How are enthesophytes typically managed?

Management of Enthesophytes

Enthesophytes are managed primarily with NSAIDs and local corticosteroid injections as first-line therapy, followed by physical therapy and exercise, with biological DMARDs reserved for refractory inflammatory cases. 1

Initial Treatment Approach

First-Line Pharmacological Management

• NSAIDs should be initiated as the primary pharmacological treatment for symptomatic enthesophytes, whether inflammatory (enthesitis) or degenerative (enthesopathy). 2, 1, 3
• Local corticosteroid injections directed to the site of inflammation are highly effective and should be considered early in management. 2, 1, 3
• These injections can be intra-articular or periarticular depending on the anatomic location of the enthesophyte. 2

Important caveat: When using local corticosteroid injections, potential complications including tendon rupture must be considered, particularly at weight-bearing entheses like the Achilles insertion. 2

First-Line Non-Pharmacological Management

• Regular exercise and physical therapy are essential components and should be implemented alongside pharmacological treatment. 2, 1
• Conservative management should focus on increasing range of motion, progressive resistance exercises, and eccentric loading. 4
• Strategies to reduce joint strain should be incorporated into the treatment plan. 4

Second-Line Treatment Options

Conventional DMARDs

• Conventional synthetic DMARDs have limited efficacy specifically for enthesopathy and are generally not recommended as primary treatment. 1
• Sulfasalazine may be considered for peripheral enthesitis, particularly in the context of spondyloarthropathy, though evidence shows inconsistent results. 2, 1
• There is no evidence supporting the use of methotrexate or other traditional DMARDs for axial enthesopathy. 2

Third-Line Treatment for Refractory Cases

Biological DMARDs

• Biological DMARDs should be considered when NSAIDs and local injections provide insufficient relief, particularly in inflammatory enthesitis associated with spondyloarthropathies. 1
• All biological DMARDs demonstrate similar efficacy for enthesitis. 1
• Options include:
  • TNF inhibitors (infliximab, etanercept, adalimumab) 2, 1
  • IL-17 inhibitors 1
  • IL-12/23 inhibitors 1

Alternative Treatment Modality

Low-Dose Radiation Therapy

• For painful plantar enthesophytes refractory to conservative management, low-dose radiation therapy is highly effective with minimal side effects. 5
• This modality achieved pain-free status in 73% of patients at long-term follow-up. 5
• Duration of pain before radiation therapy is the only significant prognostic factor—earlier integration results in superior pain reduction. 5
• This should be considered before surgical intervention in appropriate cases. 5

Surgical Considerations

When to Consider Surgery

• Radiographic characteristics can predict failure of nonoperative management in insertional Achilles tendinopathy with enthesophytes. 6
• Smaller calcaneal spur-to-skin distance, larger spur width, and larger spur height are independent risk factors for failing conservative treatment. 6
• Surgery should be reserved for cases failing comprehensive conservative management. 4, 6

Critical Diagnostic Distinctions

Inflammatory vs. Mechanical Enthesopathy

• Distinguishing inflammatory enthesitis from mechanical enthesopathy or widespread pain syndromes is essential for appropriate treatment selection. 1
• Asymmetrical pattern of painful entheses suggests inflammatory enthesitis requiring more aggressive treatment. 1
• Concomitant fibromyalgia can complicate assessment and cause overestimation of disease severity. 1

Imaging Considerations

• Ultrasound with high-frequency transducers is a simple, cost-effective method to detect enthesopathy. 3
• MRI allows visualization of bone marrow edema and soft-tissue pathology associated with symptomatic enthesophytes. 2
• CT can demonstrate enthesophytes before they are visible on radiographs but has limited assessment of associated soft-tissue pathology. 2

Common Pitfalls

• Do not overlook the potential for fracture through large enthesophytes, particularly during eccentric loading activities. 4, 7
• Enthesopathy can be occupational, metabolic, drug-induced, infective, or degenerative—not all cases are inflammatory. 3
• Unrecognized and untreated enthesopathy can lead to considerable morbidity. 3