12/29/2020    Joe Agostinelli, DPM

How do you most commonly treat acute gout?

I have read various responses as to this question
from well learned colleagues. So far, however, I
have not read about some “classic treatment“.
First of all, a good history, regular
radiographs, and physical evaluation of the great
toe joint should lead you to believe you have an
acute gouty attack.

A local or PT block, then an “aspiration” of the
joint fluid is then accomplished. You should see”
either a gouty synovial fluid aspirate or in the
rare case of a septic joint, the synovial fluid
murky with purulence. After aspiration of the
contents of the joint leaving the aspiration
needle in the joint, swap out with another
syringe for a local anesthetic/steroid injection
(provided it is not a septic joint).

This treatment should reveal immediate relief.
Synovial fluid analysis will cement your
diagnosis. However, just looking at the joint
fluid aspirate should tell you a lot. I remember
way back in podiatric medical college actually
visually examining the joint fluid and even
touching it to evaluate the joint fluid’s
consistency. Once you visualize gouty synovial
fluid or purulence from a joint aspirate, you
will never forget it! We all realize old
“orthopedic idioms “when in doubt, think of gout
“, “pus under pressure in a joint has to come
out“.

An acute gouty attack of any foot joint needs to
be aspirated. Patient history of the chief
complaint and clinical signs should lead you to
your differential diagnosis. Everything else you
do should confirm your diagnosis. It seems to me
that aspiration followed by steroidal anti-
inflammatory injection is the best treatment for
acute local gouty attack

Joe Agostinelli, DPM, Niceville, FL

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