How To Tell If Knee Pain Is Gout
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What Is Acute Gout
Acute gout is characterized by a sudden onset of severe throbbing and crushing pain, usually in a single joint . It is often described by the patient as the most severe pain ever experienced, and known clinically as excruciating pain. Pain reaches its maximum intensity within 5 hours of its onset. It can be as severe as to wake up the patient from their sleep in the middle of the night or in the early morning.
The affected joint is also tender to the touch, and may become sensitive even to the touch of clothing over the skin. Other features of acute gout include swelling of the joint and erythematous, warm, and shiny skin over the affected articulation. Most patients with acute gout show features of synovitis, bursitis, cellulitis, and tenosynovitis. In other words, the articulation and surrounding tissues go through a process of acute inflammation. This is especially the case when a bigger joint such as the knee is involved. In acute gout of the knee, the patient is usually pyretic, patient complains of malaise, and may feel disoriented and confused. When the acute attack is resolved, the skin over the affected joint is desquamated and itchy. Some patients experience cluster attacks in different joints than the primarily affected joint while some patients may experience milder episodes lasting for only a few days.
Treatment To Reduce Pain And Swelling
Gout is usually treated with anti-inflammatory medicine like ibuprofen.
If the gout does not improve after 3 to 4 days, you might be given steroids as tablets or an injection.
You should:
- take any medicine you’ve been prescribed as soon as possible, it should start to work within 3 days
- rest and raise the affected limb
- keep the joint cool apply an ice pack, or a bag of frozen peas wrapped in a towel, for up to 20 minutes at a time
- drink lots of water, unless advised not to by your GP
- try to keep bedclothes off the affected joint at night
Do not knock the joint or put pressure on it.
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Prevention Of Recurrent Attacks
Hyperuricemic therapy should be initiated in patients with frequent gout attacks, tophi or urate nephropathy. A low dosage of an NSAID or colchicine is effective in preventing acute gouty attacks. Hyperuricemic drug therapy should not be started until an acute attack of gouty arthritis has ended, because of the risk of increased mobilization of uric acid stores. A reasonable goal is to reduce the serum uric acid concentration to less than 6 mg per dL .
Uricosuric Drugs. These agents decrease the serum uric acid level by increasing renal excretion. Probenecid and sulfinpyrazone are used in patients who are considered underexcretors of uric acid. Uricosuric drugs should not be given to patients with a urine output of less than 1 mL per minute, a creatinine clearance of less than 50 mL per minute or a history of renal calculi. The physiologic decline in renal function that occurs with aging frequently limits the use of uricosuric agents.
Probenecid, in a dosage of 1 to 2 g per day, achieves satisfactory control in 60 to 85 percent of patients.23 It is important to note that the drug also blocks the tubular secretion of other organic acids. This may result in increased plasma concentrations of penicillins, cephalosporins, sulfonamides and indomethacin.
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Whats The Outlook For People With Gout
Untreated gout can lead to permanent joint damage. The buildup of uric acid in the joints and soft tissue is called tophus. Some people with gout can also develop other health problems, such as severe arthritis, kidney stones and heart disease. Its important to discuss your symptoms with a healthcare provider.
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What Causes Tophaceous Gout And Tophi Deposits
People with this kind of gout get tophi. Tophi are hard uric acid deposits that form beneath the skin. Tophi look like chalky lumps under the skin.
They can be found on or near the elbow, finger, or toe joints. Tophi can also appear on the outer part of the ear.
Tophi can destroy bone and cartilage, leading to joint damage and deformity, according to the Cochrane Database of Systematic Reviews.
They can swell during a gout attack and pop through the skin and become infected.
With treatment, tophi can dissolve and eventually disappear.
Not everyone with gout develops tophi.
Certain groups share a higher risk for tophaceous gout, according to the physician-run website UpToDate. Those at risk for tophaceous gout include:
- Organ transplant recipients who receive certain types of medication to prevent transplant rejection
- People who cant take uric-acid-lowering medicines
- Postmenopausal women, especially those taking a diuretic.
How Is Gout Diagnosed
In a clear-cut case, a primary care physician can make the diagnosis of gout with a high level of confidence. However, often there are two or more possible causes for an inflamed toe or other joint, which mimics some of the symptoms of gout, so tests to identify the presence of uric acid is performed.
Since the treatment for gout is lifelong, its very important to make a definitive diagnosis. Ideally, the diagnosis is made by identifying uric acid crystals in joint fluid or in a mass of uric acid . These can be seen by putting a drop of fluid on a slide and examining it using a polarizing microscope, which takes advantage of the way uric acid crystals bend light. A non-rheumatologist, when possible, can remove fluid from the joint by aspirating it with a small needle and send it to a lab for analysis. A rheumatologist is likely to have a polarizing attachment on their microscope at their office. Gout crystals have a needle-like shape, and are either yellow or blue, depending on how they are arranged on the slide .
Figure 11: Uric Acid Crystals Under Polarizing Light Microscopy
There are many circumstances where, however ideal it would be, no fluid or other specimen is available to examine, but a diagnosis of gout needs to be made. A set of criteria has been established to help make the diagnosis of gout in this setting .2
Table 1: Diagnosing gout when no crystal identification is possible
Ideally, 6 of 10 features will be present of the following:
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What Else Should I Ask My Healthcare Provider About Gout
Consider asking your healthcare provider:
- What is causing the gout?
- Do I have any joint damage?
- What can I do to prevent future attacks?
- Can any gout medications help me?
- How long will I need to take gout medications?
A note from Cleveland Clinic
Gout is a painful form of arthritis. Extra uric acid in your body creates sharp crystals in the joints, leading to swelling and extreme tenderness. Gout usually starts in the big toe but can affect other joints. Gout is a treatable condition, and the uric acid level can be decreased by medication and lifestyle changes. Talk to your healthcare provider about medications that can reduce uric acid levels. They can also discuss changes you can make to your diet and lifestyle to prevent and reduce gout attacks.
Last reviewed by a Cleveland Clinic medical professional on 11/15/2020.
References
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When To See A Healthcare Provider
Not everyone with gout will experience worsening symptoms or need urate-lowering therapy. With that being said, if you ignore symptoms or fail to take action to avoid attacks, you may end up causing yourself long-term harm.
People with gout will sometimes think that the prolonged absence of symptoms means that the disease has spontaneously disappeared. This is usually a fallacy. Unless the underlying cause of high uric acid levels is controlled, the disease can advance silently and reap irreversible harm.
For some guidance on talking with a medical professional about your gout, use our Healthcare Provider Discussion Guide below. It can help you start a conversation with your healthcare provider about symptoms, treatment options, and more.
Gout Healthcare Provider Discussion Guide
Get our printable guide for your next healthcare provider’s appointment to help you ask the right questions.
The following are reasons why you should definitely see a healthcare provider about your gout:
- This is your first attack. Even if treatment is not prescribed, you might benefit from lifestyle modifications to reduce the risk of future attacks.
- Your symptoms don’t improve after 48 hours or last for more than a week. If you are on therapy, this may be an indication that changes need to be made, including dietary and lifestyle interventions.
- You have a high fever. While a mild fever can accompany a gout attack, a high fever may be a sign of an infection.
The Link Between Gout And Chronic Kidney Disease
Theres a relationship between gout and chronic kidney disease.
Chronic kidney disease is a condition in which you slowly lose kidney function over time. The kidneys are important because they help remove waste products and urine from the body.
People with chronic kidney disease are at an increased risk for gout, and people with gout are at an increased risk for chronic kidney disease, says the National Kidney Foundation.
If the kidneys arent working properly, uric acid can build up in the body. Thats why kidney disease sometimes leads to high uric acid in the blood. High uric acid can cause gout.
One way that gout may contribute to chronic kidney disease is through kidney stones. People with recurrent kidney stones are at an increased risk for chronic kidney disease.
The National Kidney Foundation recommends that people with gout get checked for chronic kidney disease. Your doctor may take blood and urine samples to test for it.
Doctors commonly use two tests to help diagnose the condition. A simple blood test, called a GFR, measures how much blood your kidneys filter each minute. A urine albumin test, or ACR, can help detect kidney damage.
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How Gout Can Lead To Sleep Deprivation
Because gout attacks typically happen at night, recurrent attacks can wake you while you are sleeping. This constant awakening also disrupts rapid eye movement sleep, which is important for physical and emotional health.Once you are awake, the intense pain that follows can keep you from falling back to sleep, leading to sleep deprivation.
When Is Surgery Considered For Gout
The question of surgery for gout most commonly comes up when a patient has a large clump of urate crystals , which is causing problems. This may be if the tophus is on the bottom of the foot, and the person has difficulty walking on it, or on the side of the foot making it hard to wear shoes. An especially difficult problem is when the urate crystals inside the tophus break out to the skin surface. This then can allow bacteria a point of entry, which can lead to infection, which could even track back to the bone. Whenever possible, however, we try to avoid surgery to remove tophi. The problem is that the crystals are often extensive, and track back to the bone, so there is not a good healing surface once the tophus is removed. In some rare cases, such as when a tophus is infected or when its location is causing major disability, surgical removal may be considered.
Since it is hard to heal the skin after a tophus is removed, a skin graft may be needed. For this reason, we often try hard to manage the tophus medically. If we give high doses of medication to lower the urate level, such as allopurinol, over time the tophus will gradually reabsorb. In severe cases, we may consider using the intravenous medication pegloticase , since it lowers the urate level the most dramatically, and can lead to the fastest shrinkage of the tophus.
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How Can I Manage My Gout And Improve My Quality Of Life
Gout affects many aspects of daily living, including work and leisure activities. Fortunately, there are many low-cost self-management strategies that are proven to improve the quality of life of people with gout.
For gout in particular:
- Eat a healthy diet. Avoid foods that may trigger a gout flare, including foods high in purines , and limit alcohol intake .
CDCs Arthritis Program recommends five self-management strategies for managing arthritis and its symptoms. These can help with gout as well.
What Can Trigger A Gout Attack
Several things can cause the crystals to shake loose into your joint cavity, triggering an attack. These include:
- a knock or injury to the joint
- an illness that may make you feverish
- having an operation
- having an unusually large meal, especially a fatty meal
- drinking too much alcohol
- dehydration
- starting urate lowering therapy, especially at a high dose, or not taking your treatment regularly each day.
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When Should You Call Your Doctor
if you have:
- Severe pain in a single joint that comes on very quickly.
- Swollen, tender joints with warm, red skin over them.
Its important to see your doctor even if the pain from gout has stopped. The uric acid buildup that caused your gout attack may still be irritating your joints and could eventually cause serious damage. Your doctor can prescribe medicines that can prevent and even reverse the uric acid buildup.
How Is It Taken
Allopurinol is taken as a tablet once a day. It is usually better to take it just after eating and the tablet should be swallowed with water. It is important to drink plenty of water during the day because this will help you get rid of more urate through your kidneys.
Your dose of allopurinol may change over time, depending on the amount of urate in your body. Your doctor will monitor your urate levels with blood tests every 2-4 weeks, until they are sure that the dose that youre taking is high enough to reduce the amount of urate in your body.
You may need to remain on a lower dose if you have kidney or liver problems.
Your doctor may recommend that you do not start taking allopurinol until after an attack of gout has passed to avoid triggering further attacks. If this is not possible, it may be started when your inflammation is not too bad.
Allopurinol doesnt treat the immediate pain caused by attacks of gout. But its a long-term treatment to get rid of the urate crystals which causes gout attacks.
It is likely that you will need to take allopurinol for the rest of your life to manage your urate levels. You should keep taking allopurinol even if:
- you are experiencing more gout attacks, or it doesnt seem to help the pain and inflammation at first
- you stop having gout attacks stopping your treatment can cause urate crystals to form again, which will lead to more gout attacks.
- etoricoxib
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Stage : Intercritical Gout
After a first gout flare, 75 percent of people will have a second within a year but some people can go years before another attack, says Dr. Fields. The in-between stage is where a person has already had a gout flare but is presently not having any joint pain or swelling, he says. Almost all gout patients will go through this phase, since it is the nature of gout to have flares and then quiet down for a period of time before the next flare.
Even though it may seem like nothing is happening, this is the point in which patients should begin long-term treatment. Lowering uric acid levels with medication can prevent future gout flares and long-term complications that go with them.