The objective of this study was to determine the relative usefulness of physical examination, plain radiographs, and magnetic resonance imaging (MRI) using T1- and T2-weighted spin-echo images in evaluating the extent of urate deposition and soft tissue destruction in gouty arthritis. Seven patients with chronic tophaceous gout of the hands and wrists were examined to identify all clinically apparent tophi. Plain radiographs of the hands and wrist were obtained to further quantify soft tissue and osseous changes. MRI was then performed of the involved areas and a comparison made between soft tissue and bony changes observed by clinical examination and plain radiographs and those observed by MRI. Plain radiographs and physical examination markedly underestimate the size and extent of soft tissue and osseous involvement by tophi when compared with the findings of MRI. MRI also detects early, subclinical tophaceous deposits and indicates that urate deposits appear to spread along compartmental and fascial planes as opposed to the traditional view of strict radial growth. MRI is a useful method of determining the extent of disease in tophaceous gout and may provide information regarding the patterns of deposition and spread of monosodium urate crystals.