Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Gout and pseudogout are both crystal-induced arthropathies that produce acute, intensely painful joint inflammation — but the crystals, affected joints, treatments, and long-term management differ in important ways. Getting the diagnosis right matters.

The Crystal Difference

• Gout — caused by monosodium urate (MSU) crystal deposition; urate is the end product of purine metabolism; elevated serum uric acid (>6.8 mg/dL) leads to urate crystal precipitation in joint fluid
• Pseudogout — caused by calcium pyrophosphate dihydrate (CPPD) crystal deposition; CPPD crystals form in articular cartilage and synovial fluid; associated with calcium metabolism disorders, older age, and cartilage degeneration

Joint Involvement Differences

Gout: Classic podagra (big toe first MTP joint) occurs in 50–70% of first gout attacks. Other common gout sites: ankle, midfoot, knee, wrist, and fingers. More common in men; women typically develop gout after menopause.

Pseudogout: The knee is the most commonly affected joint (50% of attacks). Other common sites: wrist, ankle, elbow, and shoulder. Less commonly affects the first MTP joint (unlike gout). More evenly distributed between sexes; increases significantly with age (rare under 60, common over 80).

Presentation Differences

Both conditions produce: sudden onset of severe joint pain (often overnight), joint swelling, warmth, and erythema (redness), and low-grade fever. The attacks are clinically indistinguishable by history alone in many cases — diagnosis requires joint aspiration or imaging.

Diagnosis

Joint Aspiration (Gold Standard)

Synovial fluid analysis under polarized light microscopy definitively distinguishes gout from pseudogout:

• Gout crystals: Negatively birefringent (yellow under parallel polarized light), needle-shaped MSU crystals
• Pseudogout crystals: Positively birefringent (blue under parallel polarized light), rhomboid or rod-shaped CPPD crystals

Imaging

Gout: X-rays in chronic gout show characteristic “punched-out” erosions with overhanging edges (Martel’s sign); dual-energy CT (DECT) can identify urate deposits noninvasively.

Pseudogout: X-rays show chondrocalcinosis — calcification within the cartilage — particularly in the knee menisci, wrist triangular fibrocartilage, and pubic symphysis. This finding, when present, strongly suggests CPPD.

Treatment Differences

Acute attack treatment is similar for both: colchicine, NSAIDs, or corticosteroids (oral or intra-articular injection). Intra-articular cortisone injection is particularly effective for both conditions when a single joint is affected.

Long-term management differs significantly:

• Gout: Urate-lowering therapy (allopurinol or febuxostat) to maintain serum uric acid <6 mg/dL prevents future attacks and dissolves existing tophi; dietary modification (reduce purines, alcohol, fructose); adequate hydration
• Pseudogout: No urate-lowering therapy equivalent exists for CPPD; management focuses on treating acute attacks, addressing underlying metabolic disorders (hyperparathyroidism, hemochromatosis, hypomagnesemia), and managing the underlying osteoarthritis

Gout vs. Pseudogout — Expert Diagnosis in Michigan

Sudden joint pain and swelling in your foot? Our podiatrists accurately differentiate between gout and pseudogout to ensure you receive the right treatment from the start.

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Clinical References

1. Rosenthal AK, Ryan LM. Calcium pyrophosphate deposition disease. New England Journal of Medicine, 2016;374(26):2575-2584.
2. Dalbeth N, et al. Gout. The Lancet, 2021;397(10287):1843-1855.
3. Zhang W, et al. EULAR evidence based recommendations for gout diagnosis. Annals of the Rheumatic Diseases, 2006;65(10):1301-1311.

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.