Foot Gout

Foot gout is a common problem and is characterised by sudden intense pain, often starting at night with no warning. 

The classic signs are localised pain, swelling, redness, heat and tenderness which most commonly occur in the big toe, known as Podagra, but can affect other parts of the foot and ankle. 

People who sufferer from the condition often have recurrent attacks, the symptoms of which tend to be worst in the first 12-24 hours of each attack. 

Here we will look at what is going on during foot gout attacks, common symptoms, risk factors that can make you more prone to the disease, common diagnosis tools, treatment options and the best prevention strategies.

What Is Gout?

Foot gout that affects the big toe is known as Podagra

Gout is the most common type of inflammatory arthritis and is caused by a build-up of uric acid crystals in a joint.  Uric acid is a natural product that is constantly being produced when the body breaks down chemicals known as purines found in foods such as meat and seafood.  Normally, uric acid is filtered and removed through the kidneys and doesn’t cause any problems.  However, sometimes the kidneys can’t remove the uric acid quickly enough or the body just produces too much of it. 

Over time, this leads to the formation of sodium urate crystals, usually around one of the joints in the body.  The tiny crystals are shaped like hard, spiked rods.

Spiked rods of monosodium urate crystals photographed under polarized light from a synovial fluid sample seen in foot gout

Initially, there are no obvious symptoms, but as more crystals accumulate (which may take years), they can start to cause problems.  If these crystals enter the joint, they irritate the joint lining, triggering an inflammatory reaction, causing intense pain, redness and swelling around the joint.

Foot gout most commonly occurs at the base of the big toe, known as the metatarsophalangeal joint.  Gout foot here accounts for over 50% of cases of the disease and is also known as Podagra. 

Symptoms of Foot Gout

The most common symptoms of foot and ankle gout are intense pain, swelling, redness, heat and tenderness over the affected joint. 

Foot gout affecting the big toe and second toe

Symptoms from foot gout often start suddenly and progress rapidly over a few hours, particularly at night-time.  This is thought to be due to people having a slightly lower body temperature at night.  In severe cases, foot gout symptoms may also include fatigue and a fever. 

Episodes usually last between five and ten days.  However, over 60% of sufferers will experience a repeat attack within one year.  Over time, the frequency of foot gout attacks may increase, and more joints may be affected. 

It tends to affect the extremities and Podagra, where it affects the big toe is the most common place to get symptoms of the disease, but people can also suffer from ankle gout or even further up the leg with gout knee.  The upper limbs may also be affected, most commonly the fingers, wrists and elbows.  It is thought it most commonly occurs in the extremities as they tend to be the coldest parts of the body, which increases the risk of sodium urate crystal formation.

Risk Factors

Whilst gout foot flare ups often happen for no particular reason, there are a number of factors that have been linked to an increased risk of the disease:

1)  Medical Conditions: such as diabetes, kidney disease, high blood pressure, osteoarthritis and high cholesterol all increase the risk of developing the disease

Drinks with high purine levels increase the risk of foot gout

2)  Diet: foods with high purine levels such as seafood, red meat and offal, alcohol (especially beer and spirits) and sugary drinks have been shown to increase the risk of foot gout

3)  Genetics: In approximately 20% of cases there is thought to be a genetic link with a close family member also suffering from the condition

4)  Obesity:
people with a BMI greater than 35 are three times more likely to develop the condition

5)  Medication:
some medications increase uric acid levels and therefore the risk of developing the condition.  These include diuretics (water tablets), beta blockers, aspirin (when taken regularly) and niacin (for high cholesterol)

6)  Gender:
Men tend to suffer from the condition at a younger age than women due to higher levels of uric acid.  After the menopause, uric acid level rise in women increasing the risk of the condition and only 15% of female sufferers are pre-menopausal.  Over the age of 60, the risk of developing the disease is equal between the two genders but over the age of 80, it is more prevalent in females.

Foot Gout Diagnosis

Accurate foot gout diagnosis starts with the doctor asking questions about your symptoms such as when and how they started, previous episodes, diet and any family history of the disease.  It may be suspected from your history but with over two hundred other types of arthritis, your doctor may carry out further tests to ensure an accurate gout diagnosis.  This may involve:

1)  Joint Fluid Analysis: Your doctor may take a small sample of fluid from the affected joint using a syringe.  This can then be analysed for the presence of uric acid crystals, which gives a definitive foot gout diagnosis

X-ray showing foot gout affecting the big toe, aka podagra

2)  X-rays: Occasionally your doctor may send you for an x-ray but this is usually to either rule out other causes or to look for signs of chronic gout where the bone becomes affected

3)  Blood Tests: These are used to look for high levels of uric acid in the blood, known as hyperuricemia.  These blood tests are most reliable 4-6 weeks after the initial gout foot attack.  These tests can however be unreliable – 50% of sufferers may never show high uric acid levels whereas people who don’t suffer from the disease sometimes do have high levels

4)  Ultrasound Scans: These are become more popular as they are a good, non-invasive way of looking for the presence of urate crystals in the joint

Treatment Options

Foot gout treatment starts by addressing the pain associated with the flare up.  Once the symptoms have subsided, further treatment concentrates on lowering uric acid levels to prevent further attacks.

1)  Painkillers: Non-steroidal anti-inflammatory medication (NSAIDs) such as ibuprofen and naproxen help to relieve pain and inflammation associated with foot gout

2)  Colchicine: this can help to reduce further attacks, but frequent side effects often limit its use.  If tolerated, your doctor may prescribe a small daily dose to try and prevent further attacks of foot gout such as podagra

3)  Corticosteroids: If you can’t tolerate NSAIDs or colchicine, your doctor may recommend a short course of oral steroids, or a steroid injection into the affected joint to help relieve pain and inflammation.  Long term, high dose use is however not recommended due to side effects such as bone thinning and decreased ability to fight infections

4) Ice: Ice therapy can help reduce the pain and inflammation associated with flare ups – see the Ice Treatment section for advice on how to use ice safely and effectively

Prevention Strategies

Foot gout prevention aims to reduce the number of flare-ups people experience by reducing the levels of uric acid.  This can be done with medications of lifestyle changes.

1)  Medication: medication to reduce uric acid levels helps prevent the formation of urate crystals as well as dissolving any existing crystals.  Common prevention medications include allopurinol and febuxostat.  These usually need to be taken daily and it can take a while to find the correct dosage for you

2)  Diet:
Avoiding food and drinks that are high in purine is a great gout prevention tactic.  Avoid game meat, offal (e.g. liver and kidney), oily fish and seafood

Drinking lots of water helps to reduce the levels of uric acid crystals which cause foot gout

3)  Drink Plenty Of Water: keeping well hydrated reduces uric acid crystal formation in the kidneys.  Aim to drink approximately 1.5 litres per day, more if it is hot

4)  Lose Excess Weight:
Obesity often results in higher levels of uric acid.  Weight loss should be carefully controlled as crash dieting can actually increase the risk of developing the disease

5)  Vitamin C: taking a daily dose of vitamin C has been shown to reduce the risk of the disease by about 45% - always consult your doctor before taking any supplements

6)  Limit Alcohol Intake:
particularly beer which contains high levels of purine

7)  Exercise:
Regular exercise helps to reduce the risk

8)  Avoid Fructose-sweetened food and drink:
as they increase the risk of gout

What Else Could It Be?

Whilst podagra is one of the most common causes of big toe pain, there are a number of other things it could be.  If foot gout isn’t sounding quite like your problem, visit the foot pain diagnosis section for more help working out what is wrong and what you can do about it. 

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See Also

Common Causes of Foot Pain

Diagnose Your Pain

Foot & Ankle Anatomy

Treatment Options for Foot Problems



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