Enthesiopathy: clinical manifestations, imaging and treatment

Enthesitis is a distinctive pathological feature of spondyloarthropathy 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 spondyloarthropathy. 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 spondyloarthropathy, including the undifferentiated ones, and may for a long time be the only long-standing clinical manifestation of the B27-associated disease process. Various imaging methods have been suggested for studying peripheral enthesitis. Ultrasonography and magnetic resonance imaging are the most useful because they may show alterations of the structures involved. Therapy of peripheral enthesitis consists of NSAIDs, orthoses and physical therapy. Steroid injections, second line drugs such as sulphasalazine and radiotherapy are reserved for more severe cases.