Enthesitis treatment

Ross Hauser, MD

The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone. The term enthesopathy typically refers to a degenerated enthesis; though when some doctors uses this term, they typically mean enthesitis (inflammation of the enthesis). The problem occurs when allopathic physicians think every pain is due to inflammation and subsequently prescribe NSAIDs and corticosteroid shots.

The entheses can also be damaged by medications. Medical literature contains many studies and case reports on various antibiotics damaging these structures, especially the quinolone antibiotics.1-3

A combined team of German and University of Connecticut researchers wrote of the importance of the enthesis.

  • Tendon/ligament-to-bone entheses are critical components of the musculoskeletal system as they allow for the proper transmission of forces from muscle into bone.
  • Injuries to the tendon/ligament-to-bone enthesis are common in the field of orthopaedic medicine yet high failure rates are often associated with their repair.
  • Based on the structural importance of the entheses, strategies aimed at the regeneration of the tendon-bone enthesis is a rapidly evolving field of orthopaedic medicine with current strategies including the use of cell therapy, growth factors, and scaffolds.

In our office we call these strategies stem cell therapy, platelet rich plasma therapy and Prolotherapy.

These are the more common forms of entheses or enthesopathies:

  • Plantar fasciopathy, the most common cause of plantar heel pain considered to be a type of enthesopathy.
  • Adductor Longus Enthesopathy-related Groin Pain is the most common cause of groin pain in soccer players.
  • Achilles enthesopathy with extreme tenderness is seen in Fibromyalgia patients.4
  • Doctors at the Cleveland Clinic write that enthesopathy is seen in patellofemoral pain and instability in adolescent athletes.5
  • Doctors at Harvard Medical School write that cortisone was not effective for enthesopathy of the extensor carpi radialis brevis the muscle involved in Tennis Elbow.6
  • Doctors at the University of Bern in Switzerland write that one reason for the high rate failure rates of 13-94% in surgical reconstruction of chronic rotator cuff tears include compromised healing at the bone-tendon interface, the enthesis.7

Enthesitis

A true systemic inflammatory condition causes a true enthesitis, which occurs in conditions such as chondrocalcinosis, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, Reiter’s syndrome, rheumatoid arthritis, psoriatic arthritis, and other spondyloarthropathies.

There may be a limited role for anti-inflammatory medications in these conditions, but we can assure you that none of these conditions are caused by an “ibuprofen deficiency!” A comprehensive assessment by a qualified practitioner is needed to cure these types of conditions. We review things in the patient’s life that might be producing stress on the body, including the foods consumed, job, family relationships, and emotional state.

A person with a systemic inflammatory condition is more likely to be taking anti-inflammatory or immune-suppressive medications. These medications make the patient less likely to heal a ligament or tendon injury when it occurs. Everyone sustains some kind of injury every once in a while, such as a sprained ankle. In these cases we still utilize Prolotherapy for people suffering with various spondyloarthropies such as ankylosing spondylitis and autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, however, we recommend that the underlying systemic inflammatory condition be treated.

  • It is becoming clear through medical research that the area where a ligament and tendon attaches, the enthesis, should really be called “the enthesis organ.”(3).
  • This is a specialized area of the musculoskeletal system that contains fibrocartilage and other adjacent or congruous structures such as articular cartilage fat pads, bursae, or synovium.(4,5)

This “organ” may be damaged like any organ of the body. In our experience, the entheses are typically damaged by medications. NSAIDs and corticosteroids are the most common culprits, but the medical literature contains many studies and case reports on various antibiotics damaging these structures, especially the quinolone antibiotics.(6,7,8)

Most tendinopathies are actually enthesopathies; thus the injury occurs to the tendon where it attaches on the bone.  Steroid injections and other medications specifically have been shown to weaken this area.(7,8) Fortunately there is a treatment that is specifically designed to strengthen the entheses: Prolotherapy!

The major cause of degenerative arthritis, chronic pain, and injury is joint instability. Most structural chronic painful conditions involve ligament laxity.Most tendinopathies are caused by joint instability and ligament laxity. To cure these conditions, it is typically best to treat all or most of the ligaments of an unstable joint if that joint and/or its surrounding structures are painful to palpation. Many injections are needed to produce enough of a healing reaction to restore proper joint function to an unstable painful joint. It is a lot like spot welding.

Because the solutions are safe and well-tolerated, many joints and structures can be treated at the same visit. The neck, thoracic, and low back facet joints can also be thoroughly and safely treated without the need of fluoroscopy, which keeps costs down.

With a comprehensive approach, we utilize many different types of Prolotherapy solutions, individualizing each treatment according to the patients’ unique needs. The solutions are changed depending on the individual patient and the amount of inflammatory reaction required to produce sufficient healing and new collagen growth. We use natural ingredients that can be added to the dextrose-based solutions, such as minerals, fatty acids, and hormones; and of course, cellular proliferants such as blood, PRP (platelet rich plasma), bone marrow, and stem cells.

Comprehensive Prolotherapy is typically well-tolerated and does not require use of narcotic medications or NSAIDs, and certainly not steroid injections. Most patients receive treatments and are able to return to work the same or next day. Immediately following Prolotherapy treatments, we ask our patients to refrain from vigorous exercise for at least 4 days. After that, the patients are allowed to let their bodies be their guides.

Results speak for themselves! We have documented our patient results in many published papers which we will review in more detail throughout this book. Suffice it to say, we can unequivocally state that Prolotherapy is effective at producing pain relief in greater than 90% of the patients.

Are you a candidate for our non-surgical treatments? Ask our specialists: Contact us now!


References for this article.

1 Muzi F, Gravante G, Tati E, Tati G. Fluoroquinolones-induces tendonitis and tendon rupture in kidney transplant recipients: 2 cases and a review of literature. Transplantation Proceedings. 2007; 39:1673-1675. [Pubmed]

2 Kempka G, Ahr HJ, Ruther W, Schluter G. Effects of fluoroquinolones and glucocorticoids on cultivated tendon cells in vitro. Toxicology in Vitro. 1996;10:743-754. [Pubmed]

3 Sendzik J, Shakibaei M, Schafer-Korting M, Stahlmann R. Fluoroquinolones cause changes in extracellular matrix, signaling proteins, metalloproteinases and caspase-3 in cultured human tendon cells. Toxicology. 2005;212:24-36. [ Pubmed]

4 Kaşkari D, Yücel AE, Ağildere M. The prevalence of spondyloarthropathy in fibromyalgia patients. Mod Rheumatol. 2016 Dec 23:1-6. doi: 10.1080/14397595.2016.1265694. [Pubmed]

5 Bessette M1, Saluan P. Patellofemoral Pain and Instability in Adolescent Athletes. Sports Med Arthrosc. 2016 Dec;24(4):144-149. [Pubmed]

6 Claessen FM, Heesters BA, Chan JJ, Kachooei AR, Ring D. A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin. J Hand Surg Am. 2016 Oct;41(10):988-998.e2.[Pubmed]

7 Zumstein MA, Lädermann A, Raniga S, Schär MO. The biology of rotator cuff healing. Orthop Traumatol Surg Res. 2017 Feb;103(1S):S1-S10. doi: 10.1016/j.otsr.2016.11.003. Epub 2017 Jan 2. [Pubmed]

8 Topol GA, Podesta LA, Reeves KD, Giraldo MM, Johnson LL, Grasso R, Jamín A, Tom Clark DC, Rabago D. The Chondrogenic Effect of Intra-articular Hypertonic-dextrose (prolotherapy) in Severe Knee Osteoarthritis. PM R. 2016 Apr 4. pii: S1934-1482(16)30054-5. [Pubmed]

3 Benjamin M, Moriggl B, Brenner E, Emery P, McGonagle D, Redman S. The “enthesis organ” concept: why enthesopathies may not present as focal insertional disorders. Arthritis & Rheumatology. 2004 Oct 1;50(10):3306-13.
4 Slobodin G, Rozenbaum M, Boulman N, Rosner I. Varied presentations of enthesopathy. In Seminars in arthritis and rheumatism 2007 Oct 31 (Vol. 37, No. 2, pp. 119-126). WB Saunders.
5 Shaibani A, Workman R, Rothschild BM. The significance of enthesopathy as a skeletal phenomenon. Clinical and experimental rheumatology. 1993;11(4):399-403.
6 Corrao G, Zambon A, Bertù L, Mauri A, Paleari V, Rossi C, Venegoni M. Evidence of tendinitis provoked by fluoroquinolone treatment. Drug safety. 2006 Oct 1;29(10):889-96.
7 Blanco I, Krähenbühl S, Schlienger RG. Corticosteroid-associated tendinopathies. Drug safety. 2005 Jul 1;28(7):633-43.
8 Haraldsson BT, Langberg H, Aagaard P, Zuurmond AM, van El B, DeGroot J, Kjær M, Magnusson SP. Corticosteroids reduce the tensile strength of isolated collagen fascicles. The American journal of sports medicine. 2006 Dec;34(12):1992-7.

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