From the Guidelines
Enthesopathy should be treated with a combination of rest, physical therapy, and anti-inflammatory medications, with the goal of reducing pain and inflammation, and improving quality of life. The treatment of enthesopathy typically involves a multi-faceted approach, including rest, physical therapy, and pharmacological interventions. According to the 2019 update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations 1, physical therapy is strongly recommended over no treatment with physical therapy, with a moderate level of evidence.
- Key components of treatment include:
- Rest and avoidance of activities that exacerbate the condition
- Physical therapy, focusing on stretching and strengthening exercises, with sessions recommended 2-3 times weekly for 4-6 weeks
- Anti-inflammatory medications, such as NSAIDs (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) for 1-2 weeks to reduce pain and inflammation
- Corticosteroid injections, limited to 2-3 injections per year to prevent tissue damage, may be used in more severe cases
- Lifestyle modifications, including proper footwear, ergonomic adjustments, and weight management, are important preventive measures The European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies also support the use of NSAIDs to relieve musculoskeletal signs and symptoms, and recommend considering local injections of glucocorticoids as adjunctive therapy 1.
- It is essential to note that the level of evidence for some of these recommendations is very low, and therefore, treatment should be individualized and based on the specific needs and circumstances of each patient. Overall, the goal of treatment is to reduce pain and inflammation, improve function, and enhance quality of life, while minimizing the risk of complications and long-term damage.
From the Research
Diagnosis of Enthesopathy
- Enthesopathy is typically diagnosed based on clinical manifestations, such as pain and inflammation at the enthesis, which is the point of attachment of a tendon or ligament to bone 2.
- Imaging methods, including ultrasonography and magnetic resonance imaging, can be used to confirm the diagnosis and assess the extent of inflammation and damage to the enthesis 2.
Treatment Options for Enthesopathy
- Non-surgical treatment options for enthesopathy include:
- Local corticosteroid injection, which may provide short-term pain relief but can be associated with adverse events and worsening of pain at long-term follow-up 3, 4.
- Laser therapy, which has been shown to improve pain and grip strength in some studies 3.
- Extracorporeal shock wave therapy, which may provide long-term pain relief 3.
- Autologous platelet-rich plasma (PRP) injection, which is considered a safe and alternative method for treating enthesopathies, but its efficacy is still uncertain due to differences in PRP preparation systems and concentrations of growth factors 5.
- Conservative measures, such as NSAIDs, orthoses, and physical therapy, are often recommended as first-line treatments for enthesopathy 2, 6.
- Entheseal corticosteroid injections may be considered as a last treatment option, but their efficacy and tolerability are limited, and they should be used with caution, especially in high-risk patients 6.
Considerations for Treatment
- Patient-specific factors, such as the severity of symptoms and the presence of underlying conditions, should be taken into account when deciding on treatment or watchful waiting 3.
- Diagnostic ultrasound is recommended to ensure the presence of inflammation and the absence of rupture before considering entheseal injection 6.
- Ultrasound guidance for needle placement is strongly encouraged to minimize the risk of adverse events 6.