doing protein powders/drinks you need to make sure your unsupplemented diet isn’t already protein-rich!
You probably never needed to boost your immune system (FYI they give drugs which suppress the immune system for covid as well as gout) and I realize you said you would keep taking the D3 (which is of course the right choice) but please don’t skip your multivitamins if you actually need them for some reason. If they’re actual multivitamins made by a company that also sells regulated medical supplements, you should be fine as long as you follow the instructions.
Don’t worry over a couple of beers. Assuming you don’t have another disease which could make this dangerous, simply take care to drink extra water during the rest of the day even if you’re not thirsty.
You might find that there are foods and drinks which trigger symptomps but please wait until you actually get symptoms before being afraid of something which happens to trigger a couple of people on the Internet. And even then, coincidences happen so don’t jump to conclusions the first time you get symptoms after eating or drinking something.

[Subaru Pilot]

Fair enough! Thanks for your opinion. I’ll continue healing for now, and once I’m comfortable on my own two feet again, I’ll look into seeing if there’s a specific trend. I don’t necessarily need to take multivitamins, it was one of those things saying, oh crap, global pandemic, let me take something in case I’m deficient. The only thing I’ve positively been found to be deficient in was D3, and I’ve been taking a pill a day for about 3 years and the number has come up to a point where the doc is happy and now I continue as maintenance.

I’ll leave out all the added supplemental crap and see if that has anything to do with it.

[Subaru Pilot]

I still have some pain along the top of my foot. We are going on 3 weeks now with this pain, so I am not convinced it is a true gout, or at least not the underlying cause. I still have some swelling. I do not feel “heat” from the joints, but there is some bruising/redness. There is a little pain when pointing the toes downward, but it is still painful when flexing the big toe so it points upwards.

The pain starts at the tip of my big toe, along the inside of my foot (when looking at right foot, along the left side of my big toe) and runs down along the inside of my foot, past the toe joint, back towards my arch and stops around there.

I am still wearing a boot because of the fracture in the sesamoid causing pain when putting weight down, and have taken some ibuprofen here are there.

Is it possible this could be some type of ligament or tendon sprain/strain going on instead?

[nobody]

It’s of course impossible to tell based on a short description but this sounds like it could be gout. You would get some heat when inflamation is very strong but afterwards you could have big toe joint pain and reduced mobility (especially when flexing it towards you) that lasts for so long that you might need to strech it for months after the pain is gone to get most of the range of motion back.
But this could also have nothing to do with gout. Maybe an experienced doctor would make a good guess by handling your foot but, without imagery or joint fluid testing, I don’t think it’s possible to tell for sure based on a single episode.
One thing which does sound strange to me is pain is the pain location (at the tip of the toe and so forth). I wonder if pressure on a nerve might be involved somehow.

[Subaru Pilot]

Thanks. I agree, internet is not a doctor, but it is nice to put things out there on a virtual “round table” for discussion.

I made another appointment with my podiatrist for this week and I am going to discuss an MRI or other imaging.

I suppose what I was thinking was that if it was true gout, and it’s been over 3 weeks, and after the initial consult at Urgent Care suggesting it was gout, I have been very particular with my diet, including no alcohol, no red meat, and watching typical consumption triggers. And, I don’t indulge in sweets. It seemed like I was already following the gout prevention diet, which is frustrating because that means I have no other options aside from taking the medicine should it come down to it.

[nobody]

If you actually have gout, depending on what your uric acid used to be, going on a gout prevention diet could actually prolong your symptoms. It would help in the long run and allopurinol can do the same thing depending on the dose so it’s not that such diets aren’t helpful, only that they’re rarely a quick fix. To simplify things a bit, it’s mainly what you ate last year that’s the issue rather than what you ate yesterday.

[Author]

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