The Four Stages of Gout and the Early Warning Signs You Should Never Ignore
Gout is the most common form of inflammatory arthritis, and despite its reputation as a condition of sudden, intense pain in the big toe, it is a complex disease that progresses through several distinct stages. It develops when uric acid builds up in the bloodstream and forms sharp, needle-like crystals within the joints and surrounding tissues. These crystals trigger severe inflammation, redness and swelling.
While gout often begins in the big toe, it can also affect the ankle, midfoot, knee, wrist and fingers. Because its symptoms can mimic other arthritic conditions, recognising the earliest signs and understanding how gout progresses is essential for seeking the right treatment at the right time.
Below is a clear guide to the four stages of gout, the warning signs to look out for and how to prevent long-term damage.
Stage One: Asymptomatic Gout
The process begins long before any joint becomes painful. Uric acid is a natural waste product formed when the body breaks down purines. These are found in our own tissues and in certain foods, particularly red meat, organ meats, game, shellfish and alcoholic drinks.
Under normal circumstances, uric acid dissolves in the blood, passes through the kidneys and is removed in urine. However, if the body produces excess uric acid or the kidneys struggle to clear it efficiently, levels can rise. This state is known as hyperuricaemia.
Many people with raised uric acid experience no symptoms at all, but for others it marks the beginning of the gout cycle. Although silent, this stage is important because crystals may already be forming in joint spaces.
Stage Two: Acute Gout (The Gout Attack)
An acute gout attack is often the first time a person realises something is wrong. When uric acid levels become too high, crystals escape into the joint cavity and trigger intense inflammation.
A gout attack typically presents with:
Sudden, severe pain, often at night
Extreme tenderness; even a bedsheet touching the area can feel unbearable
Warmth and visible inflammation
These episodes can last anywhere from several days to a few weeks.
To confirm gout, a clinician may examine joint fluid under a microscope to identify uric acid crystals. This is the definitive method of diagnosis and helps distinguish gout from other conditions with similar symptoms, such as calcium pyrophosphate deposition disease (CPPD), also known as pseudogout.
Acute treatment focuses on reducing inflammation and pain. Longer-term management targets uric acid levels using lifestyle adjustments and medications that either limit uric acid production or improve excretion.
Stage Three: Intercritical Gout (The Interval Phase)
Following an attack, symptoms may completely disappear for months or even years. This symptom-free period is known as intercritical gout.
However, the absence of pain does not mean the condition has resolved. Uric acid may continue to accumulate, silently increasing the risk of another attack. Many patients find that flare-ups become more frequent and more severe over time if uric acid levels are not well controlled.
During this stage, treatment may include:
Uric-acid lowering medication
Maintaining a healthy weight
Drinking adequate water to support kidney function
A low-purine diet to reduce the burden of uric acid production
Maintaining a healthy diet especially during festive periods such as Christmas
Consistent management at this point can prevent the condition progressing to its most damaging stage.
Stage Four: Chronic Tophaceous Gout
If gout remains untreated or undertreated for many years, it can progress to chronic tophaceous gout. This advanced stage is characterised by the formation of tophi, which are firm, chalk-like deposits of urate crystals.
Tophi may appear:
Under the skin as lumps or nodules
Within joints
In cartilage and bone
Around protective bursae
Over time, these deposits can restrict movement, deform joints, and cause persistent pain. They may also ulcerate or become infected. Kidney stones and chronic kidney problems are more likely at this stage.
Fortunately, with modern treatment, most people never reach chronic tophaceous gout. Persistent use of urate-lowering therapy can reduce complications and may even shrink or fully resolve existing tophi.
Experiencing a Gout Attack in Your Foot or Big Toe? We Can Help Immediately
If you are currently suffering from a painful, swollen big toe or foot and suspect a gout attack, early intervention can dramatically reduce your discomfort. Our podiatry clinic offers ultrasound-guided steroid injections into the foot for a gout attack, a precise treatment that targets inflammation at its source and provides rapid relief from acute symptoms.
Contact our Birmingham podiatry clinic us today to book an urgent appointment and get back on your feet comfortably and confidently.
