# Enthesitis

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Inflammation where tendons and ligaments attach to bones

Medical condition

Enthesitis Typical joint showing the entheses Specialty Rheumatology

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**Enthesitis** is [inflammation](/source/Inflammation) of the [entheses](/source/Entheses) (singular: enthesis), the sites where [tendons](/source/Tendon), [ligaments](/source/Ligament) and [joint capsules](/source/Joint_capsule) attach to [bones](/source/Bone).[1][2]

It is a type of [enthesopathy](/source/Enthesopathy), meaning any [pathologic](/source/Pathology) condition of the entheses, with or without inflammation. There are some cases of isolated, primary enthesitis which are very poorly studied and understood. It is known to be associated with other [autoimmune diseases](/source/Autoimmune_disease), like spondyloarthropathies and psoriasis (thought to often precede psoriatic arthritis). A common autoimmune enthesitis is at the [heel](/source/Heel), where the [Achilles tendon](/source/Achilles_tendon) attaches to the [calcaneus](/source/Calcaneus).

It is associated with [HLA B27](/source/HLA_B27) arthropathies, such as [ankylosing spondylitis](/source/Ankylosing_spondylitis), [psoriatic arthritis](/source/Psoriatic_arthritis), and [reactive arthritis](/source/Reactive_arthritis).[3][4]

## Signs and symptoms

Early clinical manifestations are an aching sensation akin to "working out too much", and it gets better with activity. It is worse in the morning (after sleeping and not moving). The muscle insertion hurts very focally as it joins into the bone, but there is little to no pain at all with passive motion.

Symptoms include multiple points of tenderness at the heel, [tibial tuberosity](/source/Tibial_tuberosity), [iliac crest](/source/Iliac_crest), and other tendon insertion sites.

## Diagnosis

Sagittal magnetic resonance images of ankle region: psoriatic arthritis. (a) Short tau inversion recovery (STIR) image, showing high signal intensity at the Achilles tendon insertion (enthesitis, thick arrow) and in the synovium of the ankle joint (synovitis, long thin arrow). [Bone marrow oedema](/source/Trabecular_oedema) is seen at the tendon insertion (short thin arrow). (b, c) T1 weighted images of a different section of the same patient, before (panel b) and after (panel c) intravenous contrast injection, confirm inflammation (large arrow) at the enthesis and reveal bone erosion at tendon insertion (short thin arrows).

## Management

- [Nonsteroidal anti-inflammatory drugs](/source/Nonsteroidal_anti-inflammatory_drugs) (NSAIDs).[2]

- [Corticosteroid](/source/Corticosteroid) injections.[2]

- [Disease-modifying antirheumatic drug](/source/Disease-modifying_antirheumatic_drug) (DMARD).

## Related conditions

Anatomically close but separate conditions are:

- [Apophysitis](/source/Apophysitis), inflammation of the bony attachment, generally associated with overuse among growing children.[5][6][7]

- [Tendinopathy](/source/Tendinopathy) is a disorder of the tendon, and is associated with direct injury or repetitive activities.[8]

## References

1. **[^](#cite_ref-1)** Maria Antonietta D'Agostino, MD; Ignazio Olivieri, MD (June 2006). "Enthesitis". *Best Practice & Research Clinical Rheumatology*. **20** (3). Clinical Rheumatology: 473–86. [doi](/source/Doi_(identifier)):[10.1016/j.berh.2006.03.007](https://doi.org/10.1016%2Fj.berh.2006.03.007). [PMID](/source/PMID_(identifier)) [16777577](https://pubmed.ncbi.nlm.nih.gov/16777577).

1. ^ [***a***](#cite_ref-Watad2018_2-0) [***b***](#cite_ref-Watad2018_2-1) [***c***](#cite_ref-Watad2018_2-2) Watad, A; Cuthbert, RJ; Amital, H; McGonagle, D (30 May 2018). ["Enthesitis: Much More Than Focal Insertion Point Inflammation"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976708). *Current Rheumatology Reports*. **20** (7): 41. [doi](/source/Doi_(identifier)):[10.1007/s11926-018-0751-3](https://doi.org/10.1007%2Fs11926-018-0751-3). [PMC](/source/PMC_(identifier)) [5976708](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976708). [PMID](/source/PMID_(identifier)) [29846815](https://pubmed.ncbi.nlm.nih.gov/29846815).

1. **[^](#cite_ref-Schett2017_3-0)** Schett, G; Lories, RJ; D'Agostino, MA; Elewaut, D; Kirkham, B; Soriano, ER; McGonagle, D (November 2017). "Enthesitis: from pathophysiology to treatment". *Nature Reviews Rheumatology* (Review). **13** (12): 731–41. [doi](/source/Doi_(identifier)):[10.1038/nrrheum.2017.188](https://doi.org/10.1038%2Fnrrheum.2017.188). [PMID](/source/PMID_(identifier)) [29158573](https://pubmed.ncbi.nlm.nih.gov/29158573).

1. **[^](#cite_ref-Schmitt2017_4-0)** Schmitt, SK (June 2017). "Reactive Arthritis". *Infectious Disease Clinics of North America* (Review). **31** (2): 265–77. [doi](/source/Doi_(identifier)):[10.1016/j.idc.2017.01.002](https://doi.org/10.1016%2Fj.idc.2017.01.002). [PMID](/source/PMID_(identifier)) [28292540](https://pubmed.ncbi.nlm.nih.gov/28292540).

1. **[^](#cite_ref-Osgood-Schlatter_5-0)** ["OrthoKids - Osgood-Schlatter's Disease"](http://orthokids.org/Condition/Osgood-Schlatter-s).

1. **[^](#cite_ref-Kidshealth_6-0)** ["Sever's Disease"](http://kidshealth.org/parent/medical/bones/severs_disease.html). Kidshealth.org. Retrieved 2014-04-29.

1. **[^](#cite_ref-pmid15555843_7-0)** Hendrix CL (2005). "Calcaneal apophysitis (Sever disease)". *Clinics in Podiatric Medicine and Surgery*. **22** (1): 55–62, vi. [doi](/source/Doi_(identifier)):[10.1016/j.cpm.2004.08.011](https://doi.org/10.1016%2Fj.cpm.2004.08.011). [PMID](/source/PMID_(identifier)) [15555843](https://pubmed.ncbi.nlm.nih.gov/15555843).

1. **[^](#cite_ref-NIH2017_8-0)** ["Tendinitis"](https://web.archive.org/web/20171004212713/https://www.niams.nih.gov/health-topics/tendinitis/advanced). *National Institute of Arthritis and Musculoskeletal and Skin Diseases*. 12 April 2017. Archived from [the original](https://www.niams.nih.gov/health-topics/tendinitis/advanced) on October 4, 2017. Retrieved 18 November 2018.

## External links

Classification D DiseasesDB: 18256 SNOMED CT: 359643005

v t e Soft tissue disorders Capsular joint Synoviopathy Synovitis/Tenosynovitis Calcific tendinitis Stenosing tenosynovitis (Trigger finger) De Quervain syndrome Transient synovitis Ganglion cyst osteochondromatosis Synovial osteochondromatosis Plica syndrome villonodular synovitis Tenosynovial giant cell tumor Bursopathy Bursitis Olecranon Prepatellar Trochanteric Subacromial Achilles Retrocalcaneal Ischial Iliopsoas Synovial cyst Baker's cyst Calcific bursitis Noncapsular joint Symptoms Ligamentous laxity Hypermobility Enthesopathy/ Enthesitis/ Tendinopathy upper limb Adhesive capsulitis of the shoulder Shoulder impingement syndrome Shoulder injury related to vaccine administration Rotator cuff tear Golfer's elbow Tennis elbow lower limb Iliotibial band syndrome Patellar tendinitis Achilles tendinitis Calcaneal spur Metatarsalgia Bone spur other/general: Tendinitis/Tendinosis Nonjoint Fasciopathy Fasciitis: Plantar Nodular Necrotizing Eosinophilic Fibromatosis/contracture Dupuytren's contracture Plantar fibromatosis Aggressive fibromatosis Knuckle pads

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Adapted from the Wikipedia article [Enthesitis](https://en.wikipedia.org/wiki/Enthesitis) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Enthesitis?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.