What is the treatment for enthesopathy of the knee?

Treatment of Knee Enthesopathy

Start with NSAIDs (oral or topical) combined with quadriceps strengthening exercises and physical therapy as first-line treatment for knee enthesopathy. 1, 2

Initial Conservative Management

Pharmacological Approach

• NSAIDs are the cornerstone of treatment for reducing inflammation at the enthesis (tendon/ligament attachment site to bone), with topical formulations preferred in patients ≥75 years due to superior safety profiles 1
• Acetaminophen (up to 4,000 mg/day) serves as an alternative first-line agent for patients who cannot tolerate NSAIDs 1
• Local corticosteroid injections directly into the affected enthesis are highly effective for acute flares, particularly when inflammation is prominent 2, 3

Physical Therapy and Exercise

• Quadriceps strengthening exercises are strongly recommended and should be initiated early, as they address the mechanical stress at the enthesis while improving knee stability 1, 4
• Range of motion exercises help preserve normal knee mobility and prevent compensatory movement patterns that worsen entheseal stress 4
• Supervised physiotherapy programs demonstrate superior outcomes compared to unsupervised exercise, with benefits sustained for 6-18 months 4

Mechanical Modifications

Weight and Biomechanical Interventions

• Weight reduction is essential for overweight patients (BMI ≥25 kg/m²) to decrease mechanical load on the enthesis 1, 5
• Walking sticks or insoles redistribute forces away from the affected enthesis and provide symptomatic relief 1, 5
• Knee padding may reduce direct pressure on superficial entheses 1

Patient Education

• Explain that enthesopathy represents inflammation or degeneration at the tendon-bone junction, which responds well to conservative treatment when addressed early 2
• Activity modification to avoid repetitive stress on the affected enthesis is critical, as occupational or sports-related overuse commonly triggers symptoms 2, 6
• Emphasize that untreated enthesopathy leads to considerable morbidity, including chronic pain and functional limitation 2

Diagnostic Considerations

• High-frequency ultrasound is the preferred imaging modality for confirming enthesopathy, as it is cost-effective and readily detects entheseal inflammation, erosions, or calcifications 2
• Consider underlying seronegative spondyloarthropathies if multiple entheses are involved, as enthesitis is a hallmark feature of these conditions 2
• Radiographs may show bone erosion, hyperostosis, fragmentation, or crystal deposition at chronic entheses 6

Common Pitfalls

• Do not confuse enthesopathy with bursitis, as they closely mimic each other but require different injection techniques—entheseal injections target the bone-tendon junction, while bursal injections target the fluid-filled sac 2
• Avoid arthroscopic surgery for degenerative knee conditions including enthesopathy, as strong evidence shows no benefit over conservative management 4
• Do not delay treatment, as chronic enthesopathy becomes more refractory and may develop calcification or ossification at the enthesis 2, 6