Gout: Why Uric Acid Chooses the Big Toe

Gout is a type of arthritis in which joint pain occurs suddenly and can be very severe. The cause is an excess of uric acid in the blood: it forms crystals around the joints, and it is these crystals that cause the pain. The big toe is most often affected first.

Uric Acid and Urate Crystals

Imagine pouring sugar into tea: when there is too much, it settles as crystals — in the same way, when uric acid is in excess in the blood, it forms urate crystals around the joints, which causes pain. Insufficient elimination by the kidneys is the main cause of hyperuricemia (about 90%).

Many people have hyperuricemia, but gout develops in about 10% of them, and the risk depends on the degree of hyperuricemia.

Why the Big Toe Is Affected First

The classic location is the joint at the base of the big toe: about 50% of cases. Gout also affects other joints of the feet, ankles, hands, elbows, or knees.

An attack looks like this: sudden severe joint pain, with the skin over the joint hot, swollen, and red — on dark skin, redness is less noticeable. Without treatment, an attack lasts from one to two weeks, and subsequent attacks may be longer.

If gout symptoms appear for the first time or the usual treatment does not help, this is a reason to make an appointment with a family doctor — routinely, not as an emergency.

Call 103 or 112 immediately if the condition is life-threatening: suspected stroke or heart attack, serious injury.

Seek urgent medical attention (the same day) if sudden joint pain and swelling are increasing, and very high fever, a feeling of heat, chills or shivering, nausea, or inability to eat are added: this may be an infection inside the joint.

Risk Factors: Kidneys, Food, Heredity

Dietary causes account for about 12% of gout cases and are associated with alcohol, fructose-sweetened drinks, meat, and seafood: when processing fructose, the liver produces uric acid. Vegetables rich in purines (beans, peas, lentils, spinach) and pure proteins are not linked to gout.

Heredity matters: the SLC2A9, SLC22A12, and ABCG2 genes are associated with gout, and their variants can approximately double the risk.

Gout occurs more often in men, especially with age, and in women after menopause. The chance increases if there is:

• excess weight and alcohol in the diet;
• high blood pressure, high cholesterol, or diabetes;
• kidney disease;
• use of diuretics or blood pressure medications;
• previous surgery or joint injury.

An attack can be triggered by an illness with high fever, a large amount of alcohol or a very heavy meal, dehydration, joint injury, and certain medications. If you feel an attack coming on, see a doctor as soon as possible.

Diagnosis: Blood Test, Joint Fluid, Scanning

The family doctor asks about diet and alcohol and orders a blood test for uric acid levels. If the picture is unclear, the patient is referred to a rheumatologist: a sample of fluid is taken from the affected joint with a thin needle, and if this is not possible, scanning is ordered.

Distinguishing gout from an infection inside the joint is essential: an infection requires immediate medical care.

Complications: Tophi, Stones, Damaged Joints

If attacks recur over years and remain untreated, gout becomes chronic. The consequences are: joint damage, firm formations under the skin — tophi (more often on the ear auricles, fingers, and elbows; they are painful and interfere with daily life), kidney stones, and urate nephropathy. Chronic arthritis as a consequence occurs rarely.

Since the beginning of the 21st century, the number of gout cases has increased, affecting about 1–2% of the population of the West; this is thought to be related to metabolic syndrome, increasing life expectancy, and changes in diet. Historically, gout was called the "disease of kings" or the "disease of the wealthy."

In 1683, Thomas Sydenham described an attack that begins in the middle of the night around two o'clock with pain in the big toe and a sensation as if the joint had been doused with cold water. In 1679, Antonie van Leeuwenhoek first described uric acid crystals, and in 1848, Alfred Baring Garrod proved that excess uric acid in the blood causes gout.

This material is for reference: it explains the mechanism but does not replace consultation with a doctor who sees your joint, not a description.

This content is for reference and does not replace a doctor's consultation. Medical disclaimer