What is the management approach for enthesopathy?

Management Approach for Enthesopathy

The management of enthesopathy should follow a stepwise approach, starting with NSAIDs as first-line therapy, followed by local glucocorticoid injections, and progressing to biological DMARDs for refractory cases, with treatment decisions guided by distinguishing between inflammatory and mechanical causes. 1

Diagnosis and Initial Assessment

• Proper diagnosis requires distinguishing true inflammatory enthesitis from mechanical enthesopathy or widespread pain syndromes 1
• Clinical examination should focus on:
  • Number and pattern of painful entheses (asymmetrical pattern suggests inflammatory enthesitis) 1
  • Presence of clinical swelling at entheseal sites 1
• Ultrasound with high-frequency transducers is a cost-effective diagnostic tool that can detect enthesopathy, even when asymptomatic 2, 3
• Power Doppler ultrasound is particularly useful for differentiating mechanical/degenerative enthesopathy from inflammatory enthesopathy 3
• Concomitant fibromyalgia, present in up to 20% of patients, can complicate assessment and lead to overestimation of disease severity 1, 4

Treatment Algorithm

First-Line Therapy

• NSAIDs are the initial pharmacological treatment of choice for enthesopathy 1
• Local glucocorticoid injections directed to the site of inflammation provide targeted relief 1, 2
• Non-pharmacological approaches should be implemented concurrently:
  • Physical therapy to strengthen supporting structures 1
  • Regular exercise to maintain joint mobility 1
  • Activity modification to reduce mechanical stress on affected entheses 5

Second-Line Therapy

• Conventional synthetic DMARDs (csDMARDs) have limited efficacy specifically for enthesitis 1
• Sulfasalazine may be considered for peripheral enthesitis, though evidence shows inconsistent results 1

Third-Line Therapy

• Biological DMARDs (bDMARDs) should be initiated when NSAIDs and local injections prove insufficient 1
• All bDMARDs demonstrate similar efficacy for enthesitis and include:
  • TNF inhibitors (infliximab, etanercept, adalimumab) 1, 4
  • IL-17 inhibitors 1
  • IL-12/23 inhibitors 1
  • JAK inhibitors (for psoriatic arthritis-related enthesitis) 4

Treatment Based on Specific Clinical Context

• For enthesopathy in psoriatic arthritis:

  • Follow the treatment ladder from NSAIDs to bDMARDs 1, 4
  • Monitor for improvement in function and quality of life, as enthesitis significantly impacts these domains 4

• For enthesopathy in ankylosing spondylitis:

  • NSAIDs are first-line therapy 1
  • TNF inhibitors are recommended for inadequate response to NSAIDs 1

• For mechanical/degenerative enthesopathy:

  • Focus on addressing biomechanical factors 5
  • Implement activity modification and physical therapy 1, 5
  • NSAIDs and local injections for symptomatic relief 1, 2

Clinical Pearls and Pitfalls

• Untreated enthesopathy can lead to considerable morbidity and decreased quality of life 2, 4
• Enthesopathy can be inflammatory, degenerative, metabolic, endocrine, or traumatic in nature, requiring different management approaches 6
• Common sites of involvement include the pelvis, femoral trochanter, humeral tuberosity, patella, olecranon, calcaneus, and vertebral column 6
• Central sensitization syndromes can complicate clinical assessment, making imaging confirmation valuable 5
• Mechanical forces can trigger entheseal inflammation, blurring the line between mechanical and inflammatory enthesopathy 5