Can Gout Involve the Ankle?
Yes, the ankle is a common site for gout involvement and is explicitly recognized as a large joint frequently affected by acute gouty arthritis. 1
Clinical Recognition
The ankle is specifically identified as one of the characteristic locations for gout presentation:
Monoarticular involvement of the ankle joint is a suggestive clinical feature supporting the diagnosis of gout, particularly when accompanied by rapid onset of severe pain reaching maximum intensity within 24 hours, erythema, and swelling 1
The ankle is classified as a "large joint" in gout management guidelines (along with knee, wrist, elbow, hip, and shoulder), and involvement of 1-2 large joints represents a distinct category for treatment decision-making 1
Gout has a predilection for lower extremity joints, with the ankle being one of the most common sites after the first metatarsophalangeal joint 2, 3
Anatomical Considerations
The ankle region encompasses multiple structures that can be affected:
The ankle/hindfoot is defined as a distinct joint "region" in gout classification systems, separate from the midfoot and forefoot 1
Periarticular structures including bursae and tendons around the ankle can also be involved in acute gout flares 3
Diagnostic Approach When Ankle is Involved
Joint aspiration with synovial fluid analysis for monosodium urate crystals remains the gold standard diagnostic test, even when the ankle is the affected joint 1, 4:
Synovial fluid aspiration should be attempted in all cases of undiagnosed inflammatory arthritis of the ankle to confirm MSU crystal presence and rule out septic arthritis 1, 4
Ultrasound can identify the "double contour sign" at ankle cartilage surfaces (sensitivity 74%, specificity 88%) and detect tophi not evident on clinical examination 1, 4
Treatment Implications
Ankle involvement does not fundamentally change the treatment approach:
Acute ankle gout should be treated with NSAIDs, corticosteroids, or oral colchicine as first-line options, with pharmacologic therapy initiated within 24 hours of symptom onset 1
Intra-articular corticosteroid injection into the ankle joint is one of the most effective treatments for acute monoarticular gout when feasible 2
Common Pitfall
Do not dismiss ankle arthritis as "just a sprain" or other mechanical injury in patients with risk factors for gout (hyperuricemia, male gender, cardiovascular disease, diuretic use), as this can delay appropriate diagnosis and treatment 1, 4, 2