Elbow gout - there is a spot on the elbow that gout goes for





This page about elbow gout was last reviewed, or updated, on 27 December 2016.

The true heart of the gouty malady is the toes and feet because that's where most attacks begin. If attacks don't begin there, they almost certainly will be attacked at some stage. After the toes and feet, it's the hands. The usual, but not invariable, pattern is that attacks move up the body as the disease progresses. So gout in the elbow, like finger gout,

is clearly a sign that someone's gout has become more entrenched. The medical word for entrenched is "refractory" or in crystal-clear English, stubborn. 

A first gout flare in an elbow is very rare. Gout has been in other places before it lands in the elbow. But after around 10 - 15 years of gout attacks in the typical gouty areas, singular attacks in the elbow and simultaneous attacks of gout in the elbow plus another spot, are quite common. There is no favourite (favorite) combination with other attack locations. It could be combined with the big toes, ankle, heel etc, but perhaps its partner in agony is a place where there's been a previous attack.

This isn't an untried theory. Many gout sufferers explain they've had the disease for a number of years, and in other places, before the attack arrives in the elbow. And, at this stage of gout, pain can flit from one spot to another with a rapidity which takes its sufferers by surprise - until it becomes sadly familiar.

The elbow is at the confluence of three bones - the humerus, which comes down from the shoulder, and the ulna and the radius, the two bones of the forearm. There are actually three joints here. Each bone has its own cartilage, and there are tendons, membranes, and ligaments (associated fibres (fibers)). And the muscles. So gout can go for the elbow joints, and their synovial fluid, and also deposit its crystals in and on the associated fibres (fibers), and it sometimes does.

But according to a leading gout figure of the 19th century, the man who first realised (realized) that gout is normally caused by an excess of uric acid in the blood, Sir Alfred Garrodgout deposits usually ignore the muscles, so they should remain unaffected.

But now comes a big surprise about elbow gout.

TOPHI ON THE TIP

Elbow gout actually prefers not the elbow joints, but the olecranon bursa sac, the small cushioning bag that's found at the tip of the elbow, between the bone and the skin. The sac cushions the elbow's boney tip. So gout's MSU crystals get most deposited in the fluid in the olecranon bursa, or on the bursa, and they have the same affect on it as they would in a joint.

The bursa becomes inflamed and painful and the tip of the elbow gets the familiar reddish-purple colour (color) of a gouty stain. Eventually, just as in joints and tissues, the crystals coagulate and are transformed over time from a creamy toothpaste-like substance into a rock hard small white piece of "chalk" - tophi.

Whilst a bursae gout attack can happen in other joints where bursae are found - a good example is the bursa in the heel, which is a cause of heel gout  - it is much more probable in the elbow's olecranon bursa. This was also true in the mid nineteenth century when Sir Alfred Garrod, described this phenomenon in his book The Nature and Treatment of Gout and Rheumatic Gout.

And it's still true today because photos of elbow gout patients usually show skin stains on bulges at the tip of the elbow. Garrod thought gout went for the bursa sac because it was the part of the elbow that took the most pressure, when for example you lean on your elbows, and maybe it's this part of the elbow that takes the most pressure in all those sports where the arms are primarily used. 

Similarly, Garrod ascribed the body's pressure on the big toe as one of the reasons why the big toe is the most likely first attack spot. (Yet another reason for getting to your ideal weight - if you are not - to take pressure off the toes). So if you have had a gout attack in your elbows, leaning on them is probably not a good idea. And if you're unlucky, the crystals will be in all the joints, the bursa and the associated fibres (fibers).

And this means that elbow gout, if it's in the bursa sac, can be confused with bursitis, a painful injury where the bursa sac also becomes inflamed, but from a variety of causes, one of which can be gout crystals.

ASPIRATION TEST 

Just as a joint or tissue can be aspirated, (synovial fluid and tissue is removed for examination under a microsope), so can a bursa sac. Joint aspiration (aka arthrocentesis),and it's importance,is described in more detail on the gout foot pain page

The fluid within the sac needs to be examined to see if any crystals there are truly the needle shaped MSU gout crystals, and not some other kind (e.g. pseudo gout crystals) and that it's not bursitis. This tells your doctor, and you, that you are dealing with gout, and not the 40 plus other conditions which can painfully affect the elbows.

WHY ARE THE ELBOW JOINTS NOT ATTACKED MUCH? 

It's curious that gout should prefer the bursa to the joints, but only in the elbow. So here are my speculations, which may give you another insight into the nature of the malady you are dealing with.  

It's possibly because elbow joints are warmer joints, closer to the heart than the toes, feet, hands, fingers, wrists, ankles and heels. Gout in the shoulder, which is even closer to the heart, is less common than elbow gout. It's possibly because blood circulation is stronger here for most people than further down the body. It's possibly because generally, less pressure is placed on the elbows.

And it's possibly because the pH of the synovial fluid in the elbow is more alkaline. When I've read case histories in Sir Alfred Garrod's book, I noticed that in the few cases of gout in the elbow he describes, (and very few gout writers describe any cases of elbow gout), a higher synovial fluid pH of the elbow was associated with a less virulent attack.

This is in keeping with what we know about higher pH of other fluids and tissues and gout alleviation. Warmer joints, better blood circulation, a higher pH, (more alkaline) and less pressure on the elbows than on the feet - these are all possible reasons given as to why gout ignores the elbows for years. However, another feature of gout is that it likes to spread and that partly explains why those patients who are about 10 - 15 years into the disease, and without successful treatment, suddenly experience an attack in the elbow.

IS THERE ANY SPECIFIC TREATMENT FOR ELBOW GOUT?

When you have a gout elbow or another kind of gout, the way it is medically controlled these days, wherever it occurs, is by using medications to lower the whole body's uric acid levels. There isn't any specific treatment for a gout elbow. But for home remedies which might help, those described on ouankle gout page apply to the elbows. Raising pH with alkalising (alkalizing) agents may help, but you won't be able to measure raised pH of the synovial fluid in the elbow joints and bursa, you can just hope you are.

Gout elbow pain can be dealt with by the usual gout pain relief drugsor if necessary if they aren't working, medications like indomethacin (indocin) or corticosteroids such as cortisone or prednisone, can be injected into the affected area.

WHAT IS ELBOW GOUT LIKE? 

Although gout in the elbow is a sign that gout treatment has not worked, or not been pursued with sufficient vigour (vigor), generally elbow gout isn't as bad as big toes, feet, ankles, fingers etc. You will probably be more mobile, not stuck in bed or in a chair. And have a good chance that activities like computer keyboarding, writing and others will be possible with one hand. It's unlikely you'll be driving a vehicle or playing arm related sports. 

One suspects, from what elbow gout sufferers say, that it isn't as painful or debilitating as gout in its primary areas. Most people who get elbow gout are experienced sufferers, and they don't say the pain is agonising. However, partly depending on where, and how many of those crystals get deposited, of course it could be painful during attacks, and stiff and sore after them. And that small "pebble" of tophi will grow on the elbow tip.

Elbow gout is an experienced gout sufferers problem, and it's telling many of them that, if they can, they need re-double their efforts to reduce their uric acid level down to below 6.0 mg/dL (0.357mmol/L), or one suspects, considerably lower in cases where gout has been around for over 10 years. Doing this is the only way of beating gout.

ODDITIES OF ELBOW GOUT 

Gout is a capricious disease that personal experience stories demonstrate often doesn't follow its textbook (or website) descriptions, although there are many unchangeable and reliable truths about it. Here are some reported and very surprising oddities of elbow gout to those who know something about this disease. The inflammation may persist but there'll be no pain; tophi will be deposited but there'll be no pain (this has been reported); and the misformed, inflamed bursa remains out of shape after the gout attack has ended.

A BETTER HOPE? 

The relatively new gout drug Krystexxa,(generic name:Pegloticase) has demonstrated considerable but not complete success against tophi in its trials.

This drug may be more effective against tophi in the elbow, and gout generally, than any existing gout drug medication. It has got uric acid down to very low levels in many cases in its trials. Krystexxa is not a tablet or capsule. It's a course of intravenous infusions, probably every two weeks, at an approved medical center (centre) which gout sufferers visit. But it comes with a battery of "side effects."


Related links 

Go to the Index page for all our  gout in body parts pages.

Read what it's like when gout attacks the ears 

Gout in the hip can be hard to diagnose, but here's what you must do.

Read about what gout can do to the wrist- wrist gout page.1.

And read about diagnosing wrist gout and how to deal with wrist gout pain - wrist gout page 2




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