This page about big toe gout, and toe gout, was last reviewed or updated on 30 January 2018.
Way back in the mid 19th century a gout doctor surveyed his gout patients to find out where they had suffered their first attack. Of the 516 cases studied, 73% had their first attack in a big toe, left or right, or both simultaneously. This percentage of first attack locations rose even higher when a big toe plus other spots (simultaneous first attacks) were added up.
The second most frequent first attack location were simultaneous attacks in both ankles, (which included attacks in one ankle). Ankle gout trailed way behind with just 9% of first attacks. Physicians knew about the toe gout a long time before the 19th century. It was probably known in ancient Greek times since such a recurrent action in a highly observed event is easily noticed.
Over 150 years after the survey, and onto our own times, that percentage of first time attacks has not changed much. These days it's reckoned to be about 60 - 65%. So the big toe is still gout's favourite (favorite) first attack target, whatever the cause of gout. In fact, throughout the ages, it has been so common, and big toe pain so well known, that it even has its own name, given to it by the ancient Greeks - podagra.
It is extraordinary how many attacks occur in the big toe causing big toe pain. Or to be more precise, the attacks are in the first metatarsophalangeal joint of the big toe.(MTP)*
Tophi in the toe
And if the first attack is not in the big toe, the odds are high that a subsequent attack will happen there. When gout first attacks the big toe, many peoples' reaction is that they have broken their toe. Later on, they find out the big toe pain is big toe gout.
Big toe gout cannot be a coincidence. It happens too often. If you understood the signs of its impending arrival it might help you to prevent recurrent gout flare ups at least in the big toe. The usual signs are twinges or prickling sensations in a big toe. They are also a sign of gout lurking in the body especially if your uric acid level is above normal. They are your early warning radar.
Dealing with twinges
Because of the twinges, gout old-timers, who get to know their gout really well, can guess something could happen in time to take a remedial natural remedy. Or take preventative drug medications by swallowing NSAIDs or low dose colchicine. If you are new to gout, you may not have heard that many old-timers can do this and they learn what they should take. Sir Alfred Garrod (see below)thought that twinges (or prickly sensations), meant that some crystals had already been deposited. So, you have to act fast.
Of course if you can thwart an attack by drinking a lot of water, or cherry juice, or eating strawberries, or using any of the other natural gout remedies on this website, so much the better.
You might think this gout big toe phenomenon would be a big issue in medical research with scores of studies explaining why it happens. Surprisingly it isn't, perhaps because it doesn't hold the clues to solving gout. In other words, if the uric acid level is reduced to about 6.0 mg/dL in men and slightly less in women, (the number for each individual is never exactly the same) the gout crystals begin to dissolve, and this seems to be true wherever they are found in the body.
The uric acid-derived MSU crystals provoke the immune system into causing gout attacks.
Because there isn't much study research about the big toe gout phenomenon, we are left with opinions and intuitive guesses, which may of course be right.
WHY THE BIG TOE?
Why this unlovable affinity between the first gout attack and one of the big toes? Why does gout home in on this target like a heat seeking missile, and what lessons can be learnt from this unfortunate fact?
Uric acid crystallises (crystallizes) more easily firstly when there's a lot of it in the blood. It crystallises less easily when it's made more soluble by water and when alkalizers such as baking soda (bicarbonate of soda) make the blood more alkaline. When it reaches a certain saturation point it will crystallise (crystallize).
Eventually the crystallisation will lead to tophi in the big toe joint. Here is a YouTube video showing tophi (called in the video - gout crystals) removal from a big toe. After it, the patient will be able to move his big toe joint much better.
At what level in the blood might uric acid start to cause trouble? The rough guide number is above 7.0 mg/dL in men, about 6.5 mg/dL in women. However, around 80% of people who have uric acid levels above this number never get flare ups, in a gout toe or anywhere else. And uric acid can crystallise at below 7.0 mg/dL.
Blood circulating more slowly in a colder environment is a formula for uric acid to crystallise (crystallize) as monosodium urate (MSU) crystals, the gout crystals.
Uric acid crystallises (crystallizes) more easily in a cold environment. The toes are one of the coldest parts of the body, along with other extremities such as the fingers. Cold weather too is a gout trigger. Hence gout sufferers, or those prone to it, must dress warmly in cold weather - especially the feet, and wear gloves, because gout can attack the fingers - and be careful about dress if they work in a cold environment.
It also crystallizes more easily when the blood is sluggish, which it is at body extremities. Sir Alfred Garrod, the Britishman who discovered that an excess of uric acid was the cause of gout in the mid 19th century, believed that crystals could not be deposited when blood circulation was active.
Joint aspiration (arthrocentesis) might be more difficult with big toe gout
This test is the best test for gout, because the crystals are viewed under a special microscope to see if they really are gout crystals. The first MTP joint makes this test difficult because it's small. Your doctor may have a problem getting enough fluid and tissue out of it to see if the crystals are gout ones.
It will get the blood moving faster around the feet - blood circulates better when exercising, because the heart rate (the number of times the heart beats per minute) and the stroke volume (the amount of blood pumped with each beat) increase. But discuss an exercise program (programme) with your doctor first. You may not be in a condition to do too much, too quickly.
But why always the big toe, and not one of the smaller ones?
why the ear's ridges, which can be attacked by gout but very rarely as a
first attack. Smaller toes and the ears' ridges share these blood
circulation and colder environment properties with the big toes, but
don't get attacked first. (Although the smaller toes can be attacked later
on). That's a good question I can't answer completely at present and
I'm not sure modern science can either.
A mild swelling in a smaller toe
Part of the answer is that gout usually attacks in the lower half of the body first (big toes, ankles, insteps). The big toe is more attractive than the ears. And perhaps it's something to do with the veins' routes or density. Sir Alfred Garrod thought that uric acid was not deposited as gout crystals in body areas where there are more veins, but that it was deposited in less veinous areas.
What can you do to avoid big toe gout?
If you are prone to gout for any reason, warmth and exercise are important. Apart from this, there aren't any specific long-term gout treatments for big toe gout. There are ideas for dealing with big toe gout pain. There aren't any drugs which would reduce the uric acid level in the feet and toes only.
Are there any gout diet foods which are good for big toe gout only? This is not known but it's very unlikely. Neither can natural remedy gout products, such as Flamasil and GoutCleanse, with their blends of herbs for gout, help the big toe specifically, although like pharmaceuticals, they do contain anti-inflammatory substances.
The trick here seems to be to visit a reflexologist as soon as you feel the twinges or prickling sensations or whatever signals you learn are indicative of an impending attack.
Take care of your toes
If you have had a big toe attack, be careful not to stub your toe, or hurt it in any other way. This could trigger another attack.
COULD THIS GOUT TOE PROCEDURE BE A GOUT REMEDY ?
A 2009 Taiwan study used arthroscopy to examine and remove the MSU gout crystals in the big toes. An arthroscope allows its user to view the inside of a joint and remove crystals. The study came to a very interesting conclusion.
The researchers found that if they removed the MSU crystals from the first MTP joint, those gout patients who were arthroscopied had fewer recurrent attacks. They did better than those on medications. And they could use their feet and ankles better. What the Taiwanese researchers learnt appeals to common sense - remove the crystals before their numbers grow sufficiently to contribute to another attack. The study was called:
Arthroscopic Elimination of Monosodium Urate Deposition of the First Metatarsophalangeal Joint Reduces the Recurrence of Gout.
You can read the abstract (a summary of methods and conclusions) of this study here. If you wish to purchase the complete study to read, it costs US$31.50.
* On the right foot the joint numbers run from left to right. The second metatarsophalangeal joint is on the next toe right to the big toe, on to the fifth toe, the smallest, which has the fifth metatarsophalangeal joint. On the left foot the numbers run from right to left in the same manner so that for example the smallest, outside, toe of the left foot has the fifth metatarsophalangeal joint.