What Happens

Gout usually develops after a number of years of buildup of uric acid crystals in the joints and surrounding tissues. A gout attack usually starts during the night with moderate pain that grows worse. A gout attack typically causes pain, swelling, redness, and warmth (inflammation) in a single joint, most often the big toe (this symptom is called podagra), followed by the eventual disappearance of all symptoms.

• Most gout attacks stop after about a week.
• Mild attacks may stop after several hours or last for 1 to 2 days. These attacks are often misdiagnosed as "tendinitis" or "sprain" even though there was no trauma or overuse.
• Severe attacks may last up to several weeks, with soreness lasting for up to 1 month.
• Many people have a second attack of gout within 6 months to 2 years after their first attack, but there may be intervals of many years between attacks. If untreated, the frequency of attacks usually increases with time.

There are three stages of gout.¹ Many people never experience the third stage.

First stage: High blood uric levels

• The uric acid level in the blood may be higher than normal, but there are no symptoms of gout.
• High uric acid in the blood (hyperuricemia) may never progress beyond this stage, and symptoms of gout may never develop.
• Some people may have kidney stones before having their first attack of gout.

Second stage: Episodes of acute gouty arthritis separated by periods without symptoms

• This stage is also called intercritical or interval gout.
• Uric acid crystals begin to form in the joint fluid, usually in one joint—most commonly the big toe—and the body often responds with a sudden inflammatory reaction: a gout attack.
• Although the big toe is the most common site for a gout attack, gout may develop in other joints, including the knee, ankle, and joints in the foot, wrist, and fingers.
• After the gout attack is over, the affected joint and surrounding tissues feel normal within days until the next attack, which often occurs within 2 years.
• For many people this period becomes progressively shorter as attacks occur more often. Later attacks may be more severe, last longer, and involve more than one joint.

Third stage: Chronic tophaceous gout

• If gout symptoms have occurred off and on without treatment for several years, they may become ongoing (chronic) and frequently affect more than one joint. There may no longer be periods of time between attacks. This stage of gout is frequently confused with other forms of arthritis, most commonly osteoarthritis.
• By this time, enough uric acid crystals have accumulated in the body to form gritty nodules called tophi. When located just under the surface of the skin, these deposits are usually firm and movable. The overlying skin may be thin and red. Tophi that are very near the skin may appear cream-colored or yellow.
• At first, tophi are usually found on or near the elbow, over the fingers and toes, or on the outer edge of the ear.
• If the condition progresses without treatment, tophi may form in the cartilage of the external ear or the tissues around the joint (bursae, ligaments, and tendons), resulting in pain, swelling, redness, and warmth (inflammation). Progressive crippling and destruction of cartilage and bone is possible.
• This stage of gout is uncommon because of advances in the early treatment of gout.