What is Enthesopathy?
Enthesopathy is a disease process occurring at entheses—the anatomical sites where tendons, ligaments, fascia, or articular capsules insert into bone. 1
Pathophysiology and Classification
Enthesopathy encompasses multiple pathogenic mechanisms and can be classified by etiology 2:
- Inflammatory: Characteristic of spondyloarthropathies and rheumatoid arthritis 2
- Degenerative: Associated with osteoarthritis development 2
- Metabolic/Endocrine: Seen in various systemic metabolic and endocrine conditions 1, 2
- Traumatic: Related to mechanical stress and overuse 1
- Crystal deposition: Calcium deposition diseases represent the most significant articular cause of enthesopathies in the general population 2
- Drug-induced: Retinoid medications (isotretinoin/Accutane) can cause enthesopathy even with short-term use 3
Common Anatomical Sites
Enthesopathy frequently affects specific high-stress anatomical locations 1:
- Pelvis and femoral trochanter 1
- Humeral tuberosity (shoulder) 4
- Patella (knee) 1
- Olecranon (elbow) 1, 5
- Calcaneus (heel) 1
- Vertebral column 1
Clinical Presentation
Pain originating from nerve-enriched entheses (enthesalgia) represents a potential cause of chronic musculoskeletal pain. 2 The clinical burden includes 4:
- Stiffness due to joint involvement and enthesopathy presence 4
- Muscle weakness and fatigue 4
- Physical deconditioning 4
- Mobility impairment and reduced physical activity 4
- Reduced quality of life 4
Diagnostic Features
Specific radiographic findings allow precise diagnosis 1:
Treatment Approach
For X-Linked Hypophosphataemia (XLH)-Associated Enthesopathy
Conventional therapy with active vitamin D and phosphate supplements does not prevent or treat enthesopathies in XLH patients. 4 Enthesopathies are prevalent in adult XLH and typically become detectable by the third decade of life 4.
General Management Strategy
Physical therapy represents the primary non-pharmacological treatment for enthesopathy-related symptoms. 4 The goals include 4:
Physical therapy programs are currently based on recommendations for knee or hip osteoarthritis, as no disease-specific recommendations exist for enthesopathy management 4.
For Extensor Carpi Radialis Brevis Enthesopathy (Tennis Elbow)
No treatments, invasive or noninvasive, have been proven to alter the natural history of this condition. 5 The natural history is spontaneous resolution, though it can persist for over one year 5. Management focuses on effective communication strategies that convey accurate, hopeful information while addressing patient stress, distress, and coping strategies that influence pain intensity and disability magnitude 5.
Critical Clinical Pitfall
Physicians treating patients with a history of isotretinoin (Accutane) use should maintain high suspicion for underlying enthesopathies as the etiology of musculoskeletal pain. 3 Patients prescribed isotretinoin should be warned about this potential pathologic condition at treatment initiation 3.