Gout is a metabolic disorder that results from high levels of uric acid (a waste product of cell metabolism) in the blood. The condition can lead to joint inﬂam- mation, deposits of uric acid in and around the joints, reduced kidney function, and sometimes the development of kidney stones (see page 289).
Gout is nine times more common in men than in women. Risk factors for gout include obesity, moderate to heavy alcohol consumption, high blood pressure, and kidney disorders. Certain drugs (such as aspirin) can worsen gout, and cer- tain diseases that affect kidney function (such as diabetes and sickle-cell disease) can be a factor. Acute attacks of gout can be brought on by dehydration, joint injury, fever, large meals, high alcohol intake, stress, or recent surgery. Certain foods, such as shellﬁsh, sardines, and organ meats, also may trigger attacks.
The small joint at the base of the big toe is the most common location for an acute gout attack. Other joints affected may include the ankles, knees, wrists, ﬁngers, and elbows. An acute gout attack often begins at night, with severe pain and sometimes a fever. The attack may subside in several hours or several days but usually recurs at irregular intervals.
The symptoms alone usually are sufﬁcient to diagnose gout, but your doctor can conﬁrm the diagnosis by examining your blood for elevated uric acid levels and your joint ﬂuid for signs of uric acid crystals.
Future attacks can be prevented by increasing ﬂuid consumption (at least eight
8-ounce glasses every day), losing weight (see page 73), reducing alcohol intake, modifying your diet, and taking nonsteroidal anti-inﬂammatory drugs (such as ibuprofen) to relieve the pain and inﬂammation and medications (such as allop- urinol or probenecid) to lower blood levels of uric acid.
Disorders of the Wrist and the Hand
The hand consists of the wrist, palm, and ﬁngers. The wrist has eight bones (carpals); four are connected to the forearm bones (radius and ulna), and four are connected to the ﬁve bones of the palm (metacarpals). Each of the bones of the palm is connected to one of the ﬁnger bones (phalanges). Each ﬁnger has three phalanges; the thumb has two phalanges. Hand movements are controlled by a complex network of ligaments, tendons, and muscles. The hand has a wide range of motion that allows you to perform a wide variety of manual tasks. The complexity and versatility of the hand make it particularly vulnerable to injury.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is a common repetitive-stress injury that can affect one or both hands. Repeating the same hand motions over a prolonged period may lead to swelling of the tendons that bend the ﬁngers and the thumb, which in turn puts pressure on the median nerve where it enters the hand (the carpal tunnel). Repetitive motions such as keyboard work (including operating a computer,
adding machine, or cash register), assembly line work, painting, driving, and some sports (such as handball and racquetball) can cause this injury.
Common symptoms of carpal tunnel syndrome include numbness, tingling, and pain in the hand and forearm (especially at night), pain or weakness when gripping objects, and clumsiness in handling objects.
Diagnosis of carpal tunnel syndrome is based on your symptoms and the results of a doctor’s examination of your hand and wrist. If pain shoots down into your hand and ﬁngers or up into your forearm when the doctor taps lightly on the front of your wrist, you probably have carpal tunnel syndrome. Nerve conduction tests such as electromyography (EMG) may be performed to deter- mine whether there is any nerve damage.
Your doctor probably will recommend that you rest the affected hand and avoid the repetitive activity that is causing the problem. You also may need to wear a splint or a brace to immobilize your wrist while allowing you to continue using your hand. Nonsteroidal anti-inﬂammatory drugs such as aspirin or ibuprofen can relieve pain and inﬂammation. Injections with corticosteroids may be prescribed if pain persists. Surgery to relieve the pressure on the median nerve (a procedure called carpal tunnel release) is performed in severe cases that do not respond to other forms of treatment.
Tendons attach the forearm muscles to the elbow at bony outgrowths called epicondyles. These tendons can become inﬂamed and painful, especially with repetitive motions of the forearm (such as using a manual screwdriver, washing windows, or swinging a baseball bat). This inﬂammation is called epicondylitis. The two types of epicondylitis are called tennis elbow (the outer tendons are inﬂamed) and golfer’s elbow (the inner tendons are inﬂamed).
The usual treatment for these disorders includes ice packs, rest, nonsteroidal anti-inﬂammatory medications such as aspirin or ibuprofen, or, in severe cases, corticosteroid injections. In some cases, surgery may be necessary.
A trapped ulnar nerve is another common injury that occurs when the nerve that crosses the point of the elbow is compressed or pinched. This causes numbness,
tingling, weakness, and pain in the forearm and hand. Rest, ice, and avoiding reinjury can relieve symptoms and help the damaged nerve heal. Surgery to reposition the ulnar nerve may help prevent repeated compression.
Other possible elbow disorders include bursitis (see page 305), fractures (see page 304), and osteoarthritis (see page 308).
Disorders of the Shoulder
You may think of your shoulder as a single unit, but this joint is actually made up of three bones—the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone)—and three joints. The acromioclavicular joint is between the tip of the shoulder blade (acromion) and the collarbone. The scapulothoracic joint is between the shoulder blade and the thorax (rib cage), and the glenohumeral joint, commonly called the shoulder joint, is between the glenoid cavity (shoulder socket) and the head of the humerus. The shoulder is a ball-and-socket–type joint that permits a wide range of motion. In fact, the shoulder is the most movable—and, because of this, the most unstable—joint in the body.
Shoulder dislocation occurs when the humerus (upper arm bone) comes out of the shoulder joint. The bone is usually displaced in front of and below the shoul- der. Ligaments and other connective tissues are stretched or torn. In severe cases, nerves and blood vessels also may be damaged. The injury is caused by falling onto an outstretched hand or arm or onto the shoulder itself. It also may be caused by a powerful direct blow to the shoulder. Shoulder dislocation is some- times accompanied by a fracture (see page 304).
Symptoms of shoulder dislocation include severe pain in the shoulder accom- panied by swelling and bruising. The shoulder also may look misshapen.
To reduce pain and swelling, place an ice pack on the injured area immedi- ately after the injury occurs. Then see your doctor or go to a hospital emergency department without delay. (With a recurring dislocation, you may be able to “pop” the shoulder back into place.) To immobilize the shoulder and to aid heal- ing, the doctor may place your arm in a sling or strap your arm to your chest. He or she may prescribe an analgesic (pain-relieving) medication such as codeine with aspirin or acetaminophen. The doctor also may prescribe a nonsteroidal anti-inﬂammatory drug such as aspirin or ibuprofen to relieve pain and reduce swelling. (Warning: Do not take these medications at the same time unless your doctor tells you to do so.)
You should avoid athletic activities until after the injury has healed. Your doc- tor will probably recommend that you apply an ice pack to the injured area for 20 to 30 minutes three or four times per day for 2 to 4 days to reduce swelling and inﬂammation. After the swelling has gone down, apply a heating pad to your shoulder to increase circulation to the injured area and speed healing. (Warning: Apply heat only after swelling has subsided, or swelling in the injured area may increase. Be careful when using a heating pad; too much heat can cause tissue damage or burns.)
Once you have had a shoulder dislocation, you are at risk for a recurrence of the injury. Raising your arm over your head or sleeping with your arm above your shoulder could cause another dislocation. Your doctor may recommend that you work with a physical therapist or an athletic trainer on exercises that will stabilize the ligaments and tendons, strengthen the shoulder muscles, and help prevent another dislocation. A shoulder dislocation is usually a more serious injury than a shoulder separation (see below).
Shoulder separation occurs when the ligaments that attach the clavicle (collar- bone) to the scapula (shoulder blade) are torn. The injury is caused by falling onto an outstretched hand or arm or onto the shoulder itself. It also may be caused by a direct blow to the shoulder. Symptoms include severe pain, swelling, and bruising. There may be limited movement in the shoulder. In some cases the collarbone is pushed out of its normal position and sticks up under the skin. Also, the shoulder may look misshapen.
To reduce pain and swelling, place an ice pack on the injured area immedi- ately after the injury occurs. If symptoms persist, see your doctor as soon as pos- sible, or go to a hospital emergency department. To immobilize the shoulder and to speed healing, the doctor may place your arm in a sling or strap your arm to your chest. A nonsteroidal anti-inﬂammatory drug such as aspirin or ibuprofen will help reduce pain and inﬂammation. In severe cases, surgery to repair the damaged ligaments may be required.
You should avoid athletic activities until after the injury has healed. Your doc- tor probably will recommend that you apply an ice pack to the injured area for 20 to 30 minutes three or four times per day for 2 to 4 days to reduce swelling and inﬂammation. Use a heating pad on the injured area once the swelling has gone down, to increase circulation and speed healing. (Warning: Apply heat only after swelling has subsided, or swelling in the injured area may increase. Be care- ful when using a heating pad; too much heat can cause tissue damage or burns.) Ask your doctor if he or she has a list of recommended exercises or if you should work with a physical therapist or an athletic trainer on exercises that will stabi- lize the ligaments and tendons and strengthen the shoulder muscles. Shoulder separation usually does not cause any lasting adverse effects.