Extreme joint pain, swelling, warmth, and skin redness are classic signs of gout. The condition is the result of uric acid crystals depositing in a joint, typically in the big toe (metatarsophalangeal joint), heel, ankle, or knee. 1 Sidari A, Hill E. Diagnosis and Treatment of Gout and Pseudogout for Everyday Practice. Prim Care. 2018;45(2):213-236. doi:10.1016/j.pop.2018.02.004 , 2 Efthimiou, Petros. (2020). Absolute Rheumatology Review. 10.1007/978-3-030-23022-7. Not all cases of gout are typical, though. Different joints can be affected and less common signs and symptoms may appear.

Read on to find out about 5 unusual but possible signs and symptoms of gout.

1. Fever

The inflammation experienced during gout flare-ups can become severe enough to cause fever and other flu-like symptoms, such as fatigue and a general feeling of being unwell. These symptoms are most likely to occur when a gout attack affects two or more joints. 1 Sidari A, Hill E. Diagnosis and Treatment of Gout and Pseudogout for Everyday Practice. Prim Care. 2018;45(2):213-236. doi:10.1016/j.pop.2018.02.004

Patients and doctors should keep in mind that:

  • Inflammation in one or more joints, fever, and other flu-like symptoms can be caused by gout or another form of arthritis, such as rheumatoid arthritis or septic arthritis.
  • It is possible to have gout and another form of arthritis. 2 Efthimiou, Petros. (2020). Absolute Rheumatology Review. 10.1007/978-3-030-23022-7.

When joint pain occurs with fever and flu-like symptoms, diagnosis may be particularly challenging. A physician will perform a clinical evaluation and patient interview and may order lab testing and medical imaging. Together, these diagnostic tools can be used to rule out other medical conditions and provide an accurate diagnosis.


2. Lower Back Pain

While gout rarely affects the low back, experts suggest that a gout diagnosis be considered if low back pain is accompanied by fever and does not respond to other treatments. 3 Schorn C, Behr C, Schwarting A. [Fever and back pain--a case report of spinal gout]. Deutsche Medizinische Wochenschrift (1946). 2010 Jan;135(4):125-128. DOI: 10.1055/s-0029-1244828. (In these cases, an abscess or infection must also be ruled out.)

Gout in the low back may affect the lumbar spine and/or a sacroiliac joint. 4 Riddell CM, Elliott M, Cairns, AP. An Unusual "Gouty" Case of Back Pain and Fever. J Rheumatol October 2008 35(10):2076-2077 PMID: 18843766 , 5 Bang SY, Jeong JH, Joo KB, Jun JB, Sung YK. A Case of the Lumbar Spine Involvement and Sacroiliitis in a Patient with Gout. J Korean Rheum Assoc. 2009 Dec;16(4):318-322. https://doi.org/10.4078/jkra.2009.16.4.318 , 6 Mantle B, Gross P, Lopez-Ben R, Alarcón GS. Hip pain as the presenting manifestation of acute gouty sacroiliitis. J Clin Rheumatol. 2001 Apr;7(2):112-4. PubMed PMID: 17039107. , 7 Konatalapalli RM, Demarco PJ, Jelinek JS, Murphey M, Gibson M, Jennings B, Weinstein A. Gout in the axial skeleton. J Rheumatol. 2009 Mar;36(3):609-13. doi: 10.3899/jrheum.080374. Epub 2009 Feb 4. PubMed PMID: 19208604. The sacroiliac joints are located on either side of the pelvis between the sacrum and the ilium. Gout in these joints may result in low back pain and/or hip pain.

See Possible Causes of Sacroiliitis and SI Joint Pain

It is also possible for gout to affect the middle and upper spine. 8 Elgafy H, Liu X, Herron J. Spinal gout: A review with case illustration. World J Orthop. 2016;7(11):766-775. Published 2016 Nov 18. doi:10.5312/wjo.v7.i11.766 PMID: 27900275 When gout affects any part of the spinal column it can lead to pinched nerves and vertebral bone damage. 10 Wang W, Bhole VM, Krishnan E. Chronic kidney disease as a risk factor for incident gout among men and women: retrospective cohort study using data from the Framingham Heart Study. BMJ Open. 2015;5(4):e006843. Published 2015 Apr 13. doi:10.1136/bmjopen-2014-006843

Read more about Causes of Lower Back Pain on Spine-health.com.

3. Kidney Stones

Gout inflammation can occur when there is too much uric acid in the bloodstream. Normally, kidneys filter out uric acid from the blood, and the filtered uric acid is excreted from the body. If the kidneys cannot do their job, or if the body produces too much uric acid, uric acid crystals may build up and form kidney stones.

See Hyperuricemia - High Uric Acid Levels and Gout

Uric acid kidney stones account for 16.5% of all kidney stones. 9 Spivacow FR, Del Valle EE, Lores E, Rey PG. Kidney stones: Composition, frequency and relation to metabolic diagnosis. Litiasis renal: composición, frecuencia y su relación con diagnósticos metabólicos. Medicina (B Aires). 2016;76(6):343-348. PMID: 27959841 Kidney stones can be excruciatingly painful but are treatable. Untreated kidney stones can lead to kidney damage.

The relationship between kidney health and gout is documented in research. For example, large studies have found:

  • People who have chronic kidney disease are more likely to develop gout 10 Wang W, Bhole VM, Krishnan E. Chronic kidney disease as a risk factor for incident gout among men and women: retrospective cohort study using data from the Framingham Heart Study. BMJ Open. 2015;5(4):e006843. Published 2015 Apr 13. doi:10.1136/bmjopen-2014-006843
  • People who had advanced chronic kidney disease may be twice as likely to also have gout 11 Stack AG, Johnson ME, Blak B, Klein A, Carpenter L, Morlock R, Maguire AR, Parsons VL. Gout and the risk of advanced chronic kidney disease in the UK health system: a national cohort study. BMJ Open, 2019; 9 (8): e031550 DOI: 10.1136/bmjopen-2019-031550

For some people, gout may be a sign of kidney disease and vice versa.

4. Wrist Pain

People who experience gout-related wrist pain typically have polyarticular gout, meaning gout affects more than one joint. Gout pain appearing only in the wrist is rare. 12 Jacobs CL, Stern PJ. An unusual case of gout in the wrist: the importance of monitoring medication dosage and interaction. A case report. Chiropr Osteopat. 2007;15:16. Published 2007 Oct 9. doi:10.1186/1746-1340-15-16 PMID: 17922921

An accurate gout diagnosis can be elusive when symptoms occur in a joint that is less susceptible to uric acid deposits. When symptoms appear in the wrist, a health care provider may use ultrasound and aspiration to arrive at an accurate diagnosis.

  • Ultrasound can help a physician identify areas where uric acid crystals have deposited in wrist joints’ cartilage. 13 Amorese-O'Connell L, Gutierrez M, Reginato AM. General Applications of Ultrasound in Rheumatology Practice. Fed Pract. 2015;32(Suppl 12):8S-20S. PMID: 30766105 , 14 Klauser AS, Halpern EJ, Strobl S, et al. Gout of hand and wrist: the value of US as compared with DECT. Eur Radiol. 2018;28(10):4174-4181. DOI: 10.1007/s00330-018-5363-9
  • Aspiration involves using a needle and syringe to draw out excess fluid from a joint. A lab analysis can identify any uric acid crystals in the aspirated fluid.

Aspiration may be appropriate if the wrist is swollen. It is done using ultrasound to ensure accurate placement of the needle.

See The Joint Aspiration Procedure

Other joints that are less often affected by gout include the elbow as well as joints in the fingers.1 Gout typically affects joints in the lower extremities. 2 Efthimiou, Petros. (2020). Absolute Rheumatology Review. 10.1007/978-3-030-23022-7.

5. Bumps Under the Skin (Tophi)

People with chronic gout can develop bumps under the skin near a joint. These bumps, called tophi, can be seen and felt.

Tophi develop when excess uric acid crystals collect together and form small, chalky nodules. Tophi usually appear on joints, particularly the toes, knuckles, knees, and elbows, but they can occur anywhere in the body, including the spinal canal.

Tophi may develop if gout is untreated or undertreated for many years. Most tophi are painless and annoying. In many instances, tophi can be dissolved and completely disappear with the help of medication to lower urate levels in the blood.

If left untreated, tophi can get bigger and more numerous, leading to complications. Potential complications include 15 Słowińska I, Słowiński R, Rutkowska-Sak L. Tophi - surgical treatment. Reumatologia. 2016;54(5):267-272. doi: 10.5114/reum.2016.63819 :

  • A decrease in a joint’s ability to bend and straighten
  • Ulcerations (sores) and necrosis (tissue death) in the skin, where the tophi cause the skin to stretch or break
  • Infection, particularly for people who have large, long-lasting ulcers 16 Xu J, Zhu Z, Zhang W. Clinical characteristics of infectious ulceration over tophi in patients with gout. J Int Med Res. 2018;46(6):2258-2264. doi: 10.1177/0300060518761303
  • Compression of nearby nerves, which is uncommon but can happen when gout occurs in the spine and—more rarely—in the wrist and elbow 17 Luo PB, Zhang CQ. Chronic carpal tunnel syndrome caused by covert tophaceous gout: A case report. World J Clin Cases. 2018;6(9):279-283. doi: 10.12998/wjcc.v6.i9.279 , 18 Akizuki S, Matsui T. Entrapment neuropathy caused by tophaceous gout. J Hand Surg Br. 1984;9(3):331-332. DOI: 10.1016/0266-7681(84)90054-8

A doctor may recommend surgical removal if the tophi are large and painful or risk causing complications.


Get an Accurate Diagnosis and Treatment

While gout attack symptoms do resolve on their own, people are advised to seek medical treatment. If left untreated, gout can become chronic and cause lasting joint damage.

Diagnosis begins with a clinical exam and interview. Patients are encouraged to be honest with their health care providers about their eating, drinking, and other lifestyle habits. This honesty can be helpful both for diagnosing gout and creating a treatment plan. Diagnosis may also involve blood tests, urine tests, and medical imaging, such as x-rays and ultrasound.

See Gout Diagnosis

Treatment typically involves advice to avoid alcohol and certain foods known to trigger gout, such as foods and drink high in sugar, seafood, red meat, and organ meats. 19 Gout. Centers for Disease Control and Prevention. Page last reviewed January 28, 2019. Accessed July 14, 2020. https://www.cdc.gov/arthritis/basics/gout.html Medications to lower urate levels in the blood—which can lead to gout attacks—are often recommended. Losing excess weight is another effective way to reduce the risk of a gout attack and chronic gout. 20 Nielsen SM, Bartels EM, Henriksen M, et al. Weight loss for overweight and obese individuals with gout: a systematic review of longitudinal studies. Ann Rheum Dis 2017; 76: 1870–1882. DOI: 10.1136/annrheumdis-2017-211472

See Gout Treatment

Dr. Jill Crosson is a family medicine and sports medicine physician at OAA Orthopaedic Specialists in Allentown, PA. She specializes in non-operative orthopedics and sports medicine injuries. She has several years of clinical experience treating people of all ages who have fractures, dislocations, strains and sprains, osteoarthritis, concussions, and more.