Clinical implications of reconsideration of enthesitis/enthesopathy/enthesial erosion, as tendon attachment-localized avulsions and stress fracture equivalents

Abstract

Recognizing the mechanical origin of enthesitis/enthesopathy and the avulsion-nature of what had previously been considered erosions, it seems inappropriate to attribute it to stresses related to a person’s normal activities. Conversely, sudden or unconditioned repetitive stresses appears the more likely culprit. Studies of enthesial reaction have lacked standardization as to findings present among individuals who appear to be healthy. Clinical evaluation by palpation and manipulation may be as effective as application of radiologic techniques. Recognition of the mechanical nature of the disease, including individuals with inflammatory arthritis suggests prescription of mechanical solutions that reduce stresses across the involved enthesis.

Keywords: Enthesitis; Epicondylitis; Erosion; Avulsion; Clinical examination

Core Tip: Enthesitis, unrelated to inflammatory diseases, is not the result of, and its presence is not a measure of, routine activities. It results from the application of sudden or unconditioned repetitive stresses. Bone defects at tendon/ligament insertion sites are not the result of biological erosion, but rather of avulsions. To avoid overinterpretation of osseous reaction at entheses, their presence needs to be compared to findings among individuals who appear to be healthy. Recognition of clinically significant enthesitis may be as effectively identified by physical examination, with radiologic techniques possibly redundant. An important component of treatment is reduction of the mechanical stresses to which a given enthesis is exposed.