Gout – it’s like pounding a nail into my big toe

“My big toe won’t even fit into my shoe!” I remember a 300 pound Hawaiian football player on crutches, tears in his eyes, with the toe of his tennis shoe cut out so it wouldn’t touch his foot.  The typical gout attack with a swollen, hot red big toe is very dramatic – and painful. Bedsheets feel like hot pokers.

Gout Gout,  by James Gillray 1799

Not all gout is in the big toe – it can (and often does) affect any joint, and often several at the same time. It is caused when uric acid crystalizes in or around the joint, forming microscopic needles  which are attacked by our own white blood cells. This causes intense inflammation and pain with joint and tissue damage. After a gout attack, the skin may peel almost like a sunburn.

Uric acid is normally produced when our bodies use food proteins for energy. The only mammals who make uric acid besides humans are Dalmation dogs and the great apes – although I remember a professor telling me he once treated gout in an elephant’s ankle.

In severe cases of gouty arthritis, the uric acid levels are so high it forms deposits of uric acid,  whitish lumps in the skin filled with chalky material made of pure uric acid.

finger tophus

These lumps are called tophi. The word tophus is a Latin term that refers to a porous type of volcanic rock called tufa. If your fingertip looks like this, you have tophitic gout (photo from dermis.net).

Gout also can cause an ongoing (chronic) arthritis, which is not as intensely painful as a gout attack but may cause severe joint damage.

The reason you may have high uric acid levels is not known, but heredity seems to play a role. Other conditions may cause an increase in uric acid. Foods high in a certain class of protein called purines can increase uric acid in some people (such as foods containing organ meats – such as sausage made using animal liver, hearts or kidneys). Fatty fish (anchovies, tuna, mackerel) and shellfish (shrimp, lobster), dark beers and heavy red wines also contain high purine levels. The uric acid level goes up with dehydration and obesity. Medications used to treat high blood pressure called diuretics (“water pills”) may increase uric acid. It now is known that sugary drinks containing high fructose corn syrup can also increase your uric acid level.

The diagnosis of gout is certain when uric acid crystals are seen in fluid removed from the joint or from a tophus.


Sometimes it is not possible to see the crystals, and gout may be presumed to be present if other typical gout signs and symptoms are present. These include a typically red painful and swollen big toe joint, attacks painful arthritis starting abruptly in other joints, along with high uric acid levels (uric acid crystals – photo wikipedia).

Treatment for a gout attack is usually very effective, if done correctly. Several different approaches are used, and should be tailored based on your individual circumstances. Situations such as diabetes, stomach ulcers, high blood pressure or kidney disease may require a specialist in arthritis called a rheumatologist to get involved.

If you think you might have gout or want to learn about the latest treatment advances, visit PainSpot.com and take the quiz, or go to the gout information page.

About Doug Roberts MD

Board certified practicing rheumatologist and founder of PainSpot.com
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