Foot and Ankle Characteristics in Gout: A Systematic Review

Kerry Bendell1 MSc, Brunilda Agalliu2 BSc(Hons), Simon Otter2,3* PhD

1Podiatry Department Sussex Community NHS Foundation Trust, Durrington Health Center, BN13 2RX 2School of Sport & Health Science, University of Brighton, 49 Darley Rd, Eastbourne, BN20 7UR, UK 3Centre for Regenerative Medicine and Devices, University of Brighton, Lewes Rd, Brighton, BN2 4AT

Objectives: Gout has a predilection for the foot and ankle, but the impact of gout has limited presence in the literature. The aim of this systematic review was to synthesise existing literature which has investigated the characteristics of foot and ankle involvement in gout; identifying consensus and highlighting areas for further study.

Methods: Studies were included if they were published in English and involved participants over 18 years of age with gout, and presented original findings relating to outcome measures associated with the foot and ankle. Methodological quality was assessed using a modified version of the Quality Index Tool.

Results. Of 707 studies identified, 16 met the inclusion criteria and were included in this review. The mean (range) quality score was 68.1% (38.9%-88.9%). Compared to controls, participants with gout reported higher levels of activity limitation, foot-related pain and disability and walked more slowly. Plain radiography, dual-energy Computer Tomography and diagnostic ultrasound consistently demonstrated pathological features of gout in the first metatarsophalangeal joint and Achilles tendon. However, studies offered limited quality, particularly around recruitment strategies, validity and potential impact of confounding factors, making definitive statements difficult.

Conclusions: This systematic review highlights the negative impact of gout on the structure and function of the foot and ankle causing significant impairment and disability. To effectively guide management, improvements in methodological quality are recommended.

Keywords: Gout, Foot, Ankle

Free Full-text PDF

How to cite this article:
Kerry Bendell, Brunilda Agalliu, Simon Otter. Foot and Ankle Characteristics in Gout: A Systematic Review. American Journal of Orthopedic Research and Reviews, 2021, 4:28. DOI: 10.28933/ajorr-2021-09-3005


1. Schlesinger N. Management of acute and chronic gouty arthritis. Drugs. 2004;64(21):2399-416
2. Towiwat, P., Chhana, A. & Dalbeth, N. The anatomical pathology of gout: a systematic literature review. BMC Musculoskelet Disord 2019 20, 140
3. Yokose C, Dalbeth N, Wei J, Nicolaou S, Simeone FJ, Baumgartner S, et al. Radiologic evidence of symmetric and polyarticular monosodium urate crystal deposition in gout – A cluster pattern analysis of dual-energy CT. Seminars in Arthritis and Rheumatism. 2019;(19):30120-9.
4. Schumacher HR, Wortmann RL. Monosodium urate crystal deposition arthropathy part I: review of the stages and diagnosis of gout. Johns Hopkins Advanced Studies in Medicine. 2005;5(3):133-8.
5. Yao Q, Tian W, Qiu L. High-resolution ultrasound images in gouty arthritis to evaluate relationship between tophi and bone erosion. Future Generation Computer Systems. 2019;98:131-4.
6. Rome K, Survepalli D, Sanders A, Lobo M, McQueen FM, McNair P, et al. Functional and biomechanical characteristics of foot disease in chronic gout: a case-control study. Clinical Biomechanics. 2011;26(1):90-4.
7. Dalbeth N, Kalluru R, Aati O, Horne A, Doyle AJ, McQueen FM. Tendon involvement in the feet of patients with gout: a dual-energy CT study. Annals of the Rheumatic Diseases. 2013;72(9):1545-8.
8. Stewart S, Dalbeth N, Vandal AC, Rome K. The first metatarsophalangeal joint in gout: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2016;17(69):1-15.
9. Petty HR, Rathod-Mistry T, Menz HB, Roddy E. Foot structure, pain and functional ability in people with gout in primary care: cross-sectional findings from the Clinical Assessment Study of the Foot. Journal of Foot and Ankle Research. 2019;12(8):1-9.
10. Stewart S, Dalbeth N, Otter S, Gow P, Kumar S, Rome K. Clinically-evident tophi are associated with reduced muscle force in the foot and ankle in people with gout: a cross-sectional study. Journal of Foot and Ankle Research. 2017;10(25):1-7.
11. Roddy E, Muller S, Rome K, Chandratre P, Hider SL, Richardson J, et al. Foot problems in people with gout in primary care: baseline findings from a prospective cohort study. Journal of Foot and Ankle Research. 2015;8(31):1-11.
12. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology and Community Health. 1998;52(6):377-84.
13. Stewart S, Brenton-Rule A, Dalbeth N, Aiyer A, Frampton C, Rome K. Foot and ankle characteristics in systemic lupus erythematosus: a systematic review and me-ta-analysis. Seminars in Arthritis and Rheumatism. 2018;48(5):847-59.
14. Poratt D, Rome K. Surgical management of gout in the foot and ankle: a systematic review. Journal of the American Podiatric Medical Association. 2016;106(3):182-8.
15. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews. 2015;4:1.
16. Bursill D, Taylor WJ, Terkeltaub R, et al Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) consensus statement regarding labels and definitions of disease states of gout Annals of the Rheumatic Diseases 2019;78:1592-160
17. Carroll M, Dalbeth N, Allen B, Stewart S, House T, Boocock M, et al. Ultrasound characteristics of the Achilles tendon in tophaceous gout: a comparison with age- and sex-matched controls. The Journal of Rheumatology. 2017;44(10):1487-92.
18. Dalbeth N, Aati O, Kalluru R, Gamble GD, Horne A, Doyle AJ, et al. Relationship between structural joint damage and urate deposition in gout: a plain radiography and dual-energy CT study. Annals of the Rheumatic Diseases. 2015;74(6):1030-6.
19. Stewart S, Dalbeth N, Vandal AC, Rome K. Characteristics of the first metatarsophalangeal joint in gout and asymptomatic hyperuricaemia: a cross-sectional obser-vational study. Journal of Foot and Ankle Research. 2015;8(1):41-9.
20. Stewart S, Dalbeth N, Vandal AC, Allen B, Miranda R, Rome K. Are ultrasound features at the first metatarsophalangeal joint associated with clinically-assessed pain and function? A study of people with gout, asymptomatic hyperuricaemia and normouricaemia. Journal of Foot and Ankle Research. 2017;10(22):1-8
21. Carroll M, Boocock M, Dalbeth N, Stewart S, Rome K, Frampton C. Ankle joint function during walking in tophaceous gout: a biomechanical gait analysis study. Gait & Posture. 2018;63:150-3.
22. Rome K, Erikson K, Otene C, Sahid H, Sangster K, Gow P. Clinical characteristics of foot ulceration in people with chronic gout. International Wound Journal. 2014;13(2):209-15.
23. Sapsford M, Gamble GD, Aati O, Knight J, Horne A, Doyle AJ, et al. Relationship of bone erosion with the urate and soft tissue components of the tophus in gout: a dual energy computed tomography study. Rheumatology (Oxford, England).2017;56(1):129-33.
24. Wolfe F, Michaud K, Pincus T. Development andvalidation of the health assessment questionnaire II: a revised version of the health assessment questionnaire, Arthritis Rheum. 50 (2004) 1740–1751.
25. Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol. 1991;44:561–570.
26. Helliwell P, Reay N, Gilworth G, Redmond A, Slade A, Tennant A, Woodburn J. Development of a foot impact scale for rheumatoid arthritis. Arthritis Rheum. 2005 Jun 15;53(3):418
27. Stewart S, Mawston G, Davidtz L, Dalbeth N, Vandal AC, Carroll M, et al. Foot and ankle muscle strength in people with gout: a two-arm cross-sectional study. Clinical Biomechanics. 2016;32:207-11.
28. Stewart S, Morpeth T, Dalbeth N, Vandal AC, Carroll M, Davidtz L, et al. Foot-related pain and disability and spatiotemporal parameters of gait during self-selected and fast walking speeds in people with gout: a two-arm cross sectional study. Gait & Posture. 2016;44:18-22
29. Garrow AP, Papageorgiou AC, Silman AJ, Thomas E, Jayson MIV, Macfarlane GJ. Development and validation of a questionnaire to assess disabling foot pain. Pain. 2000;85:107–13.
30. Garrow AP, Papageorgiou A, Silman AJ, Thomas E, Jayson MI, Macfarlane GJ. The grading of hallux valgus. The Manchester Scale. J Am Podiatr Med Assoc. 2001 91(2):74-8
31. Stewart S, Dalbeth N, Vandal AC, Rome K. Spatiotemporal gait parameters and plantar pressure distribution during barefoot walking in people with gout and asymptomatic hyperuricemia: comparison with healthy individuals with normal serum urate concentrations. Journal of Foot and Ankle Research. 2016;9:15.
32. Stewart S, Dalbeth N, Vandal AC, Allen B, Miranda R, Rome K. Ultrasound features of the first metatarsophalangeal joint in gout and asymptomatic hyperuricemia: comparison with normouricemic individuals. Arthritis Care & Research. 2017;69(6):875-83.
33. Otter SJ, Payne C, Jones A-M, Webborn N, Watt P, Differences in Achilles tendon stiffness in people with gout BMC Musculoskeletal disorders 2020 21 658.
34. Roddy E, Mallen CD, Doherty M. Gout. The British Medical Journal. 2013;347(5648):1-7
35. Karlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983 May;16(1):87-101
36. Kersten P, White PJ, Tennant A. Is the pain visual analogue scale linear and responsive to change? An exploration using Rasch analysis. PLoS One. 2014 Jun 12;9(6)
37. Budiman-Mak E, Conrad KJ, Mazza J, Stuck RM. A review of the foot function index and the foot function index – revised. J Foot Ankle Res. 2013 Feb 1;6(1):5.
38. Carter K, Tannous C, Walmsley S, Rome K, Turner DE. Linking the effect of psoriatic arthritis-related foot involvement to the Leeds Foot Impact Scale using the In-ternational Classification for Functioning, Disability and Health: a study to assess content validity. J Foot Ankle Res. 2020 Aug 24;13(1):52.
39. ten Klooster PM, Vonkeman HE, Oude Voshaar MAH, Bode C, van de Laar MAFJ. Experiences of gout-related disability from the patients’ perspective: a mixed methods study. Clinical Rheumatology. 2014;33(8):1145-54.
40. Chhana A, Callon KE, Dray M, et al. Interactions between tenocytes and monosodium urate monohydrate crystals: implications for tendon involvement in gout Ann Rheum Dis 2014;73:1737–1741
41. Naredo E, Uson J, Jimenez-Palop M, Martinez A, Vicente E, Brito E, et al. Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Annals of the Rheumatic Diseases.2014;73(8):1522-8
42. Costantino F, Carmona L, Boers M, Backhaus A, Balient PV, Bruyn GA, et al. EULAR recommendations for the reporting of ultrasound studies in rheumatic and musculoskeletal diseases (RMDs) Annals of the Rheumatic Diseases 2021;80:840-847.
43. Roddy E, Zhang W, Doherty M. Are joints affected by gout also affected by osteoarthritis? Annals of the rheumatic diseases. 2007;66(10):1374-7.
44. Arnold JB, Halstead J, Grainger AJ, Keenan A-M, Hill CL, Redmond AC Foot and leg muscle weakness in people with midfoot osteoarthritis Arthritis Care & Research 2021 73 (6) 772-780
45. Roddy E, Thomas MJ, Marshall M, Rathod T, Myers H, Menz HB, et al. The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot. Annals of the Rheumatic Diseases. 2013;74(1):156-63.
46. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TsF. Preliminary criteria for the classification of the acute arthritis of primary gou. Arthritis and Rheu-matology. 1977;20(3):895-900.
47. Malik A, Schumacher HR, Dinnella JE, Clayburne GM. Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis. Journal of Clinical Rheumatology. 2009;15(1):22-4.
48. Vargas-Santos AB, Taylor WJ, Neogi T, Gout classification criteria: update and implications Current Rheumatology Reports 216 18 (7) 46
49. Gurney JK, Kersting UG, Rosenbaum D. Dynamic foot function and morphology in elite rugby league athletes of different ethnicity. Applied Ergonomics. 2009;40(3):554-9.
50. Winnard D, Wright C, Taylor WJ, Jackson G, Te Karu L, Gow PJ, et al. National prevalence of gout derived from administrative health data in Aotearoa New Zealand. Rheumatology (Oxford). 2012;51 (5):901-9.

Terms of Use/Privacy Policy/ Disclaimer/ Other Policies:
You agree that by using our site, you have read, understood, and agreed to be bound by all of our terms of use/privacy policy/ disclaimer/ other policies (click here for details).

This work and its PDF file(s) are licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.