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Accessory navicular region pain, muscle twitching, taken Indomethacin. Can this be gout or nerve problem?

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Orthopaedic Surgeon
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I am 28 years old, male, a competitive swimmer and in good health. Blood pressure typically at 120/80, general check ups indicates that i am healthy. Creatine and other blood hematology test results seem alright.
I have got pain at the accessory navicular region, which started with an attack/flare very similar to gout. Afterwhich, it slowly recovered and another attack/flare occured. The right foot accessory navicular suffered the attacks on end October, end November, early January. The left foot accessory navicular suffered an attack at mid december. Its now mainly pain on weight bearing, with occasional non-voluntarily muscle/tendon twitches, mostly occuring along the path of posterial tibial tendon, sometimes at the ankle, other times at the forefoot (around the 1st cuneiform).
Nsaids (indomethacin) is helpful during a flare, but not for the pain (on weight bearing) after the flare. Indomethacin, celebrex, colchicine does not help the latter. During the flare, its impossible to bear weight due to excruciating pain. After the flare, it is mainly pain on foot landing whilst walking slowly. The pain increases in intensity with distance, and at about 200-400m, the pain would be excruciating. The pain will then die down with rest. First few steps typically encounter stress but not pain.
MRI indicates bone oedema at the site of accessory navicular and navicular synchondrosis. The reports states that it is in line with symptomatic accessory navicular. PTT and other tendons/ligaments is preserved. All other bones in good shape.
Sometimes while resting, i find false pain around the foot, lasting for split-2 seconds. Sometimes at the cineiform, other times at the arch, XXXXXXX ankle. Each time i touch the pain site immediately after the pain is detected, there is no pain. I am unable to replicate it. It only occur on rest.
Prior to the first flare attack, i was indeed eating pretty XXXXXXX food and walking around alot. I stood and walked for approximately 15 hours the day before. No running, no jumping, no trauma. Wearing custom orthotics, but this insole presses very hard against the pain site, and i am wearing a off the shelf overproner shoe, the XXXXXXX beast.
My question would be:
1) Can this be gout? ESR and CPR readings are low, but uric acid is 7-8.2mg/dl. I understand that my uric acid is on the high side. No synovial fluid sample was taken because the doctor i saw claimed that there is no synovial fluid @ the pain site. The pain site is not red nor swollen. Excruciating pain when pressed during a flare. Pain when pressed otherwise.
2) Can this be a nerve problem? Can the accessory navicular somehow catch or pinch the medial plantar nerve/other nerves when my arch collapse? I do have collapsible flat foot.
3) Is it possible for gout to develop at the accessory navicular, or to cause bone oedema at the accessory navicular-navicular synchondrosis?
4) What in your opinion, am i suffering from? I am mostly home bound these days, as i can't really walk. Please help!!!

Posted Tue, 24 Apr 2012 in Bones, Muscles and Joints
Answered by Dr. Praveen Tayal 16 hours later
Thanks for posting your query.
I understand your concern. You have given a very good description of your problem.
1. Your problem is likely to be related to gout. Your doctor is right in pointing out that the synovial fluid in this area is minimal and cannot be aspirated for investigations.
2. Nerve problem is unlikely as nerve related pains are not so localized. These are more shooting in nature and involve a bigger area.
3. Gout can develop in these joints and the bone edema is suggestive of an inflammatory process around the bone.
4. The treatment you are getting right now is adequate. Such attacks of gout do show considerable improvement on dietary restrictions.
Taking a diet XXXXXXX in vitamin C, dairy products and coffee is likely to help in improvement of symptoms.
Drink plenty of water daily to help the kidneys clear the uric acid. Reducing meat intake will help a little.
You can ask your doctor to consider adding steroids orally for 4-5 days to control the severe symptoms.
I hope this answers your query effectively.
In case you have additional questions or doubts, you can forward them to me, and I shall be glad to help you out.
Please accept my answer in case you do not have further queries.
Wishing you good health.
Dr. Praveen Tayal.

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