Can Gout Occur in Only One Finger or Toe?
Yes, gout absolutely can—and frequently does—present in a single finger or toe, as monoarticular involvement is a classic and well-recognized presentation pattern of acute gout. 1
Typical Monoarticular Presentation
The European League Against Rheumatism (EULAR) explicitly identifies monoarticular involvement of a foot or ankle joint (especially the first metatarsophalangeal joint) as one of the key clinical features supporting a diagnosis of gout. 1 This single-joint presentation is not only possible but is actually the most characteristic initial manifestation of the disease. 2, 3
Classic Patterns by Location
- Lower extremity joints are preferentially affected, with the great toe (first metatarsophalangeal joint/podagra) being the most common single site of initial presentation 1, 4
- Single finger involvement can occur, particularly in women and patients with multiple comorbidities or those on chronic diuretics 5
- The disease characteristically affects peripheral, cooler joints where monosodium urate crystals preferentially precipitate 6
Clinical Characteristics of Monoarticular Gout
When gout presents in a single digit, it typically demonstrates:
- Rapid onset with severe pain and swelling reaching maximum intensity within 6-24 hours 4
- Erythema overlying the affected joint 1
- Pain described as "the worst pain ever experienced" 6
- The attack usually reaches peak severity within 24 hours 4
Diagnostic Confirmation
Even when clinical presentation strongly suggests gout in a single joint, synovial fluid aspiration with polarized light microscopy remains the gold standard for definitive diagnosis (sensitivity 63-78%, specificity 93-100%). 4 This is particularly critical because:
- Clinical features alone have high sensitivity (98%) but very low specificity (23%) 4
- Septic arthritis can coexist with gout and must be ruled out, especially when systemic symptoms are present 7, 4
- Monosodium urate crystals appear needle-shaped with strong negative birefringence under polarized microscopy 4
Disease Progression Considerations
While gout commonly starts as monoarticular disease in a single toe or finger:
- Untreated gout can progress from acute monoarticular attacks to recurrent episodes and eventually polyarticular involvement 1, 2
- Patients with chronic gout and multiple comorbidities more commonly present with asymmetrical polyarthritis 6
- The presence of monoarticular involvement does not exclude the possibility of urate crystal deposition in other joints that may become symptomatic later 6
Common Pitfall to Avoid
Do not dismiss the diagnosis of gout simply because only one digit is involved—this is actually the expected presentation pattern, particularly for initial attacks. 1 The key error would be assuming that gout must be polyarticular or that single-joint involvement suggests an alternative diagnosis.