What is the initial treatment for enthesopathy?

Initial Treatment for Enthesopathy

For patients with enthesopathy, the initial treatment should be NSAIDs and local corticosteroid injections, followed by physical therapy. 1

Understanding Enthesopathy

Enthesopathy refers to pathology at the entheses - the attachment sites of muscles, tendons, joint capsules, ligaments, and fascia to bone. It can be:

• Inflammatory (enthesitis) - common in spondyloarthropathies
• Degenerative
• Metabolic
• Occupational
• Drug-induced
• Traumatic 2

Treatment Algorithm

First-Line Treatment

1. NSAIDs:

   • Recommended as initial therapy for mild enthesopathy 1
   • Example: Naproxen 500mg initially, then 250-500mg every 12 hours as needed 3
   • Use the lowest effective dose for the shortest duration to minimize side effects 3

2. Local Corticosteroid Injections:

   • Highly effective for localized enthesopathy 1
   • Should be considered when NSAIDs provide insufficient relief 1
   • Technique considerations:
     • Perientheseal injections may be safer than direct entheseal injections
     • Ultrasound guidance is strongly recommended for accurate placement and to ensure absence of rupture 4

3. Physical Therapy:

   • Should be implemented alongside pharmacological treatment 1
   • Focuses on stretching and strengthening exercises for the affected area

Second-Line Treatment

If first-line treatments fail after 3-6 months:

1. Disease-Modifying Antirheumatic Drugs (DMARDs):

   • Consider for moderate enthesopathy, particularly in the context of underlying inflammatory arthritis 1
   • Limited evidence for effectiveness specifically for enthesopathy 5

2. Biologic DMARDs:

   • For severe or refractory enthesopathy, especially in patients with spondyloarthropathies 1
   • TNF inhibitors, IL-17 inhibitors, and IL-12/23 inhibitors have all shown efficacy 5
   • Emerging evidence suggests IL-17 or IL-12/23 inhibitors may be more effective than TNF inhibitors for enthesitis 5

Special Considerations

Location-Specific Approaches

• Axial enthesopathy: May respond better to TNF inhibitors or IL-17 inhibitors if associated with axial spondyloarthritis 1
• Peripheral enthesopathy: Local injections may be more effective 1

Cautions with Injections

• Avoid direct entheseal injections in patients with risk of tendon rupture
• Use diagnostic ultrasound before injection to:
  • Confirm inflammation that would benefit from corticosteroid injection
  • Rule out partial or complete rupture 4

Monitoring and Follow-up

• Assess response to NSAIDs within 2-4 weeks
• For corticosteroid injections, evaluate response within 1-2 weeks
• If no improvement after 3 months of conservative therapy, consider advancing to second-line treatments 1

Common Pitfalls

1. Misdiagnosis: Bursitis can closely mimic enthesitis and requires different management approaches 2
2. Overuse of injections: Multiple corticosteroid injections at the same site can lead to tissue weakening and rupture 4
3. Inadequate imaging: Ultrasound with high-frequency transducers is recommended for accurate diagnosis and treatment guidance 2
4. Focusing only on symptom relief: Addressing the underlying cause (e.g., inflammatory arthritis, biomechanical issues) is essential for long-term management

By following this stepwise approach to treatment, most patients with enthesopathy can achieve significant symptom relief and improved function.