Gout symptoms, gout diagnosis and how gout develops if it's not treated

This page about gout symptoms was last reviewed, or updated, on 19 December 2014. 

What are gout's symptoms? How do you know you’ve really got gout and not another form of arthritis, or pseudo gout, or a fatty liver which can cause joint pain, or something else? It's a good question because it often takes a long time to diagnose gout correctly.

Early symptoms You may notice that something is not quite right in a joint (especially the joint of the big toe, either foot). It could be a little numb, and/or there might be a slight prickling sensation. These are early gout symptoms.

What are flare ups like?  A gout flare up is painful, inflamed, very sore, reddish and shiny. Please look at the toes in the above photo. A gout attack often happens between midnight and 5 am - this has been widely thought for years, and was also found to be the case in a time-of-gout-attacks study (1).  It develops quickly - the attack itself has not built up over time, although the underlying condition almost certainly has. In addition, you may have a fever, a chill and a loss of appetite.

End of the attack If untreated, these gout symptoms will peak after one to three days, and retreat after five days to a week. These events are telling you that gout is likely.


Age and Sex The first question is, are you over 40 and male or female? Although children can get gout (this is rare), gout usually occurs after the age of 40, and in men much more than women. Some say that before the female menopause men are as much as 20 times more likely to catch gout than women. But after the female menopause, gout occurs almost equally between the two sexes. If you are under 60, gout usually first attacks the joint of a big toe that connects to the foot bone, or one single joint elsewhere. If you are over 60 it usually starts in the fingers or other joints.

Tests  Before five days have passed you should have had a couple of tests because you need to act immediately and know whether the gout symptoms really are gout or not.

Initially, a uric acid test to discover your uric acid level. It may show uric acid levels above 7.0 mg/dL(men)or about 6.5 mg/dL(women).

But the results will probably not be accurate since during a gout attack, blood uric acid levels fall because more uric acid is excreted. Therefore the test will be repeated after the attack, and the results most likely will be more accurate. 

The second test is a joint aspiration, also called arthrocentesis. What happens here is that a sample of synovial fluid (the fluid between the joints) is taken from the gout attack site. An examination under an illuminated, polarised, (polarized) microscope reveals whether there are MSU gout crystals or not. The crystals are not rounded but needle shaped and you won't see them with your naked eye. If correctly identified, they confirm gout. 

The difficulty with this test is that frequently the doctor or rheumatologist cannot get enough fluid out of a joint for the test to be accurate. It might seem to the practitioner that there isn't any fluid in the joint. The big toe joint, a very common first attack spot, is one such joint. The best, that is the easiest to aspirate, is said to be the knee because it has a large synovial cavity.

Most GP's (PCP's) are not practiced at doing this test. And they probably will not have a polarising (polarizing) microscope. You should be sent to a rheumatologist.

A doctor's clinic setting, where the doctor wants you in and out in 20 minutes, is not the best place to discuss the possibility of gout.

I would say push hard to get this tests done if you have to. Better to be certain now than uncertain for maybe another 2 plus years.

In the absence of aspiration (arthrocentesis), doctors use a list of around 10 - 12 gout symptoms, drawn up by national rheumatology associations. Your doctor has to compare your symptoms with the symptoms on this list to make a diagnosis. And s/he relies on experience. Sometimes it's easy to confirm gout..... and sometimes it isn't.


How does untreated gout develop? What is likely to happen? Gout flare ups can disappear for over a year. Or they could happen again in a matter of days or weeks. Over time, attacks become more frequent, and more painful to the point where a sufferer has daily pain. Gout affected joints may cease to work.

Tophi develop These are the irregularly shaped lumps of growing MSU gout crystals which develop at the initial attack site and later in other parts of the body such as fingers and wrists. And even in unusual spots unrelated to joints such as the ears’ ridges, and around the heart and spine. These latter three locations are not common. This is called tophaceous gout. New crystals develop in joints with existing crystals or in previously crystal free joints. Crystals can destroy cartilage as well as forming tophi.

Kidney stones develop in some gout sufferers. Kidney stones are usually made from calcium oxalate, and therefore are not related to excessive uric acid, but some can be made of uric acid. These stones, whatever they are made from, can lead to kidney disease and eventual kidney failure.

Eventually, maybe 10 or 20 years after the first attack, the joints are destroyed and there is permanent pain. If treated it is highly unlikely the disease will reach this level. And tophi can be removed by surgery.

But if any reader really suspects gout symptoms or has had a gout attack, and hasn't yet seen a doctor, this is your wake up call ! And if you haven’t yet had a gout attack, but think you might, this is your wake up call too, that is before your big toe calls on you. Sorry to put it so bluntly.

(1)  Nocturnal risk of gout attacks. Choi H.K, Niu J, Neogi T, Chen C, Chaisson C, Hunter D, Zhang Y. Arthritis and Rheumatology. 2014 Dec 11. doi: 10.1002/art.38917. [Epub ahead of print]

Related pages

Visit our main page about gout crystals. What are they like ?

Click here if you want to know the difference between gout and pseudo gout

What do you have to do to adjust to living with gout? Read this page.

And tips to help you control gout

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