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

Prolotherapy has emerged as a cost-effective treatment option for chronic musculoskeletal and arthritic pain. It involves the injection of a small amount of solution into multiple painful ligament and tendon insertions (enthesis), typical trigger points, as well as into the adjacent joint spaces to induce healing of the injured structures. It is presumed to work by stimulating weakened structures such as ligaments and tendons to strengthen, tighten and heal by the induced proliferation of cells.

  • In one study Prolotherapy was given to 24 elite kicking-sport athletes (soccer and rugby) with chronic groin pain on average for 15 months from osteitis pubis and/or adductor tendinopathy.
  • Monthly injections were given into the enthesis around the symphysis pubis.
  • Twenty of the 24 patients had no pain and 22 of 24 played their sport without restrictions.8

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]

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