Gout in the foot and big toe

A big toe that turns red, hot and very painful overnight is the classic picture of gout, but not every red, swollen toe is gout. We see patients with painful, swollen toe and ankle joints at our offices in Lyndhurst, Paramus and Millburn, NJ. For other causes, see our guide to big toe pain.

What gout is

Gout happens when urate builds up in the body over a long period and forms needle-shaped crystals in and around a joint, which then becomes inflamed.^[1] Urate (uric acid) comes from the breakdown of purines, found in the body and in many foods; some people make too much, and in others the kidneys don’t clear enough.^[2] Gout is the most common inflammatory arthritis, and it typically strikes one foot or ankle joint, especially the big-toe joint (the first metatarsophalangeal, or MTP, joint).^[7] Gout at the big toe is called podagra.

Gout is more common in men and usually starts in middle age; women usually don’t develop it before menopause.^[1,3] Other risks include a family history, excess weight, high blood pressure, kidney disease, alcohol, sugary drinks, purine-rich food and some medicines, such as diuretics (“water pills”) and low-dose aspirin.^[1] Don’t stop a prescribed medicine, such as aspirin taken for your heart, without talking to your doctor.^[6]

What a gout flare looks and feels like

• It starts suddenly, often at night, and the pain can wake you. Even the touch of a bedsheet can hurt.^[1,3]
• The joint turns red, swollen and warm.^[1]
• Usually one joint is involved, most often the big toe, though gout can affect others, including the ankle.^[1,7]
• It settles over a week or two, and between flares you usually have no symptoms.^[1]

Flares can be triggered by certain foods, alcohol, some medicines, an injury or an illness.^[1] Untreated, gout can also form tophi (chalky lumps of crystals under the skin) and damage the joint.^[1,3]

When it needs same-day care

The body reacts to urate crystals much as it reacts to bacteria, so a gout flare can look just like an infection.^[3] An infected joint (septic arthritis) is the most urgent cause of a single painful, swollen joint,^[4] and infection can even be present alongside gout.^[3] Get seen the same day, or go to an emergency department, if:

• you have a fever^[3] or chills;
• the redness is spreading, or the skin nearby is broken;
• you have diabetes, which raises the risk of infection.^[3]

A first attack should also be checked promptly.^[3] With diabetes and numb feet, a warm, red, swollen foot can also be Charcot foot, which needs early diagnosis.^[8]

How gout is diagnosed

The visit starts with your history and an examination of the joint. Blood tests and X-rays are sometimes used to check whether something other than gout is causing the inflammation.^[2]

• Joint fluid. Urate crystals seen under a microscope in fluid drawn from the joint, or from a tophus, confirm gout; European guidelines recommend looking for them in everyone with suspected gout.^[7] The same fluid is checked for infection.^[3]
• Blood uric acid. Useful, but not decisive. A high level alone doesn’t prove gout,^[7] and in two large trials about 1 in 7 people having a flare had a normal level.^[9] It may be rechecked once the flare has passed.^[3]
• Imaging. X-rays help rule out other causes and can show joint damage from long-standing gout.^[2,3] Ultrasound and a special CT scan (dual-energy CT) can show urate deposits.^[7,4,6]

Because gout often comes with high blood pressure, kidney disease, diabetes or heart disease, European guidelines recommend checking for these too.^[1,7]

Treating a flare

The American College of Rheumatology strongly recommends any of three kinds of medicine to calm a flare:^[5]

• Anti-inflammatory medicines (NSAIDs). Check with your doctor first, because even over-the-counter strengths can have serious side effects.^[3]
• Colchicine, which works best when started as soon as symptoms appear.^[6] Limited evidence suggests a low dose works about as well as a high dose, with fewer side effects.^[10]
• Corticosteroids, as tablets or as an injection into the joint or a muscle.^[5] In trials, steroid medicine probably relieved pain about as well as NSAIDs, with fewer side effects overall.^[11]

Your doctor will choose based on your other health conditions and medicines. Meanwhile, rest and raise the foot, and apply an ice pack wrapped in a towel for about 20 minutes at a time.^[3,6] With treatment, a flare usually settles within three to ten days.^[2]

Preventing the next flare

For frequent flares, tophi or joint damage on X-ray, the American College of Rheumatology strongly recommends medicine that lowers uric acid, with allopurinol usually the first choice. The dose is adjusted with blood tests until uric acid stays below 6 mg/dL, and an anti-inflammatory medicine is taken alongside it for at least the first three to six months.^[5] Taken regularly, it is the key to preventing flares and can shrink tophi.^[6] Most people with gout are treated by their primary care doctor, who usually manages this long-term care.^[6,2]

Everyday changes help too: losing extra weight; less alcohol (including non-alcoholic beer) and fewer sugary drinks; less red meat, organ meat and shellfish; and the DASH eating plan, which also helps blood pressure. When flares are frequent or tophi have formed, these changes alone aren’t enough. Talk with your doctor before changing any medicine.^[6]

Gout, bunion, arthritis, turf toe or infection?

Several problems cause pain at the big-toe joint, and the way the pain began usually tells them apart. For a fuller comparison, including sesamoid problems and a broken toe, see big toe pain.

	How it starts	What you notice
Gout	Suddenly, often at night	A red, hot, swollen joint; flares come and go[1]
Bunion	Slowly, over years	A bony bump on the inner side of the joint, red where the shoe rubs[12,13]
Big-toe arthritis (hallux rigidus)	Gradually	Pain and stiffness when the toe bends, worse in cold, damp weather[14]
Turf toe	With an injury, usually in sport	Pain at the joint after the big toe is forced upward[15]
Infected joint	Quickly	A hot, swollen joint, often with fever: an emergency[3,4]

They can overlap: repeated gout attacks can wear out the joint, and gout is one of the causes of big-toe arthritis.^[3,14] Our pages on bunions, big-toe arthritis and turf toe explain each one.

How we can help

We can evaluate a painful, swollen toe or ankle joint, look for signs of infection, and take X-rays at the practice to check for other causes such as a fracture, a bunion or arthritis. If gout is likely, we go through the options for calming the flare and share our findings with your primary care doctor or rheumatologist. If repeated flares have damaged the joint, see foot and ankle arthritis.

When surgery is considered

A gout flare is treated with medicine, not surgery. Surgery is for complications: an infected joint that needs washing out, tophi that stay painful or break open, or a joint destroyed by long-standing gout, which at the big toe may be fused to relieve pain.^[3]

Common questions

Can a Foot and Ankle Surgeon or podiatrist treat gout?

Yes, in the foot and ankle. A Foot and Ankle Surgeon diagnoses gout with a history, an examination and, when needed, blood tests and X-rays, and treats flares with prescription medicine or injections.^[2] If flares keep coming back, medicine to lower uric acid is usually managed by your primary care doctor or a rheumatologist.^[2,6]

How long does a gout flare in the foot last?

Most flares settle within a week or two, and with treatment often within three to ten days.^[1,2] Flares slowly settle even without treatment, but improve much faster with it.^[3] Starting early helps: colchicine, for example, works best when taken as soon as symptoms appear.^[6]

Will gout go away on its own?

A single flare usually settles, but have a first attack checked, because an infected joint can look the same.^[3] Without preventive treatment, the next attack typically comes within two years, and attacks can become more frequent and more severe.^[3] With early diagnosis, treatment and lifestyle changes, gout is one of the most controllable forms of arthritis, and many people stop having flares.^[1]

When to seek care