Enthesopathy

Enthesopathy is a medical term used to describe pathology at the enthesis, the connective tissue interface where a tendon, ligament, or joint capsule attaches to bone. The term covers a spectrum of conditions, including enthesitis (inflammation of the enthesis) and noninflammatory degenerative changes at the enthesis, often referred to as enthesopathy.

Causes and sites

Enthesopathy arises from a range of factors. Mechanical overuse and repetitive microtrauma can produce noninflammatory enthesopathic changes, commonly at the Achilles tendon insertion on the heel bone, the plantar fascia origin, the patellar tendon insertion, and other traction sites such as the greater trochanter or elbow epicondyles. Enthesitis is a hallmark of inflammatory diseases, particularly the spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis), and can accompany conditions like psoriasis, inflammatory bowel disease, or gout in some cases. Metabolic and age-related degenerative processes may also contribute.

Clinical features and diagnosis

Patients typically present with focal tenderness and pain at a bone-tendon or bone-ligament insertion, sometimes with swelling. Inflammatory enthesitis may be associated with morning stiffness and systemic features depending on the underlying disease. Imaging aids diagnosis: ultrasound can reveal thickened enthesis, erosions, calcifications, and Doppler signal indicating inflammation; MRI can show enthesis inflammation and adjacent bone marrow edema. Radiographs may show enthesophytes or calcifications. Laboratory tests help identify associated inflammatory conditions (for example, inflammatory markers, HLA-B27, or other disease-specific tests).

Management and prognosis

Treatment targets the underlying cause. Inflammatory enthesitis is managed with anti-inflammatory medications, therapies for the associated systemic condition, and physical therapy. Noninflammatory enthesopathies are addressed with activity modification, targeted rehabilitation, orthotics, and pain management. Corticosteroid injections are used cautiously, and advanced therapies such as extracorporeal shock wave treatment or surgical debridement may be considered in refractory cases. Prognosis varies with etiology; inflammatory enthesitis can be chronic, while overuse-related enthesopathy often improves with rehabilitation.