Description
Enthesitis refers to inflammation of the entheses, which are the sites where tendons or ligaments attach to the bone. Enthesitis is commonly associated with spondyloarthritis (SPA), a group of inflammatory rheumatic diseases that includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and others. Enthesitis is a hallmark feature of SPA and can cause pain, swelling, and tenderness at the sites of tendon or ligament attachments, often affecting areas such as the spine, pelvis, and peripheral joints.
Referral to a specialist, such as a rheumatologist, is crucial for the diagnosis and management of SPA with enthesitis. Rheumatologists are trained to evaluate and treat inflammatory joint and connective tissue disorders, including SPA. The referral may be prompted by symptoms such as persistent joint pain, stiffness, swelling, or signs of inflammation, along with a comprehensive medical history and physical examination.
Summary Listen
- Enthusiasm is a Greek term describing the attachment of a tendon to a bone. Medically, it involves a complex structure including fibrous cartilage, bursa, fat pad, and bone. Enthusiasm can occur in joints like elbows and knees, or in more fibrous tissues like plantar fascia or the Achilles tendon.
- The pathophysiology of enthusiasm often begins with initial pain after a mechanical injury stimulus. This leads to vasodilation, prostaglandin release, and an influx of inflammatory cells. The proliferation of osteoblasts and osteocytes results in spurs, which are a consequence of pain and inflammation. Rheumatologists should recognize early signs of enthusiasm.
- Inflammatory bowel disease and enthusiasm share similar cellular involvement. The inflammatory process may start in the gut due to microbiome imbalances and spread to the tendons. Differentiating tendinitis from enthusiasm is important. Tendinitis can be due to repetitive strain, while enthusiasm is a more pathological disease involving multiple organs.
- The IL-23/IL-17 pathway is crucial in understanding enthusiasm. This pathway starts with dendritic cells, leads to monocyte activation, cytokine secretion, and the activation of TH17 cells. This results in osteoclast and osteoblast activation, leading to bone erosion and new bone formation. Treatments target cytokines like IL-23, IL-17, TNF, and JAK inhibitors.
- Differential diagnoses for enthusiasm include diffuse idiopathic skeletal hyperostosis (DISH) syndrome and knee pain primarily from tendinous issues rather than articulation. Diseases affecting enthusiasm include axial spondyloarthritis, psoriatic arthritis, and undifferentiated arthritis. The guidelines for managing enthusiasm start with NSAIDs, followed by biologics for refractory cases.
- Heel pain is a common presentation, and the presence of multiple spurs indicates a significant pathophysiological illness. It is vital to differentiate enthusiasm from fibromyalgia, which often requires blood tests and X-rays. A mildly elevated CRP, especially if repeated, can indicate an underlying inflammatory process.
- Certain antibiotics, particularly fluoroquinolones, can cause acute tendinopathy. Symptoms include intense pain and swelling, and treatment may include steroids. Immature granular sites may serve as a biomarker, particularly in cases of lower limb pain. Finally, recognizing and addressing enthusiasm earlier can improve patient outcomes.
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