From the Guidelines
Mild enthesopathy at the distal quadriceps attachment should be treated with conservative management, including rest, ice, and over-the-counter anti-inflammatory medications, due to the risk of tendon rupture associated with local injections around the quadriceps tendon. Treatment should begin with rest, ice application for 15-20 minutes several times daily, and over-the-counter anti-inflammatory medications like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily with food) for 1-2 weeks 1. Physical therapy focusing on gentle quadriceps stretching and strengthening exercises is recommended, starting with isometric exercises and progressing to eccentric strengthening. Avoid activities that aggravate symptoms, particularly jumping, running, or deep squatting. A patellar strap or knee sleeve may provide symptomatic relief during daily activities.
Some key points to consider in the management of mild enthesopathy at the distal quadriceps attachment include:
- The risk of tendon rupture associated with local injections around the quadriceps tendon, as noted in the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis 1
- The importance of early recognition and treatment of enthesitis, as it can lead to persistent inflammation and progressive joint damage if left untreated 1
- The variable and unpredictable course of psoriatic arthritis, which can range from mild and nondestructive to severe and debilitating 1
If symptoms persist beyond 4-6 weeks despite these measures, consult with an orthopedic specialist for further evaluation, as they may recommend other interventions. This condition results from repetitive stress or overuse at the tendon-bone junction, causing microscopic tears and inflammation that, if properly managed, typically resolves with conservative treatment.
From the Research
Mild Enthesopathy at Distal Quadriceps Attachment
- Enthesopathy refers to pathology at the attachment sites of muscles, tendons, joint capsules, ligaments, and fascia to the bone 2.
- It can be inflammatory, occupational, metabolic, drug-induced, infective, or degenerative in nature 2.
- Enthesopathy can lead to considerable morbidity if left unrecognized and untreated 2.
- The distal quadriceps attachment is a common site for enthesopathy, and ultrasound with high-frequency transducers can be used to detect it 2.
- Treatment options for enthesopathy include local steroid injections, physiotherapy, and non-steroidal anti-inflammatory drugs, in addition to treating the primary disease 2, 3.
Clinical Manifestations and Imaging
- Enthesitis is a distinctive pathological feature of spondyloarthropathy and may involve synovial joints, cartilaginous joints, syndesmoses, and extra-articular entheses 3.
- The entheses of the lower limbs are more frequently involved than those of the upper limbs, and heel enthesitis is the most frequent 3.
- Imaging methods such as ultrasonography and magnetic resonance imaging can be used to study peripheral enthesitis 3.
Treatment Options
- Therapy for peripheral enthesitis consists of NSAIDs, orthoses, and physical therapy 3.
- Steroid injections, second-line drugs such as sulphasalazine, and radiotherapy are reserved for more severe cases 3.
- Platelet-rich plasma injection, corticosteroid injection, and physical therapy can be effective in treating subacromial impingement syndrome 4.
- Regenerative injection therapy, including autologous blood and platelet-rich plasma injections, can be effective in treating lateral epicondylitis 5.