Enthesitis

What is Enthesitis?

Tendons are tissues that join your muscles to the bones. Ligaments connect bones to each other. The area where your tendons and ligaments come together with your bones is called entheses. This connection point can be irritated due to injury or other diseases. This condition is known as Enthesitis or enthesopathy.

Enthesitis manifests in form of irritation of soft tissues like the tendons, ligaments, and muscles where these tissues enter the bones.

This condition may arise due to a joint disease and it is usually seen as the main sign of a condition known as spondyloarthritis. Enthesitis is also associated with diffuse idiopathic skeletal hyperostosis, commonly referred to as dish.

Irritation of entheses can lead to formation of new bone tissue which affects your normal mobility to perform other functions.

Enthesitis is very prevalent in people suffering from arthritis and also happens in children with juvenile idiopathic arthritis. Juvenile idiopathic arthritis is an autoimmune disorder where your immune system attacks cells and tissues leading to swelling or inflammation. ¹

Although enthesitis is not commonly associated with people having osteoarthritis and adult rheumatoid arthritis, it is possible that these people can have this condition.

Causes

Enthesitis may occur as a result of different things, which include:

Defective genes

Enthesitis can be inherited. When one of your family members manifested this condition; you are more likely to inherit those mutated genes that cause Enthesitis.

Proinflammatory cytokines

Cytokines control your body reaction to inflammation, infection and trauma. Some of the Cytokines can be harmful to your body by causing inflammation and they are called proinflammatory. Other cytokines can relieve inflammation hence boosting healing.

Proinflammatory cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF), when administered to human beings can destroy your tissues, causes swelling and even death.

Autoimmune diseases

Autoimmune disorders cause unusual activity of the immune system; it can result in over- activity or reduced activity of your immune system. During over activity, your immune system attacks and destroys body tissues .This reduces your body’s ability to fight and protect you against infections hence your body is vulnerable to any infection.

An example of autoimmune disease is rheumatoid arthritis. Rheumatoid arthritis occurs when your immune system secretes antibodies that attack the lining of your joints leading to painful swelling. If rheumatoid arthritis is left untreated for longer periods, it will lead to complete damage of your joint.

Risk factors

There are many factors that are associated with Enthesitis. People with conditions such as rheumatic and non-rheumatic swellings are more susceptible to Enthesitis. In addition, people who suffer from the following diseases are more likely to develop Enthesitis:

Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Septic arthritis
Spondyloarthropathies

Symptoms

The following are the signs and symptoms you will exhibit associated with enthesitis:

Enthesitis usually occurs in areas around your knee, elbow, hip, toes, fingertips, backbone and bottom of the foot. You are highly likely to notice swelling near the above mentioned areas. You will feel pain and stiffness when moving around.
There is soreness at the back of your heel which is painful and makes it difficult for you to climb stairs.
When your condition worsens without treatment, your tendons and ligaments become thick, swollen and hard and makes your movement painful and difficult.

Diagnosis

Physical assessment

Diagnosis of enthesitis begins with a physical examination .Your doctor touches your knee, elbow, hip, toes, fingertips, backbone and bottom of the foot to check for swelling, soreness and redness. The doctor will check your joints to determine if there is any reduced movement.

Medical tests

Your doctor can conduct several tests to determine the cause of this condition. Some of these tests are Erythrocyte Sedimentation Rate (ESR) to help detect any inflammation and infection .Complete Blood Count (CBC) is used to rule out infection as the cause.

X-rays

X–rays can be used to determine any variations in the Enthesis and bones.

MRI and Ultrasound

These imaging tests produce comprehensive details of the Enthesis and are used to detect inflammation in the soft tissues.

Treatment

Treatment for Enthesitis focuses on preventing inflammation or curbing your immune system or defense mechanism. The following are treatment options you can get when diagnosed with Enthesitis:

Non-steroidal anti-inflammatory drugs (NSAIDs)

These medicines are used to relieve pain and swelling. They block enzymes such as ox-1 and Cox-2 to produce prostaglandins which is responsible for swelling and pain.

By blocking secretion of prostaglandins, your body is relieved from pain and swelling. Non-steroidal anti-inflammatory drugs can be purchased from over- the -counter or prescribed by the doctor. Examples include aspirin, Ibuprofen, lodine, Indocin, voltaren.

Biologics

These are genetically modified proteins obtained from human genes. They are used to hinder some components of your immune system that cause inflammation.

They are used to slow down the spread of rheumatoid arthritis. Biologics can cause pain and rashes at the point of injection on your body. It can also cause allergic reaction, fever, nausea, headache, flu and chills.

Biologics can also cause chronic diseases such as tuberculosis. People with multiple sclerosis and acute conditions such as congestive heart failure should not use biologics. The following are biologics your doctor can administer to you:

Actemra
Amjevita
Cimzia
Enbrel
Erelzi
Prednisone

It is a corticosteroid medication that is used to reduce inflammation and control your immune system. You should not take Prednisone if you have a fungi infection or allergic to this medication. Prednisone can be harmful to you. Therefore inform your doctor if you have any of the following:

Kidney diseases
Liver cirrhosis
Diabetes
Tuberculosis
Malaria
A thyroid disorder
Mental illness
Pregnant

Prednisone can make you develop the following side effects:

Blurred vision
Rapid increase in weight
Swelling
Acute depression

Methotrexate

Methotrexate is a type of a drug that is used to control your immune system by minimizing its activities. The drug also alters the disease causing process in order to limit damage to your joints.

Some of the common side effects of Methotrexate are vomiting, nausea, mouth ulcers, headaches and fatigue. However, these side effects can be treated when you take folic acid supplements.

Sulfasalazine

This is a drug that can treat swelling and pain in arthritis. This drug also protects your joints from any form of injury or damage. Breastfeeding mothers should not use Sulfasalazine because it may cause brain complications to infants below the age of two. It can also lower sperm production in men but this will improve when you stop taking the drug.

References

What Is Enthesitis (or Enthesopathy)? Available at http://www.webmd.com/arthritis/psoriatic-arthritis/enthesitis-enthesopathy#1
Enthesitis Symptoms and Treatments. Available at http://enthesitis.org
Enthesitis and Enthesopathy. Available at http://www.medicinenet.com/enthesitis_and_enthesopathy/article.htm
Classification of Psoriatic Arthritis. Available at https://www.psoriasis.org/psoriatic-arthritis/classification-of-psoriatic-arthritis
Enthesitis. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5195265/
Diagnosis and treatment of Enthesitis-related Arthritis. Available at https://www.orpha.net/data/patho/Pro/en/enthesitis_related_arthritis.pdf