Back Pain Doctor
Gout
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Gout is a form of inflammatory arthritis caused by uric acid crystals depositing in a joint, triggering sudden attacks of intense pain, swelling, heat and redness. Most often first in the big toe, but it can affect many joints. It develops when uric acid in the blood is persistently high. Attacks settle over days, but without treatment they tend to recur, become more frequent, and can eventually cause permanent joint damage and lumps called tophi.
An acute attack can closely resemble a joint infection, so a hot, swollen joint (particularly with fever or feeling unwell) needs prompt assessment. Diagnosis uses a uric acid blood test (interpreted carefully, as it can be normal during a flare) and, where needed, examination of joint fluid for crystals.
Management has two parts: settling the acute attack (an NSAID, low-dose colchicine or a corticosteroid), and (for recurrent gout, tophi or joint damage) long-term urate-lowering therapy using a treat-to-target approach, with allopurinol first-line (febuxostat or probenecid as alternatives). The Australian serum urate target is below 0.36 mmol/L, or below 0.30 mmol/L with tophi. Lifestyle measures help, and because gout is closely linked with cardiovascular and metabolic disease, it is also an opportunity to review blood pressure, weight, diabetes and medications. This is usually managed in general practice.
Common symptoms
- A sudden, very painful, red, hot, swollen joint, classically the big toe
- Pain so severe that even light touch or bedsheets are unbearable
- Attacks that often come on overnight and last several days
- Recurrent attacks, or lumps (tophi) around joints in longstanding gout
Evidence for twelve treatment options in gout
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
Education and lifestyle advice sit alongside urate-lowering treatment, not instead of it. The EULAR recommendations make education about the disease and its treatment, together with lifestyle advice including weight loss where appropriate, cutting back alcohol and sugary drinks, and regular exercise, an overarching principle of gout care, with urate-lowering treatment to keep uric acid below 360 µmol/L (Richette, Ann Rheum Dis 2017). The American College of Rheumatology guideline likewise recommends treating to a uric acid target and gives conditional recommendations on alcohol, diet and weight loss (FitzGerald, Arthritis Care Res 2020). The strongest trial evidence is for education and engagement: in a multicentre randomised trial of 517 people in UK general practice, nurse-led care built on individual education and shared decision making got 95% to target uric acid at two years against 30% with usual care, with fewer flares and fewer tophi (Doherty, Lancet 2018). That benefit came through better uptake of urate-lowering treatment; the exercise advice in these guidelines is general lifestyle guidance rather than the result of trials of an exercise programme in gout.
Pairing reviewed 2026-11-04.
Where it fits
This does not replace medical treatment. In gout, what prevents flares and joint damage is getting the uric acid level down and keeping it there, so assessment here is aimed at recognising the pattern, making sure that treatment is in place, and keeping you moving and loading the affected joints as flares settle.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Only if relevant
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Trigger-point injection reviews address confirmed myofascial pain and find heterogeneous, generally low-certainty results; they do not establish the technique as treatment for the underlying diagnosis. Condition reviewed: gout.
Evidence source: Debrosse et al., trigger-point injection systematic review (2022)
Pairing reviewed 2026-08-30.
Where it fits
For gout, this may be considered only when examination finds a separate tender muscle band reproducing part of the pain. It does not treat the primary pathology and is used to help movement or rehabilitation.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Guideline-backed, no trials
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Injecting corticosteroid into a gouty joint is standard practice that has never been put through a randomised trial. A Cochrane review looking for trials of corticosteroid injection in acute gout found none (Wechalekar, Cochrane Database Syst Rev 2013), and searches of PubMed in October and November 2026 for any randomised or controlled trial since, or any comparison of guided with unguided injection, found none. It rests on guidelines instead: the American College of Rheumatology strongly recommends colchicine, anti-inflammatories or corticosteroid (by mouth, into the joint or into muscle) for a flare (FitzGerald, Arthritis Care Res 2020), EULAR lists an injection into the joint among its first-line options (Richette, Ann Rheum Dis 2017), and Chinese guidelines prefer an injection into the joint over corticosteroid tablets for people who also have cardiovascular disease or diabetes (Li, Int J Rheum Dis 2025). In one uncontrolled study of this row's exact procedure, 21 people with an acute attack in the big toe joint had ultrasound-guided triamcinolone: pain fell by an average of 48 points out of 100 within 48 hours, with no adverse events and no comparison group (Kang, J Clin Ultrasound 2015).
Pairing reviewed 2026-11-05.
Where it fits
Useful for a single hot, swollen joint when tablets are unsuitable or have not settled it, once infection has been ruled out, which may mean taking fluid from the joint for testing first. It treats the flare, not the urate level that causes flares, so it is coordinated with your GP or rheumatologist and your long-term treatment, not used instead of it.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Not offered for this
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.
Pairing reviewed 2026-08-30.
Where it fits
Not offered for this.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Only if relevant
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Searched 27 October 2026: shockwave, shock wave, ESWT or pressure wave with gout, gouty, tophus, tophi or tophaceous, excluding kidney-stone records (2 records, neither a treatment study), and radial device terms with gout (0 records). The trial and review pass for this condition is named in the focused row. No study has tested radial shockwave in gout. Gout is treated by lowering urate and settling flares, and a pressure wave over an inflamed joint has no tested role in either.
Pairing reviewed 2026-10-27.
Where it fits
Considered only for a separate muscle or tendon problem alongside it, never over a joint that is flaring.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Only if relevant
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
A search of PubMed for shockwave terms with gout or gouty, and separately with tophus, tophi, tophaceous, crystal arthritis or monosodium urate, with a trial and systematic-review pass, found no study of shockwave as a treatment for gout: every record concerned kidney-stone lithotripsy or a different crystal disease. Gout is managed by lowering urate and settling flares, and shockwave has no tested role in either.
Pairing reviewed 2026-10-22.
Where it fits
Considered only for a separate mechanical problem alongside it.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Only if relevant
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.
Pairing reviewed 2026-08-30.
Where it fits
Not part of the plan here.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Not a gout treatment; flares reported
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
No study has tested PRP as a treatment for gout. A PubMed search in October 2026 pairing platelet-rich plasma with gout, tophi, urate and the other crystal arthritis terms returned 19 records, and none is a trial or a case series of PRP for a gouty joint. What the literature holds instead is reports of crystal arthritis set off by PRP given for something else: a first attack of gout in several joints after a PRP injection (Porter, Scand J Rheumatol 2023), a knee that swelled within an hour of PRP and was shown to contain pseudogout crystals, settling over two weeks (Andrews, Clin J Sport Med 2026), and a case series of pseudogout flares after PRP (Schroeder, PM R 2022). In a review of 225 people given PRP for knee osteoarthritis at three hospitals, those whose uric acid was poorly controlled were among those with marked pain and swelling afterwards; the report gives no figures for this (Chen, J Orthop Surg (Hong Kong) 2024). A platelet gel has also been used as a dressing on a gouty ulcer in a single case (Chen, Indian J Dermatol 2020), which is wound care and not joint treatment.
Pairing reviewed 2026-10-12.
Where it fits
Not a treatment for gout, which is managed by settling attacks and lowering uric acid with your GP or rheumatologist. PRP is considered only for a separate tendon or joint problem, between attacks, and patients are told that flares after PRP have been reported, particularly where uric acid is not well controlled.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Not a gout treatment
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
No study has tested prolotherapy as a treatment for gout. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose, hyperosmolar dextrose or regenerative injection therapy with gout, gouty, crystal arthritis or inflammatory arthritis, then randomised-trial and systematic-review passes) returned no trial, case series or case report of prolotherapy for a gouty joint; the records that matched were reviews of other injections that mention gout in passing.
Pairing reviewed 2026-10-17.
Where it fits
Not a treatment for gout, which is managed by settling attacks and lowering uric acid with your GP or rheumatologist. Prolotherapy is considered only for a separate ligament or tendon problem, between attacks, assessed on its own evidence.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Only if relevant
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
No trial has treated gout itself with hyaluronic acid. What the literature answers is the opposite question (whether a history of gout rules out viscosupplementation for osteoarthritis in the same joint) and the EUROVISCO consensus answers no: it supports intra-articular hyaluronic acid in knee osteoarthritis in people with a history of gout or calcium pyrophosphate deposition, while recommending against injecting during an active flare (Conrozier, Cartilage 2024). In calcium pyrophosphate disease, a different crystal arthritis, a systematic review of 22 studies and 403 patients found intra-articular hyaluronic acid associated with symptomatic improvement, but only in uncontrolled reports (Parperis, Semin Arthritis Rheum 2020).
Pairing reviewed 2026-09-12.
Where it fits
Not a treatment for gout, which is managed by lowering urate and settling attacks. Discussed only where a joint is left with established osteoarthritis between attacks, and not while a joint is flaring.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Only if relevant
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
Perineural dextrose evidence is concentrated in diagnosed peripheral compression neuropathies, particularly the upper limb; no direct evidence was identified for this diagnosis itself. Condition reviewed: gout.
Evidence source: Perineural dextrose for upper-limb entrapment neuropathy review (2025)
Pairing reviewed 2026-08-30.
Where it fits
For gout, perineural treatment may be considered only if a separate superficial neuropathic pain pattern is found on examination. It is not treatment of the primary diagnosis.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Hydrodissection evidence is concentrated in ultrasound-confirmed peripheral nerve entrapment, especially carpal tunnel syndrome; no direct evidence was identified for this diagnosis itself. Condition reviewed: gout.
Evidence source: Buntragulpoontawee et al., hydrodissection injectate review (2021)
Pairing reviewed 2026-08-30.
Where it fits
For gout, hydrodissection may be considered only if ultrasound and examination identify a separate compressed or tethered peripheral nerve. It is not treatment of the primary diagnosis.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
How is gout diagnosed?
How is an attack treated?
How are future attacks prevented?
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