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Enthesitis – Causes, Symptoms & Treatment
Enthesitis is an inflammation of the enthesis, the site where tendons or ligaments attach to bone. It is commonly associated with rheumatic diseases and causes pain and stiffness.
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Enthesitis is an inflammation of the enthesis, the site where tendons or ligaments attach to bone. It is commonly associated with rheumatic diseases and causes pain and stiffness.
What Is Enthesitis?
Enthesitis refers to inflammation of the enthesis – the anatomical region where tendons, ligaments, or joint capsules attach to bone. These transition zones are particularly susceptible to mechanical stress and immune-mediated inflammatory reactions. Enthesitis can affect one or multiple sites simultaneously and is a hallmark feature of several rheumatic conditions, particularly the spondyloarthropathies.
Causes
Enthesitis can arise from several different mechanisms:
- Autoimmune conditions: Spondyloarthritides such as ankylosing spondylitis, psoriatic arthritis, and reactive arthritis are among the most common underlying causes.
- Mechanical overuse: Repetitive strain on tendon insertion sites, for example during sports or physical labor, can trigger local inflammation.
- Infections: Certain bacterial infections may provoke reactive enthesitis.
- Psoriasis: Enthesitis frequently accompanies psoriatic skin disease, even in the absence of frank arthritis.
Symptoms
The typical symptoms of enthesitis include:
- Localized pain at tendon insertion sites, often worsened by pressure or movement
- Swelling and local warmth over the affected area
- Morning stiffness or stiffness after periods of inactivity
- Restricted range of motion in the surrounding joint
Commonly affected sites include the Achilles tendon insertion, the plantar fascia (sole of the foot), the patellar tendon insertion, and attachment sites along the spine and pelvis.
Diagnosis
Enthesitis is diagnosed through a combination of:
- Clinical examination: Tenderness on palpation at characteristic entheseal sites
- Imaging: Ultrasound can reveal thickening, calcifications, and abnormal blood flow; MRI provides detailed visualization of soft tissue inflammation
- Laboratory tests: Inflammatory markers such as CRP and ESR may be elevated; HLA-B27 testing is relevant when spondyloarthritis is suspected
- Medical history: Questions regarding associated conditions such as psoriasis, inflammatory bowel disease, or prior infections
Treatment
Treatment is tailored to the underlying cause and severity of inflammation:
Pharmacological Treatment
- NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen or naproxen for pain relief and reduction of inflammation
- Local corticosteroid injections at the affected enthesis in cases of severe symptoms
- Biologics (e.g., TNF inhibitors, IL-17 inhibitors) for enthesitis associated with spondyloarthritis or psoriatic arthritis
- DMARDs (disease-modifying antirheumatic drugs) for specific underlying conditions
Physical Therapy
- Physiotherapy to restore mobility and strengthen the surrounding musculature
- Extracorporeal shock wave therapy (ESWT) for chronic enthesitis, particularly at the Achilles tendon
- Orthotic devices (e.g., insoles) to offload affected insertion sites
General Measures
- Rest during acute flares
- Gradual return to physical activity
- Weight management to reduce mechanical load on entheseal regions
References
- Rudwaleit M. et al. - The Assessment of SpondyloArthritis International Society (ASAS) classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Annals of the Rheumatic Diseases, 2011.
- Mease P.J. - Enthesitis in psoriatic arthritis pathophysiology, assessment, and treatment. Drugs, 2014.
- Sieper J. et al. - Axial spondyloarthritis. Nature Reviews Disease Primers, 2015.
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