Gout is a painful form of inflammatory arthritis caused by the body’s inability to process uric acid. This metabolic issue causes sharp, needle-like crystals to form and deposit in the joints, triggering sudden and severe attacks. While the joint at the base of the big toe is the most common site for a gout flare, the condition can affect many other joints. It is possible to get gout in your heel, although this presentation is less frequent than in the toe.
The Mechanism of Gout and Typical Sites
Gout originates with hyperuricemia, an abnormally high concentration of uric acid in the blood. Uric acid is a waste product created when the body breaks down purines, compounds found naturally in the body and in many foods. If the kidneys cannot efficiently excrete this excess uric acid, or if the body produces too much, the concentration rises. The acid can then no longer remain dissolved in the blood.
Once the uric acid concentration exceeds a certain threshold, it precipitates out of the solution to form monosodium urate crystals. These crystals settle in the joint spaces and surrounding soft tissues. The immune system recognizes these crystals as foreign invaders and launches an inflammatory response to eliminate them.
This inflammatory cascade causes the characteristic symptoms of a gout flare, including pain, swelling, and redness. The most frequent location for these crystals is the first metatarsophalangeal joint, at the base of the big toe, known as podagra. This preference is partly due to the lower temperature of the peripheral joints in the feet. Urate crystals are more likely to form in cooler environments.
Gout Manifestation in the Heel
While the big toe is the classic site, gout affects the heel and other midfoot structures. When gout manifests in the heel, it typically involves the small tarsal joints or the soft tissues surrounding the heel bone. The presentation can include the insertion point of the Achilles tendon. Here, the buildup of urate crystals can mimic or coexist with tendon inflammation.
Symptoms of a heel gout flare are similar to those in the big toe, but they are localized to the back of the foot. The pain is sudden, severe, and rapidly escalating, often reaching maximum intensity within 12 to 24 hours. The affected area becomes tender, swollen, and warm to the touch. The overlying skin may appear red or purplish.
The pain can make bearing weight or having the heel touched by a bedsheet difficult. Unlike other common causes of heel pain that might improve with movement, the pain from a gout attack remains severe and debilitating. These episodes typically resolve on their own within a few days to a few weeks, even without treatment. However, medical intervention is necessary to manage the symptoms.
Distinguishing Gout from Other Causes of Heel Pain
The sudden, severe pain of gout in the heel is often confused with other common foot conditions, making accurate diagnosis a challenge. Plantar fasciitis is the most frequent cause of heel pain and presents differently from a gout flare. Plantar fasciitis pain is localized to the bottom of the heel and is typically worst with the first steps in the morning or after rest. This pain often improves as the foot “warms up” with light activity.
In contrast, gout pain is often maximal at night and is relentlessly severe, without the temporary relief that movement might provide. The inflammatory signs are distinct. Plantar fasciitis involves inflammation of the ligament, but it rarely produces the redness, warmth, and swelling characteristic of a gout attack. The pain associated with gout is often described as incapacitating.
Another common cause of pain in the back of the heel is Achilles tendonitis, which involves inflammation of the tendon connecting the calf muscle to the heel bone. Achilles tendonitis pain is usually localized higher up on the back of the ankle and is related to activity or overuse. This pain often improves slightly with initial movement. A gout attack, even if affecting the Achilles tendon, presents as a much more inflammatory process, with pronounced redness, swelling, and tenderness not typical of simple tendonitis. Gout flares may also be accompanied by systemic signs such as a fever, which are not usually seen with plantar fasciitis or tendonitis.
Diagnosis and Acute Treatment of a Gout Flare
A healthcare provider will suspect gout based on the sudden onset of inflammatory symptoms, but a definitive diagnosis requires laboratory confirmation. The gold standard for diagnosing gout is joint fluid aspiration. A sample of fluid is drawn from the affected joint or surrounding tissue and examined under a microscope. The presence of monosodium urate crystals confirms the diagnosis.
While blood tests can measure uric acid levels, they are not always conclusive during an acute flare. The blood level may temporarily drop to a normal range while crystals are being deposited in the joint. Imaging tests, like ultrasound or dual-energy computed tomography (DECT), can visualize urate deposits. However, crystal analysis remains the most accurate diagnostic method.
Once a gout flare is confirmed, immediate treatment focuses on reducing inflammation and pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin or naproxen, are often the first-line treatment. They should be started within 24 hours of symptom onset for maximum effectiveness. Colchicine is another frequently used medication that acts as an anti-inflammatory agent. Systemic corticosteroids, administered orally or by injection, are also used to control inflammation when NSAIDs or colchicine are not suitable.