From the Guidelines
Enthesopathy should be treated with a biologic disease-modifying antirheumatic drug (bDMARD) in patients with unequivocal enthesitis and insufficient response to non-steroidal anti-inflammatory drugs (NSAIDs) or local glucocorticoid injections, as recommended by the most recent EULAR guidelines 1.
Treatment Approach
The treatment of enthesopathy typically involves a step-wise approach, starting with:
- Rest, ice, and anti-inflammatory medications like ibuprofen (400-800mg three times daily with food) to relieve musculoskeletal signs and symptoms
- Physical therapy focusing on gentle stretching and strengthening exercises
- For persistent cases, corticosteroid injections may be considered, though these should be limited due to potential tendon weakening
Biologic Disease-Modifying Antirheumatic Drugs (bDMARDs)
In patients with unequivocal enthesitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a bDMARD should be considered, as recommended by the EULAR guidelines 1. The choice of bDMARD may depend on various factors, including the presence of non-musculoskeletal manifestations related to psoriatic arthritis.
Important Considerations
- Enthesopathies often develop from repetitive stress, overuse injuries, or systemic inflammatory conditions like ankylosing spondylitis or psoriatic arthritis
- Proper biomechanics, appropriate footwear, gradual activity progression, and addressing underlying inflammatory conditions are essential for both treatment and prevention of recurrence
- The treatment target is elimination of inflammation and optimization of quality of life, as stated in the EULAR guidelines 1
From the Research
Definition and Prevalence of Enthesopathy
- Enthesopathy refers to a condition characterized by inflammation of the entheses, which are the sites where tendons or ligaments attach to bone [ 2 ].
- Enthesitis is a hallmark feature of spondyloarthropathies (SpA) and can lead to pain and substantial limitations in patients with psoriatic arthritis (PsA) [ 3 ].
Clinical Manifestations and Diagnosis
- Enthesitis can involve synovial joints, cartilaginous joints, syndesmoses, and extra-articular entheses [ 4 ].
- The entheses of the lower limbs are more frequently involved than those of the upper limbs, with heel enthesitis being the most frequent [ 4 ].
- Diagnostic ultrasound and magnetic resonance imaging (MRI) are useful for studying peripheral enthesitis and can show alterations of the structures involved [ 4 ].
Treatment Options
- Treatment of enthesitis typically consists of nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, and physical therapy [ 4 ].
- Steroid injections, second-line drugs such as sulphasalazine, and radiotherapy are reserved for more severe cases [ 4 ].
- Targeted and biologic disease-modifying antirheumatic drugs (DMARDs) have shown efficacy in treating enthesitis compared to placebo [ 2 ].
- Emerging data suggest that interleukin-17 and 12/23 inhibitors may be the first choice in PsA patients with enthesitis [ 2 ].
Management and Recommendations
- The decision to use entheseal injection should be made on an individual basis, considering the use of corticosteroid injection as the last treatment option following more conservative measures [ 3 ].
- Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture [ 3 ].
- Recommendations for the management of enthesitis in patients with PsA include various pharmacological and nonpharmacological therapies [ 5 ].