Q. How to know the reason for my big toe pain?

Hi doctor,

I have been suffering lately from pain in my big toe joint. It is very severe that I could not sleep two nights when I ran out of painkillers. I thought it might be a gout attack. Because I do have gout. Though my uric acid levels are mostly high, I do not really watch what I eat. My triggers for gouty attacks happen to be rapid weight loss. It was actually the cause I had gout in the first place, I lost 40 kg in a few months when I was 18. So, if I count the attacks I had since the first time (8 years ago) perhaps only six times, three times my right big toe and three times my left ankle. All when I was not eating well and lost a lot of weight. The last attack was a year ago. But, it has never been too severe and the most painful period will last for hours in one single night. I cannot step on it and eventually it will go away gradually.

But, this time it is too intense. Especially if I try to sleep, I will sleep in minutes and the moment I move my toe while asleep, I wake up with an extreme pain like someone stabbing my foot with a knife and cut it through from the big toe joint through the upper foot. I even cried as I felt helpless with extreme pain that will not let me rest. And, it has been a week now and the pain is not going down with medication. The moment I finished my Voltaren 50 mg in four days I thought it is much better now, but it came back like a demon.

The problem is that I am confused and cannot run into all options of diagnoses due to financial situation. I went today to a hospital. The orthopedic was full, could not get an appointment urgently. So, it was a general doctor, he did not know for sure what is going on. He suspected gout, so he made blood test and uric acid was 326 umol/L, which is the best I have ever had. As he still not sure, he advised to do an x-ray and the result he said as normal. So, he gave me strong painkillers and Allopurinol, which I did not use as my uric acid is fine and told me to see how it goes for two weeks. In my x-ray see I noticed there is a slight difference in distance between the bones of the toes and the foot. The big toe is a bit closer to the bone comparing with the other toes. I do not know if this has anything to do, but I want you to double check. I have attached the photo taken. To give you more information, the pain is so intense if I am out of medication. The big toe flexes up or down, but up is more difficult than down and also upon stepping on it. So, I have to walk, stepping half side of my foot, avoiding landing on the big toe base. Of course, I apply ice water almost every three hours to feel ease and also pain upon touch from the outer side of the joint to the left. Also, you can see clear swelling and color change of the skin in the photo.

I am totally confused because I happen to make many mistakes that might cause different problems to my joint. I am not sure which one triggered it or the cause of it. I lost a lot of weight in a short period of time. I was recently (last month) on a ketogenic diet low carbohydrate high fat in which there is a debate that it might be problem for gout sufferers. I have also increased my volume and intensity of the workout due to the extra energy felt when I was keto adapted. I usually stop exercising when I feel I spent a lot of hours, not because I was tired, so perhaps that caused a lot of stress on my body. My daily workout was something like 90 minutes weight lifting in the gym and 45 minutes running and maybe 30 minutes walking to the gym if we count this as well. I remember running in barefoot too. I changed my shoes just a week before the pain and I chose a good quality running shoe. I chose a fit one, not painful or even uncomfortable, but I thought because it is filled with cushioning and felt light and good. I have not even known that there could be a problem until last night I read some articles against tight fit shoes, especially for those with gout. So, I am really confused about the problem. Am I suffering from gout or sesamoiditis or tendonitis or turf toe? I need you to guide me. What should I do? Will I need to do an MRI or CT or bone scan? Which one will confirm everything?