Gout in Shoulder: Symptoms and Relief Options

March 16, 2024

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While gout most famously strikes the big toe, this inflammatory arthritis can arise in any joint. The shoulders represent an uncommon site of acute gouty flares and urate crystal deposition. Appreciating the typical clinical features, risk factors and diagnostic approach for shoulder gout allows for prompt management.

Anatomy and Function of the Shoulder Joint

The shoulder joint comprises the articulation between the rounded head of the humerus bone and the shallow glenoid socket of the scapula. This ball and socket design allows impressive mobility at the expense of stability.

Numerous muscles, tendons and ligaments surround the shoulder joint, enabling and reinforcing its wide range of motion. These include the rotator cuff muscles along with the biceps tendon sheath.

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What Causes Gouty Inflammation in the Shoulder?

The pathophysiology provoking gout in the shoulders mirrors what drives it elsewhere in the body:

  1. Genetics and lifestyle factors lead to hyperuricemia – chronically elevated blood uric acid levels.
  2. Over months to years, monosodium urate crystals slowly deposit in cooler peripheral joints.
  3. Local factors then trigger acute inflammation – the crystals incite a fierce immune reaction involving white blood cells.

This sequence underlies the episodic, severe arthritis flares and joint changes classically seen. The shoulders represent an uncommon site, with few cases reported to date.

Symptoms of Gout Occurring in the Shoulder

When gout strikes the shoulder joint space, amenities or surrounding structures, patients experience:

  • Sudden, severe shoulder pain often waking one from sleep, with rapid crescendo over hours
  • Local swelling, redness and warmth around the shoulder and upper arm
  • Extreme tenderness hampering any movement or palpation of the shoulder
  • Stiffness and sharply limited range of motion – attempts worsen pain
  • Low grade fever, fatigue and malaise sometimes accompany joint symptoms

If untreated, an attack typically lasts 7-10 days before slowly resolving. Recurrences likely hit unless urate levels are adjusted.

Risk Factors for Developing Gout in Shoulder

Those especially vulnerable to gout in atypical locations like the shoulder share these predisposing traits:

  • Longstanding history of gout -recurrent attacks over many years
  • Allopurinol or probenecid use in suboptimal doses
  • Major joint trauma or surgery triggering the initial flare
  • Chronic kidney insufficiency impairing uric acid excretion
  • Obesity with diabetes and hypertension
  • Diuretic medication treatment
  • Family history suggesting genetic risk

Late middle age often serves as the backdrop when gout migrates beyond the feet. Awareness of associated conditions directs diagnostic suspicion.

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Physical Exam Findings and Imaging of Shoulder Gout

Identifying shoulder gout relies heavily on clinical acumen given limited testing findings early on:

Physical Examination

  • Local swelling and tenderness out of proportion to range of motion deficits
  • Adjacent joints appearing thickened or lumpy from tophus deposits over time
  • Warmth, redness and reduced shoulder mobility – mainly externally rotated

Imaging – X-rays, Ultrasound, CT, MRI Shoulder

  • Mild periarticular demineralization of bone seen on X-ray late
  • Widened joint space with bony erosions and subcortical cysts eventual
  • Sonography and advanced imaging reveal subtle tophus buildup in rotator cuff

Where clinical suspicion runs high, definitive diagnosis requires joint fluid analysis – microscopy visualizing needle aspirate loaded with white cells and needle-shaped monosodium urate crystals.

Available Treatment Avenues for Gout in Shoulder

Overall treatment strategies for shoulder gout echo those at other sites:

1. Flare Management – potently anti-inflammatory medications rapidly reduce symptoms to restore function and quality of life during attacks. Common drugs include oral steroids, colchicine and NSAIDs. Joint injections are also highly effective. These work alongside activity modification, alternating heat/ice and massage.

2. Hyperuricemia Control – once acute issues settle, long term lowering of blood uric acid prevents recurrence. Xanthine oxidase inhibitors achieve this, with allopurinol representing first-line. Febuxostat offers an alternative. Additional prophylaxis early on reduces risk of repeat attacks. Diet and medication adjustment also optimize associated comorbidities.

3. Referral to Specialist – rheumatology guidance ensures the above measures are instituted properly. Suboptimal gout care risks further joint damage and complications like kidney stones over time. Surgical debridement very uncommonly tackles refractory tophaceous disease destroying bone and tendon.

Can Shoulder Gout Increase Risk of Bursitis Too?

An inflammatory response provoked by urate crystals does make the shoulder area more prone to accompanying bursitis as collateral damage. Bursitis refers to inflammation affecting the numerous fluid-filled bursa sacs cushioning shoulder structures. Septic versions with overt infection require urgent intervention. Losing mobility from concurrent problems causes significant frustration which therapy directly addresses.

Takeaway Points

In summary, critical pearls regarding gout flares arising within the shoulder joint or surrounding tissues:

  • The shoulder represents an uncommon site of acute gout but still warrants consideration diagnostically
  • Middle aged men with predisposing factors and a prior gout history remain at highest risk
  • Clinical exam drives suspicion without reliance on unrevealing imaging this early on
  • Definitive diagnosis involves demonstrating urate crystals in aspirated fluid
  • Treatments target both the acute attack and long term hyperuricemia
  • Associated bursitis often compounds shoulder symptoms

Though rare, accurately identifying shoulder gout allows specific therapy preventing future joint damage and disability. Patients exhibiting features concerning for atypical gout deserve rheumatological referral for optimal care.

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Frequently Asked Questions

Can gout spread to the neck muscles as well as shoulder joints?

Yes, in advanced gout, urate crystal deposits called tophi can arise in the tendons and soft tissues around the shoulder such as the neck. Dense collections cause local swelling, stiffness and tenderness. These respond to systemic urate lowering therapy over months, with surgical release very rarely required.

If my elbow was the first joint affected by gout, could gout spread to my shoulders later?

Absolutely – gout frequently touches down in a newer seemingly random joint years after the initial attacks elsewhere. Given proximity and mechanical forces in play, the shoulder represents a logical subsequent site for recurrent gout after the elbow. Urate crystals likely already lie dormant there awaiting factors triggering symptomatic inflammation locally.

Is gout or arthritis more common in shoulders of older adults?

Upwards of 85% of community seniors show some osteoarthritic shoulder changes on imaging. So wear and tear shoulder arthritis outpaces inflammatory gout by orders of magnitude, despite sharing select symptoms. Nevertheless, atypical gout presentations do increase in frequency among older individuals with predisposing risks.

Can gout and rotator cuff tears produce nearly identical shoulder pain?

Yes the sudden onset severe shoulder discomfort reducing range of motion seen in both advanced rotator cuff tears and acute gouty arthritis poses diagnostic challenges. However classic gout being exquisitely tender, inflamed and frequently cured by joint aspiration helps distinguish it from cuff tears often requiring surgery.

If suspecting gout, should I request shoulder x-rays at the first doctor visit?

Likely not – Early on, plain films prove insensitive lacking findings to help secure a gout diagnosis. Clinical suspicion paired with joint aspiration crystal analysis confirms the diagnosis. However, later down the line, conventional radiography better conveys patterns of bone loss and erosion unique to chronic gouty arthropathy.

References

  1. Dalbeth, N., Merriman, T.R. and Stamp, L.K., 2016. Gout. The Lancet, 388(10055), pp.2039-2052.
  2. Neogi, T., Jansen, T.L., Dalbeth, N., Fransen, J., Schumacher, H.R., Berendsen, D., Brown, M., Choi, H., Edwards, N.L., Janssens, H.J. and Lioté, F. 2015. Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Annals of the rheumatic diseases, 74(10), pp.1789-1798.
  3. Bursill, D., Taylor, W.J. and Terkeltaub, R.A., 2019. Hyperuricemia and gout: state of the art and future perspectives. Nature Reviews Rheumatology, 15(7), pp.410-424.
  4. Dalbeth, N. and Stamp, L., 2007. Hyperuricaemia and gout: time for a new staging system?. Annals of the rheumatic diseases, 66(12), pp.1598-1600.
  5. Ottaviani, S., Richette, P. and Allard, A., 2017. Ultrasonography in gout: a case-based review. Clinical and experimental rheumatology, 35(5; SUPP/108), pp.75-84.
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