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Enthesitis

https://doi.org/10.1016/j.berh.2006.03.007Get rights and content

Enthesitis is a distinctive pathological feature of spondyloarthritis and may involve synovial joints, cartilaginous joints, syndesmoses and extra-articular entheses. This review focuses on peripheral extra-articular enthesitis, which is a clinical hallmark of spondyloarthritis. The entheses of the lower limbs are more frequently involved than those of the upper limbs, and heel enthesitis is the most frequent. Entheseal pain may be mild or moderate as well as severe and disabling. Peripheral enthesitis may be observed in all forms of spondyloarthritis, including the undifferentiated forms, and may, for a prolonged period, be the only longstanding clinical manifestation of the B27-associated disease process. The conceptual understanding of spondyloarthritis and the ability to image sites of skeletal inflammation accurately, i.e. ultrasound and magnetic resonance imaging, confirm that enthesitis is the primary lesion of spondyloarthritis. This advance has been occurring simultaneously with the therapeutic advances in spondyloarthritis due to the introduction of anti-tumour necrosis factor-α agents.

Section snippets

Evolution of the enthesis concept

Benjamin and McGonagle recently suggested that there are sufficient arguments for broadening the meaning of the term ‘enthesitis’ beyond the confines of a simple tendon–bone junction.4, 5, 6, 7 In the enthesis, the principal role is played by the fibrocartilage that undergoes functional adaptation to resist shear and compressive mechanical stress. Certain entheses are closely associated with other fibrocartilagineous structures that also contribute to reduce stress concentration and that can be

Clinical manifestations

As stated above, entheseal sites are numerous and ubiquitous. McGonagle identified almost 20 major insertions adjacent to the knee joint, most of which are not accessible to palpation.7 Although any insertion all over the body can be involved, some are more important in clinical practice, i.e. the insertions of the plantar fascia on the base of the fifth metatarsal bone, on the metatarsal heads and on the lateral and medial processes of the calcaneal tuberosity; the insertion of the long

Clinical evaluation

One of the most important problems is the clinical assessment and quantification of peripheral enthesitis in daily practice and during therapeutic trials.

The Assessment in Ankylosing Spondylitis (ASAS) Working Group has recently proposed a new index for the clinical assessment of enthesitis to be included in the core set of outcome measures for the clinical trials on AS.53 The new index, named the ‘Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), is less time consuming and more

Treatment

Conservative treatment of enthesitis is directed to relieve pain and stiffness, and includes non-steroidal anti-inflammatory drugs (NSAIDs), ortheses, local steroid injections and anti-tumour necrosis factor (TNF) inhibitors.

Mild or moderate heel pain can be treated successfully with NSAIDs, activity modification, supportive or accommodative ortheses, and physiotherapy. In unresponsive cases, local steroid injections can be tried. In Achilles enthesitis, steroids should not be injected into or

Summary

Peripheral extra-articular enthesitis is a clinical distinguishing feature of SpA. The entheses of the lower limbs are involved more frequently than those of the upper extremities, and heel enthesitis is the most frequent. Peripheral enthesitis causes pain but may also be asymptomatic and only revealed by ultrasonography, especially if combined with power Doppler. Peripheral enthesitis may be observed in all forms of SpA and all phases of the disease, and seems to be particularly frequent in

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