Can Gout Attack the Top of the Foot?
Yes, gout absolutely can and frequently does attack the dorsal (top) surface of the foot, including the midfoot, tarsal joints, and ankle/hindfoot regions, not just the classic big toe location.
Joint Distribution in Gout
Gout can affect multiple regions of the foot beyond the commonly known first metatarsophalangeal joint (big toe):
- The foot is divided into specific regions that can all be affected by gout: forefoot (metatarsophalangeal joints and toes), midfoot (tarsal joints), and ankle/hindfoot 1
- The top of the foot (midfoot/tarsal region) is explicitly recognized as a distinct anatomical region where acute gouty arthritis occurs 1
- While the first metatarsophalangeal joint is affected in approximately 50% of initial gout attacks, this means the other 50% of first attacks occur elsewhere, including the top of the foot, ankle, knee, wrist, fingers, and elbow 2, 3, 4
Clinical Presentation on the Dorsal Foot
When gout attacks the top of the foot, it presents with characteristic features:
- Rapid onset of severe pain reaching maximum intensity within 6-12 hours, often peaking within 24 hours 1
- Marked swelling and erythema over the affected area, which is highly suggestive of crystal inflammation 1
- Severe tenderness that may make walking or wearing shoes impossible 4
Diagnostic Considerations
The diagnosis remains the same regardless of foot location:
- Synovial fluid aspiration with crystal identification remains the gold standard, showing needle-shaped, negatively birefringent monosodium urate crystals under polarized microscopy 1, 5
- Ultrasound imaging can detect the "double contour sign" with 74% sensitivity and 88% specificity, and is particularly useful for examining multiple foot regions 1, 5
- Dual-energy CT has 85-100% sensitivity and 83-92% specificity for detecting monosodium urate crystal deposition throughout the foot 1, 5
Common Pitfall to Avoid
Do not assume gout only affects the big toe. This misconception can lead to delayed diagnosis when patients present with acute inflammatory arthritis affecting other parts of the foot. The midfoot, ankle, and dorsal foot surfaces are all well-recognized sites of gouty attacks, and the same diagnostic and treatment principles apply regardless of the specific foot location involved 1, 4.