The aim was to compare X-ray and ultrasound (US) in diagnosing gout. In a prospective study, 105 consecutive patients with clinical suspicion of gout underwent conventional X-ray und high-resolution US in order to help in arriving at a definite diagnosis. X-ray findings suggestive of gout included soft-tissue opacifications with densities between soft tissue and bone, articular and periarticular bone erosions, and osteophytes at the margins of opacifications or erosions. US findings suggestive of gout included bright stippled foci and hyperechoic soft-tissue areas. Fifty-five patients had a definite diagnosis of gout (102 involved sites), 31 patients were diagnosed as having another disease (59 involved sites), and 19 patients were excluded from the study because a definite diagnosis could not be established. X-ray suggested gout with a sensitivity of 31% (32/102) and a specificity of 93% (55/59), whereas US suggested gout with a sensitivity of 96% (98/102) and a specificity of 73% (43/59). US was much more sensitive than conventional X-ray but less specific. Our data show that US often provided additional diagnostic information in patients with clinical suspicion of gout when laboratory findings and X-ray results were negative or inconclusive and should therefore be used in these cases.