Entesopathy

Entesopathy is a broad term for disorders affecting the enthesis, the connective tissue junction where tendons, ligaments, or joint capsules attach to bone. The term encompasses inflammatory conditions (enthesitis) as well as degenerative or noninflammatory disorders (enthesopathy) at these insertion sites.

Pathophysiology and presentation

Entheses can be damaged by mechanical overuse, aging, or metabolic factors, leading to degenerative changes such as enthesophyte formation and calcification. Inflammatory enthesitis occurs in certain spondyloarthropathies and related conditions, where the enthesis becomes painful, swollen, and tender, often with accompanying axial or peripheral skeletal symptoms. Common sites include the Achilles tendon insertion on the heel, the plantar fascia at the calcaneus, the lateral epicondyle of the elbow, and the greater trochanter. Clinically, patients may report focal tenderness at the insertion point, morning stiffness, and activity-related pain.

Diagnosis

Evaluation combines history, physical examination, and imaging. Radiographs may reveal enthesophytes or calcifications, especially in chronic cases. Ultrasound can detect thickened or hypoechoic insertional tissue, erosions, and Doppler signals indicating active inflammation. MRI is useful for assessing bone marrow edema, soft tissue changes, and the extent of inflammatory involvement, particularly in suspected inflammatory enthesitis.

Management

Treatment targets the underlying mechanism. Noninflammatory enthesopathy is managed with activity modification, physical therapy, orthotics, NSAIDs, and, when appropriate, localized corticosteroid injections. Inflammatory enthesitis may require disease-modifying antirheumatic drugs or biologics guided by an underlying rheumatologic diagnosis. Refractory cases may benefit from shock-wave therapy or, rarely, surgical intervention.

Prognosis

Outcomes depend on the underlying cause and site of enthesis involvement. With appropriate treatment, many focal enthesopathies improve, though chronic inflammatory enthesitis can be part of a longer-term systemic condition.