A patient who has inflammatory arthritis, particularly spondyloarthritis such as ankylosing spondylitis or psoriatic arthritis, may experience pain caused by changes to an enthesis – an enthesis is a point where a ligament or tendon attaches to the bone.
Enthesopathy is a disorder of the enthesis, which are the connective tissues between bones and tendons or ligaments. Enthesopathy occurs when these tissues have been damaged, due to overuse, injury, or infection. It may also be caused by an inflammatory condition such as ankylosing spondylitis, sarcoidosis, or gout. Some research indicates that enthesopathy may develop as a result of an autoimmune disorder. Enthesopathy may also develop in various parts of the body, including the shoulders, hips, elbows, wrists, knees, heels, or feet.
Enthesopathy can also affect fixed joints. Fixed joints are places where two bones meet but there is little movement. For example, the joints between the breastbone and ribs are fixed joints.
Causes & Symptoms
The most noticeable symptom of enthesopathy is a pain in the area around a joint when you use that joint. You may also notice that the area of the tendon that attaches to the bones is tender to the touch. The level of pain you feel can vary widely. With mild enthesopathy, the pain may only be an annoyance. You’ll likely be able to do everyday tasks without a lot of discomforts.
With severe enthesopathy, the pain may keep you from being able to do everyday activities. Enthesopathy can also be a symptom of underlying conditions such as psoriatic arthritis, spondyloarthritis, and joint space narrowing.
Other symptoms associated with these potential underlying conditions include:
- Inflammation – Enthesopathy causes swelling of the joints at the point where ligaments are attached.
- Calcification – In enthesopathy, hardening of tissues with lime salts or calcification at the site of attachment to the bone is observed.
- Immobility – The patient suffering from this condition may experience loss of mobility. This is because the affected area becomes sore and tender and hence resulting in immobility.
- Soreness – The affected area becomes sore and tender which causes immobility in the affected bone area.
- Pain – Patients feel stabbing pain in the affected bone area.
- Burning sensation – A patient who is suffering from enthesopathy feels a burning sensation at the point where ligaments are attached to the bone.
- Irritation – Feeling of pain and burning are also accompanied by irritation in the affected area.
- Stress – Patients are more likely to be in an irritated state because of the stress caused by the pain and irritation.
Additionally, conditions that affect the spine, such as spondyloarthritis, can cause pain in your hip bones. They can also cause general lower back pain. You may feel less able to move your spine, as spondyloarthritis can cause your vertebrae to fuse together.
Hip enthesopathy can also sometimes be linked to bowel conditions, such as inflammatory bowel disease, or to a gene that is passed down in families. Knee enthesopathy is normally associated with overuse or stress put on your knees. This type of enthesopathy results from conditions such as patellar tendonitis. Patellar tendonitis is also called “runner’s knee”.
Generally, pain with this condition is typically worse when you’re exercising and putting stress on your knees. You may also feel pain when performing certain daily tasks, such as getting up from a sitting position or going up the stairs. Enthesopathy in your foot usually affects your plantar fascia. This is the tissue under your foot arch. It can also affect your calcaneus, or heel bone. This pain occurs because the enthesis of your plantar fascia has thickened. This can cause pain in your heel and around your foot arch when you walk or put stress on your foot.
Lastly, enthesopathy in your ankle and tarsus, or Achilles tendon, usually affects the point where your Achilles tendon attaches to your heel bone. If you have enthesopathy in this area, you will feel pain when you move your foot around. You may also feel pain when you step down and put pressure on either your heel or the front of your foot. For instance, it may hurt to stand on the tip of your toes.
Who Gets Enthesopathy?
Enthesopathy is often a symptom of another disorder, such as inflammatory arthritis of the spine or an autoimmune condition. Therefore, patients with enthesopathy may experience symptoms of these other conditions, which may, in turn, help diagnose the underlying cause of the joint pain. For example, gout is a type of arthritis that causes uric acid crystals to deposit within and around some joints. This can cause enthesopathy. People with gout may have pain involving a variety of joints, particularly those in the feet and toes.
A person’s genetics may also play a role in the development of enthesopathy. Some people are more predisposed to developing weak ligaments and tendons, resulting in the onset of the condition. Unfortunately, there is no way to cure enthesopathy, as the patient’s genetics determine the skeletal and muscular structure. A patient’s genetics may also make them more susceptible to specific injuries. For example, women are born with wider hips than men. This genetic disadvantage places pressure on the hips and knees, increasing their exposure to injuries in these areas.
People who are dealing with the effects of degenerative bone diseases, such as arthritis and spondylosis, are at high risk of developing enthesopathy. As we age, the bones begin to leach calcium, which is a vital mineral for generating new bone cells. The calcium deposits may attach to the surface of the bone, causing the onset of osteophytes, also known as bone spurs.
How Does It Affect You? How Serious Is It?
Enthesopathy may be linked to inflammatory conditions, or it may be mechanically induced by injury. Peripheral enthesopathy is characteristic of all the spondyloarthropathies, including ankylosing spondylitis and reactive arthritis:
This is a form of arthritis that results from infection. The swelling of reactive arthritis is commonly triggered by an infection in a more remote body part, such as the urinary tract, intestines, or genitals. Typically, the joints of the knees, feet, and ankles are targets for inflammation secondary to reactive arthritis. More specifically, enthesopathy in patients with reactive arthritis usually occurs in the plantar fascia, pelvic bones, or Achilles tendon. However, reactive arthritis is uncommon and normally goes away in most people within a year after onset.
This is an inflammatory condition that is most prevalent in men. The inflammation of ankylosing spondylitis affects the vertebrae and causes them to fuse. Chronic enthesopathy of the tendons and ligaments of the vertebrae is the first step in the eventual fusion of vertebrae, which is the main feature of ankylosing spondylitis. Patients with ankylosing spondylitis can also experience enthesopathy of the joints of the ribs. The term plantar aponeurosis refers to the thickened connective tissue that supports the arch of the foot.
Other conditions associated with enthesopathy include Achilles tendinitis, rheumatoid arthritis, and osteoarthritis. It may be degenerative enthesopathy that develops with osteoarthritis. The degenerative changes that occur with wear-and-tear osteoarthritis also affect the fibrocartilages.
Enthesopathy may involve any area of the body, but it is most common in the heel, spine, hip, elbow, and knee. However, a wide variety of medical conditions can also cause joint and localized pain. Since many conditions cause pain at or near a joint, people with joint or muscle pain should not self-diagnose.
Conditions that may appear similar to enthesopathy include:
- Strains and sprains
- Overuse injuries
- Bone injuries
- Medical conditions such as rheumatoid arthritis or gout
Recommended Treatment & Rehabilitation
A doctor can diagnose enthesopathy based on symptoms and an examination alone. When symptoms are unclear, or when another condition might be the cause, imaging scans, such as an ultrasound, X-ray, or MRI (magnetic resonance imaging) scan, can all be helpful. These images look for swelling and damage at the enthesis and can rule out other diagnoses.
To help you deal with the pain that comes along with enthesopathy, your doctor will most likely prescribe NSAIDs (non-steroidal anti-inflammatory drugs). NSAIDs help relieve the pain and inflammation of enthesopathy. These types of medications include aspirin (Ecotrin), naproxen (Aleve), and ibuprofen (Advil).
If an immune system disorder, such as psoriatic arthritis, is causing your enthesopathy, your doctor will then recommend medications to help reduce the immune system response that is causing the pain. A DMARD (disease-modifying antirheumatic drug) can help treat immune responses. Other medications such as methotrexate and sulfasalazine (Azulfidine) may also help relieve symptoms.
Surgery is usually seen as the last option. Therefore, when it is necessary, it is often due to enthesopathy caused by an underlying condition. Your doctor may recommend a total hip replacement. In this procedure, your doctor will surgically remove your affected bone and puts it in a plastic or metal prosthesis.
Physiotherapy can reduce pain and stiffness of the joints and nearby areas. Most physiotherapy focuses on strengthening and loosening tense muscles, along with improving flexibility near the enthesis. For instance, patients with Achilles tendon enthesopathy may benefit from calf muscle stretches performed 2-3 times a day. Performing these types of exercises on both sides, and not just the side affected by enthesopathy can help prevent muscle imbalances, problems with posture, and making the pain worse. Physiotherapy can help patients with enthesopathy work around their injuries without worsening the pain.
Alternative & Homeopathic Treatment
Patients with enthesopathy may need to avoid exercises that increase stress on the joints. Running can irritate enthesopathy, as can some weight-bearing exercises. Individuals who develop enthesopathy may benefit from non-weight-bearing exercises such as biking, swimming, and rowing. Other treatments that can help include:
- Cold and hot packs, or alternating the two to help reduce further inflammation.
- Massaging the affected joint, or of surrounding muscles.
- Cold laser therapy (or low-level laser therapy), a light therapy that can help reduce inflammation and pain.
- Alternative therapies such as acupuncture.
- Corticosteroid injections for inflammatory enthesopathy.
If a movement is painful, then a patient would be advised to avoid it as much as he / she can.
When it comes to natural treatment for enthesopathy, there are few types of research. However, there are some natural remedies to help to cure psoriatic arthritis along with medical treatment. Here are some natural treatments you can try, including vitamins, to reduce the symptoms linked to enthesopathy:
- Acupuncture – Acupuncture relieves pain and also helps in the movement of muscles.
- Vitamin D – Intake of Vitamin D can reduce joint pain hence treating enthesopathy.
- Vitamin B12 – Patients who suffer from enthesopathy have a deficiency of Vitamin B12. Intake of Vitamin B12 can help reduce the symptoms of joint pain.
- Traditional herbal medicines – Herbs used in medicines are famously known for benefiting patients with arthritis. They contain anti-inflammatory effects in enthesopathy.