Why does my ankle hurt?
Figuring out why your ankle is throbbing can be a guessing game.
Was it from rolling your ankle in the backyard yesterday? Or could it be tendonitis from the extra miles you can this week?
Maybe it’s from gout, a type of arthritis sometimes known as “the disease of kings” (and queens) because only the monarchs of yesteryear could afford the food and drinks that are known to exacerbate its symptoms.
Gout cases have been on the rise in recent years due to the increasing obesity rate, although anyone can get gout. Just as the royalty’s diet was to blame for many gout symptoms recorded in history, our modern diets are one reason the disease is on the rise.
And while historically gout was associated with the big toe, the condition is becoming more common in other places—joints like the hands, foot, or ankle.
Diagnosing ankle symptoms isn’t always easy. Even some doctors mistake ankle pain for something other than gout.
“Patients are often misdiagnosed with sprains, cellulitis, and other disorders when gout is unrecognized due to both severe pain and appearance,” explains Victoria Seligman, MD, a rheumatologist with UCHealth Rheumatology Clinic Cherry Creek in Denver.
And while an ankle sprain, tendonitis, osteoarthritis, and other issues share similar symptoms with gout, there are some signs and symptoms that are clearly due to gout in the ankle.
Here’s how to know when your ankle symptoms are due to gout and how to treat them.
What is gout?
Gout is a form of inflammatory arthritis that is very painful. It happens when the body produces or holds on to too much uric acid.
If your parents or grandparents had bouts of gout, they may have passed genes on to you that cause your body to produce too much or not excrete uric acid as it should.
Uric acid is a byproduct of the breakdown of high-purine foods we eat, like red meat, certain seafood, high-sugar foods and drinks, and alcohol.
When uric acid builds up, tiny crystals that can cause unbearable pain take up residence in a joint of their choice. This is known as a gout attack or flare-up.
“Any joint can be affected by gout, though feet and ankles are probably the most commonly affected joints,” says Bernadette Siaton, MD, a rheumatologist at the University of Maryland Medical Center and assistant professor of medicine at the University of Maryland School of Medicine.
Symptoms of gout in the ankle
Gout symptoms are on a whole other level compared to a sprained ankle, cellulitis (a bacterial skin infection), tendonitis, or other ankle issues.
“The gout symptoms such as acute swelling/pain and erythema [redness] are typically much more severe,” says Dr. Seligman. “This is much different than chronic weakness or swelling.”
Seeking medical attention sooner than later is always recommended to get the pain under control.
Before we dive into the symptoms of ankle gout, know this: you shouldn’t use these symptoms to self-diagnosis ankle pain.
Always see a doctor when you have one of the symptoms or a combination of the following symptoms.
Gout pain can be excruciating. People often describe it as being stuck with tiny, sharp, hot knives. That’s an accurate description of what’s happening in the joint.
When uric acid builds up and breaks down, small, needle-like crystals of uric acid settle into the joint. They’re what cause the intense pain.
After diagnosing gout, a doctor will typically prescribe an OTC pain reliever like colchicine, which reduces gout pain, swelling, and inflammation when taken within the first 36 hours of an attack.
You might also take a nonsteroid anti-inflammatory drug (NSAID) like Motrin, Aleve, or Advil.
If you don’t tolerate NSAIDs or colchicine, your doctor may recommend a corticosteroid pill or injection.
Timing is of the utmost importance to manage the pain.
“Medications such as prescription steroids and colchicine and over-the-counter NSAIDs are most effective when started early in the attack,” says Dr. Siaton. “The best thing to do is realize that an attack is starting and seek care as soon as possible.”
Changes in the skin
Certain skin problems can indicate disease. During a gout flare-up, the skin over the ankle joint area is often a bright red.
Other gout indicators include shiny skin around the joint and skin that’s noticeably very warm to the touch.
People with gout frequently say the ankle area is painful and extremely sensitive to the touch.
Even a soft and light fabric on the skin can be excruciating.
Avoid putting any pressure on the ankle during the most-painful acute stage.
Swelling and stiffness
Google “ankle gout,” and you’ll immediately wish you hadn’t.
There are countless photos of people with massive swelling at the ankle.
Is it possible? Yes. But golf-ball-size swelling isn’t typical of an initial attack of ankle gout.
Uric acids create irritation and inflammation, but the result is not quite as big as the pictures you might find online.
“Those knobs are likely tophi, which are deposits of uric acid that stay chronically in patients with severe gout,” explains Dr. Seligman. “Swelling may last for a few days to a week in acute attack, though patients with severe disease start to develop intercritical gout [the time between gout flares] or symptoms and swelling that persist for longer and longer and, in the last stages, indefinitely.”
Many people report that their ankle joint will become stiff when a gout attack is setting in.
It may start with a dull ache that turns into severe stiffness.
Elevate the ankle on a pillow or footstool. If the ankle isn’t too sensitive, apply an ice pack (wrap it in a cloth first!) to the swollen area. Icing helps dull the pain and reduce swelling.
Pain, tenderness, and swelling can significantly limit the joint’s range of motion and ability to function.
Dr. Siaton says the pain can be so severe that a bedsheet touching the toe is painful. So it’s unlikely that walking around the house is tolerable at the height of the attack.
“Someone with a gout attack might have difficulty moving the ankle or walking,” says Dr. Siaton.
It may be too painful or even impossible to put weight on an affected foot or knee. Resting will help alleviate pain, swelling, and other symptoms.
Pain comes on suddenly and fiercely
Usually, when pain comes on suddenly, it’s something you can track—like twisting your ankle or tripping. But there’s no rhyme or reason with gout.
You may feel perfectly healthy, and out of nowhere, gout strikes. “The symptoms usually come on fairly abruptly and worsen very quickly,” says Dr. Siaton.
The worst pain usually occurs within the first 24 hours. As mentioned, NSAIDs can relieve pain, but they are usually more effective if taken as soon as the pain hits.
Pain that wakes you up
More often than not, gout flare-ups happen in the middle of the night, interrupting a peaceful slumber with intense pain.
“It’s true, gout attacks are more common overnight,” Dr. Seligman says. But exactly why is a bit of mystery.
One theory: “It has been postulated that this relates to cooler body temperature at night,” she says.
The foot is cooler because it is the farthest body part away from the heart.
At cooler temperatures, uric acid turns into crystals and could settle into a cool spot like the foot and ankle.
Other theories center on sleep disorders that cause less oxygen in the blood, such as sleep apnea.
Who gets ankle gout?
So why is this old disease coming back to life, and who is at risk for it?
Whether gout strikes your foot, ankle, hand, or other joint, the recent spikes in gout could be due in part to weight gain.
A March 2021 study published in Arthritis Research and Therapy revealed gaining weight through adulthood was associated with a higher risk of gout.
An earlier study, published last year in Arthritis & Rheumatology, discovered overweight people were 85 percent more likely to have higher levels of uric acid than people who were at a healthy weight. (Although, again, anyone can get it.)
Here are some other things that make you more likely to get gout:
- Genetics, especially if a first-degree relative has gout
- Being male
- Being postmenopausal—a decline in female sex hormones reduces protection against elevated uric acid levels
- Regularly eating and drinking high-purine foods, like veal, bacon, turkey, venison, liver, trout, codfish, anchovies, sardines, herring, haddock, scallops, muscles, liquor, beer, wine, and high-fructose beverages
- Having a chronic health condition, such as diabetes, congestive heart failure, and high blood pressure. Chronic kidney disease is a big risk factor because the kidneys don’t work efficiently to filter uric acid out of the body
- Taking medications that can lead to higher uric acid levels, such as diuretics and immunosuppressants
Certain ethnicities, especially people who are Black, have a higher prevalence of gout and are less likely to receive the proper care and treatment.
How does a doctor diagnose ankle gout?
Whether gout is in the ankle joint, foot, or hand, it is diagnosed with a combination of medical history, symptoms, and physical exam.
“A doctor might an order an X-ray to look for fracture or other injury,” says Dr. Siaton. “In someone with untreated, long-standing gout, certain findings, such as bone erosion, can be seen on the X-ray.”
Doctors can order a blood test to check for elevated uric acid levels, but they probably won’t do the test during a flare-up.
“It is not as helpful to check uric acid during a flare, as it is lower when the uric acid deposits in a joint during a flare,” Dr. Seligman.
Occasionally, fluid is drawn from a needle from the ankle joint to identify urate crystals.
How is gout managed?
Here’s the truth: there is no cure for gout, although there are many ways to treat it and prevent flare-ups.
Oddly enough, some people only have a gout flare-up once, while others have flare-ups more often.
So how might you avoid future flare-ups? It makes sense to avoid high-purine foods, but eating a purine-free diet is pretty hard to do.
And though elevated uric acids are a precursor to a gout attack, having high levels doesn’t mean you’ll automatically have an attack. Still, eating and drinking excessive amounts of high-purine foods isn’t good for anyone.
Following a healthy and safe diet may help reduce symptoms.
“As gout is also felt to have a relationship to metabolic disease in general, weight loss helps with disease prevention as well,” says Dr. Seligman.
A doctor may recommend prescription medications, such as colchicine, to manage uric acid levels and prevent future attacks. But colchicine can have unpleasant side effects, Dr. Seligman says, so lower doses may be advised when managing out.
Allopurinol (Lopurin, Zyloprim, and Uloric) are medicines that block uric acid might be used in conjunction with colchicine.
In addition to medication, you might want to try some of these natural remedies for gout.
Though there usually isn’t much warning a gout attack is on the way, there are steps you can take right away, which will make sure the treatment is most effective.
“With close rheumatologic or primary care follow-up, patients are educated to recognize early symptoms and use appropriate medications,” says Dr. Seligman says. “Early signs include pain and swelling that sometimes start before they go into full flare.”