Raj N. Sureja, MD
The human skeleton is comprised of over 200 bones and over 600 muscles, all of which are connected to one another by specialized, fibrous tissues called tendons and ligaments. Tendons attach muscle to bone and ligaments attach bone to other bones. Each of these has a special connection or an attachment point called an enthesis. These attachment points can become inflamed and painful, hence the condition called enthesitis or ensenopathy.
What causes enthesitis? Overuse (like repetitive motion), injury (traumatic or from sports) or diseases, such as psoriatic arthritis or ankylosing spondylitis, are the most common causes. People who develop enthesitis may been seen by a physician for continued bouts of tendinitis, that may either affect one part of the body or multiple areas of the body, before a diagnosis of enthesitis is made.
Pain is typically felt in areas such as the heel, bottom of the foot, hip, knee, toes, or spine, but it can happen anywhere there is an attachment point of a tendon or a ligament. One person may have rib pain, another may feel pain in their shoulder or they may have pain at multiple sites. There can also be swelling, stiffness and tenderness that occurs with this condition.
When a patient comes to see me for a diagnosis, I begin with a thorough physical exam, which includes palpation of the sore areas and my observation of their movement. I also ask lots of questions about health history, when the problem started, what makes it better or worse, etc. I may order x-rays to rule out boney abnormalities or an MRI to confirm soft tissue injury. I may order lab tests to look for inflammation markers and indicators of autoimmune disorders.
Often, I have to play detective because enthesitis can be difficult to diagnose, and I may come to the diagnosis after most other explanations have been ruled out. However, there are some pre-existing conditions that a patient may have which tend to go hand-in-hand with enthesitis. Psoriasis, an auto-immune condition that causes the skin cells to regenerate too quickly, is one of those conditions. Psoriatic arthritis, which occurs in about 30% of patients who suffer from psoriasis, is often preceded by enthesitis. Ankylosing spondylitis, which is a rare type of arthritis that affects the spine, may also be present in those with enthesitis. Some adolescents with juvenile rheumatoid arthritis can also be affected, but typically are not once they become adults.
I may treat enthesitis in coordination with a Rheumatologist, who will help patient manage the patient’s auto-immune condition, if one exists. Often, when the underlying condition is well-treated, the enthesitis improves as well. Conversely, when patients have a flare of their arthritis, the enthesitis can worsen. DMARDS or biologic drugs are often prescribed by Rheumatologists to lessen the inflammation and retard joint damage caused by the auto-immune arthritis. Gentle exercise, behavior modification, an anti-inflammatory diet, therapeutic massage, rest and NSAIDs are often helpful for patients with this condition.
Enthesitis that is not well-treated and managed can cause tendons or ligaments to become very fibrous and rope-like or to even begin forming bone spurs, which is called ossification. I typically become involved when a patient has chronic, recurring bouts of enthesitis that result in pain and dysfunction, no matter what the cause. I may choose to inject steroid medication at/around the attachment point that is painful and inflamed to speed recovery.
I might also recommend the use of PRP (platelet rich plasma) to be injected into especially painful or damaged tendons or ligaments. This injection uses the patient’s own blood and the healing factors contained within to regenerate the damaged tissue, reduce inflammation, and promote healing and recovery. Patients with enthesitis are typically not treated with opioids for their pain, as these drugs are extremely problematic, and their efficacy is questionable for this condition.
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