Yes, you can get gout in your Achilles tendon, and it can easily be misdiagnosed as Achilles tendonitis. In this article, Maryke explains how you can tell the difference between a gout attack and tendonitis, how gout affects the Achilles tendon, and how to treat heel pain caused by gout. Remember, if you need help with an Achilles injury, you're welcome to consult one of our team via video call.
The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in most of our articles.
In this article:
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What is gout?
Gout is an extremely painful condition that occurs when urate crystals form in your joints or tendons, causing severe inflammation and swelling.
Why does this happen? Urate crystals form when you have very high levels of uric acid in your blood. Uric acid forms when your body breaks down purines – substances that are naturally found in your body and in some foods.
For most people, uric acid isn’t a problem – the body simply gets rid of it via their kidneys. But some people’s genetic make-up is such that their body isn’t very good at getting rid of it. Chronic diseases (like kidney disease) that affect your kidney function can also cause gout. When the uric acid concentration in the blood gets too high, those crystals that cause so much pain form.
How to tell the difference between Achilles tendonitis and gout
Family and medical history
If you’re getting gout attacks, someone else in your family probably also gets it, because in most people it’s a genetic thing. This is why we always ask our patients about their family history.
Now, just because your grandfather suffered from gout or you’ve had gout in the past doesn’t mean I’m immediately going to diagnose your Achilles pain as it being that. It’s also possible that the pain is caused by a proper Achilles tendinopathy and not by gout. I will just file this information in my mind as a clue and then check what else I find out during our conversation.
How the injury started
Achilles tendonitis is an overload injury. So, you only get it if you overdo an activity that uses your Achilles, for example a sudden increase in how much your walk or run, or a change in footwear (switching to flat shoes).
Gout, on the other hand, develops suddenly and without a clear link to activity. In fact, it is sometimes a lack of activity – such as sitting still for hours on a long-haul flight – that precedes a gout attack.
The symptoms
Gout usually causes an extreme inflammatory reaction. The affected area is often red, swollen, and warm to the touch. And the pain is quite extreme – it is painful to move the affected joint or tendon (in this case your ankle), it can keep you awake at night, and even contact with something as flimsy as a bedsheet can be painful.
Yes, Achilles tendonitis can also be very painful, but the pain behaves differently:
It doesn’t usually hurt when you’re just sitting around or sleeping, and it definitely won’t keep you awake.
It can feel super stiff and uncomfortable when you take your first few steps after sitting still or getting out of bed, but then the tendon usually warms up and walking becomes easier.
Wearing shoes where your heel is somewhat elevated (like most running shoes) can reduce your pain when you have Achilles tendonitis, because it reduces the strain on the tendon, whereas this won’t have any effect on pain caused by gout.
Also, Achilles tendonitis is not associated with redness, swelling, or the affected area feeling warm to the touch (although those might be signs of heel bursitis).
👉 If we suspect that you have gout, we will refer you to your doctor so that they can assess it.
How do you test for gout?
Your doctor can make the diagnosis by delving into the history (again, looking for the signs and symptoms discussed above) and ordering some blood tests. They typically test to see whether the uric acid levels in the blood are elevated.
The only problem is that research has found that for some people the blood test might come back showing low uric acid levels during an acute gout attack. So, the blood test isn’t 100% accurate and could be misleading during that period.
If your tendon shows obvious signs of inflammation (red, swollen, hot) despite a blood test coming back with low levels of uric acid, they might first prescribe medication (typically anti-inflammatory medication) to help your symptoms to settle down and then repeat the blood test.
Ultrasound scans can show up crystal deposits in the tendon. So, if your blood tests have come back negative, an ultrasound scan might be useful to help to establish a diagnosis.
If you also have a joint that is flared up, they may decide to draw some joint fluid and send that off for analysis. But this is usually only done in cases that are stubborn to treat or if they feel the diagnosis is unclear.
How to treat Achilles pain caused by gout
The first step is to get medication to calm the gout down – in most cases this will actually resolve the problem, and you may not need anything else.
Sometimes, you can actually have Achilles tendonitis in addition to gout. If that is the case, you should first sort out the acute gout attack and then you can start treating the tendonitis as normal. You can find a detailed discussion of the best treatments for Achilles tendonitis in this article.
Your doctor can also advise on things you can do to avoid future gout attacks, which may include changes to your diet and exercise habits.
Sometimes simple things can make a huge difference. My boyfriend is prone to gout, and he has found that sitting still for hours and not drinking enough water trigger gout much more consistently for him than the types of food and drink he consumes. I suspect the poor circulation from sitting still and the dehydration combine to cause increased uric acid levels.
Does gout damage the Achilles tendon?
Several studies have looked at how gout affects the Achilles tendon. The good news is that, despite being extremely painful, gout doesn’t seem to cause any structural damage to the tendon.
When researchers compared the Achilles tendons of people with gout with the tendons of people who didn’t suffer from it, they didn’t find significant differences in the tendon structures other than crystal deposits in the tendons of the gout group.
In a recent study, a group of researchers tested the stiffness of the Achilles tendons of people with gout vs. people without gout – you can do that with a special type of ultrasound machine. They found that the tendons of people with gout were less stiff. Several other studies have reported that people with Achilles tendonitis have reduced tendon stiffness, so this could be interpreted as evidence of an injured Achilles tendon.
However, we also know that people who do sport tend to have stiffer tendons than people who don’t. And unfortunately, the researchers did not report the activity levels of the participants in this study. So, it might be that the gout sufferers were less active because of their condition and that that was the reason for their tendons not being as stiff as those of the others, rather than the gout directly affecting the tendon stiffness.
How we can help
Need help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. All of us have a wealth of experience working with athletes across a broad variety of sports and ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
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