Can Gout Manifest Bilaterally in the Feet?
Yes, gout can absolutely present bilaterally in the feet, though it more commonly begins as monoarticular disease and evolves to polyarticular involvement over time, particularly in patients with inadequately controlled hyperuricemia or multiple comorbidities. 1
Typical Presentation Pattern
Gout classically begins as monoarticular arthritis, most commonly affecting the first metatarsophalangeal (MTP) joint of one foot (podagra), which is the initial presentation in approximately 50% of cases. 1, 2
Monoarticular involvement of a foot or ankle joint is one of the most discriminating clinical features supporting an initial diagnosis of gout, particularly when combined with rapid onset of severe pain reaching maximum intensity within 6-24 hours and overlying erythema. 1, 3
Evolution to Bilateral and Polyarticular Disease
As gout progresses without adequate treatment, it frequently becomes polyarticular, affecting multiple joints including bilateral foot involvement. 1, 3
Polyarticular gout is defined as either acute arthritis involving 3 or more separate large joints, or acute arthritis of 4 or more joints involving more than one anatomic region (forefoot, midfoot, ankle/hindfoot, etc.). 1, 3
Patients with chronic, inadequately treated gout commonly present with asymmetrical polyarthritis affecting feet, knees, hands, and elbows, with joints affected by osteoarthritis being preferentially targeted. 4
Bilateral foot involvement is particularly common in patients with multiple comorbidities (chronic kidney disease, metabolic syndrome, obesity, hypertension), those on diuretics, and those with contraindications to urate-lowering therapy. 5, 6
Clinical Implications for Diagnosis
When bilateral foot involvement is present, synovial fluid analysis with polarized light microscopy to identify monosodium urate crystals remains the gold standard for definitive diagnosis, with sensitivity and specificity approaching 100% when performed by experienced operators. 1, 7
If joint aspiration is not feasible, ultrasound imaging of both feet should always include the first MTP joints bilaterally, even if asymptomatic, as the "double contour sign" has 74% sensitivity and 88% specificity for detecting MSU crystal deposition. 7
Dual-energy CT can detect bilateral MSU crystal deposits throughout both feet with 85-100% sensitivity and 83-92% specificity, making it particularly useful for comprehensive assessment of disease burden. 7
Common Pitfalls to Avoid
Do not assume bilateral foot involvement excludes gout—this is a common misconception, as polyarticular and bilateral presentations are well-recognized patterns, especially in advanced or poorly controlled disease. 1, 4, 5
Bilateral presentation should prompt consideration of septic arthritis, particularly if fever or systemic signs are present, as gout and infection can coexist; joint aspiration with Gram stain and culture is mandatory in this scenario. 7
Recognize that bilateral foot gout often indicates more severe disease requiring aggressive urate-lowering therapy with target serum uric acid <6 mg/dL (or <5 mg/dL if tophi are present). 5