What is enthesopathy (inflammation of the entheses, the sites where tendons or ligaments insert into the bone)?

From the Guidelines

Enthesopathy treatment should prioritize physical therapy and NSAIDs as first-line treatments, with consideration of biologic DMARDs for patients with unequivocal enthesitis and insufficient response to initial therapies. Enthesopathy is a disorder affecting the entheses, which are the connection points where tendons, ligaments, or joint capsules attach to bones. According to the 2020 EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies 1, NSAIDs and local glucocorticoid injections are the first-line treatment for enthesitis.

For patients with stable axial disease and active enthesitis despite treatment with NSAIDs, locally administered parenteral glucocorticoids may be considered over no treatment with local glucocorticoids, although the level of evidence is very low 1. However, physical therapy is strongly recommended over no treatment with physical therapy, with a moderate level of evidence 1. Active physical therapy interventions, such as supervised exercise, are conditionally recommended over passive physical therapy interventions, such as massage, ultrasound, or heat 1.

Some key points to consider in the treatment of enthesopathy include:

• Rest and physical therapy to reduce pain and inflammation
• Anti-inflammatory medications like NSAIDs (ibuprofen 400-800mg three times daily or naproxen 500mg twice daily) for 1-2 weeks
• Corticosteroid injections for more severe cases, though these should be limited to avoid tendon weakening
• Orthotic devices or braces to reduce stress on affected areas
• Gradual return to activities to prevent reinjury

It is essential to note that enthesopathy often results from repetitive stress, overuse injuries, or inflammatory conditions like ankylosing spondylitis or psoriatic arthritis, and common sites include the Achilles tendon, plantar fascia, patellar tendon, and elbow tendons. Recovery typically takes several weeks to months depending on severity. In patients with unequivocal enthesitis and insufficient response to NSAIDs or local glucocorticoid injections, therapy with a biologic DMARD should be considered 1.

From the Research

Definition and Causes of Enthesopathy

• Enthesopathy refers to pathology at the attachment sites of muscles, tendons, joint capsules, ligaments, and fascia to the bone 2.
• It can be caused by various factors, including inflammatory, occupational, metabolic, drug-induced, infective, or degenerative processes 2.

Diagnosis and Treatment of Enthesopathy

• Ultrasound with high-frequency transducers is a simple and cost-effective test to detect enthesopathy, which can be treated with local steroid injections, physiotherapy, and non-steroidal anti-inflammatory drugs 2.
• Imaging techniques, such as MRI and ultrasound, have higher sensitivity and specificity compared to clinical examination for diagnosing enthesitis, a hallmark feature of spondyloarthropathies (SpA) 3.
• Targeted and biologic disease-modifying antirheumatic drugs (DMARDs) have shown efficacy in treating enthesitis, while synthetic DMARDs have limited information on their efficacy 3.

Enthesopathy in Specific Conditions

• Enthesitis is a key pathological and clinical feature of psoriatic arthritis (PsA) in children and adults, and its treatment response has been reported as change in the total enthesitis score or the proportion of patients who achieved complete resolution 4.
• Enthesopathy may play an underappreciated role in osteoarthritis (OA), as functional incompetence of the enthesis resulting from degenerative or inflammatory changes could be an initiating factor for OA 5.
• Therapies for psoriatic enthesopathy have been reviewed, and several outcome measures have been developed to assess enthesitis, but none have been validated in psoriatic arthritis 6.

Management and Recommendations

• The management of enthesitis in clinical practice involves the use of imaging for diagnosis and treatment with targeted and biologic DMARDs, as well as local measures such as steroid injections and physiotherapy 3, 4.
• Recommendations for the treatment of enthesitis in patients with PsA have been formulated based on a systematic literature review, including pharmaceutical and non-pharmaceutical interventions 4.