<p>This study aimed to evaluate and compare the differences in musculoskeletal ultrasound semi-quantitative scores between acute gouty arthritis patients with normal and elevated serum uric acid levels. We prospectively evaluated 25 patients with acute gouty arthritis and normal serum uric acid, alongside 32 patients with elevated serum uric acid. Clinical data and ultrasound features (double-contour sign, tophi, aggregates, bone erosion, synovial hyperplasia, power Doppler signal, and joint effusion) were compared. Ultrasound successfully detected urate crystal deposition in 68.0% (17/25) of affected joints in the normal uric acid group. However, the elevated uric acid group showed significantly higher semi-quantitative scores for crystal deposition features, including double-contour sign, tophi, aggregates, and bone erosion (<i>P</i> &lt; 0.05). Additionally, pain scores, erythrocyte sedimentation rate, and C-reactive protein levels demonstrated strong positive correlations with the semi-quantitative scores of inflammatory ultrasound features (r_s = 0.738–0.861, <i>P</i> &lt; 0.01). Musculoskeletal ultrasound semi-quantitative scoring can effectively assess the urate crystal deposition burden and reflect acute-phase inflammatory activity, providing valuable imaging characteristics to inform clinical evaluation during the acute phase.</p>