The enthesis is the insertion of a tendon, ligament, capsule, or fascia into bone.
Enthesitis is inflammation of the origin and insertion of ligaments, tendons, aponeuroses, annulus fibrosis, or joint capsules and is a characteristic feature of Seronegative spondyloarthritis. Inflammation may occur at any enthesis in AS, although it is most common in the entheses of the lower limbs, especially in the calcaneus at the insertion of the Achilles tendon and the plantar fascia.
Pathologic examination of enthesitis in AS demonstrates local inflammation, fibrosis, erosion, and ossification. Bursitis and synovitis may also occur adjacent to the entheses, and it has been postulated that the entheses may be the initial site of joint inflammation in AS. In conventional system of medicine the treatment only relies on analgesics, NSAIDs, certain biologics agents and DMARDs class of drugs, which only gives temporary relief from the symptoms and as the time passes even this relief period is shortened to an extent where the person becomes resistant to its action. Thus this article intends to elucidate the use of homoeopathy remedies which not only helps to subside the various sign and symptoms but also if prescribed early can eradicate the disease.
KEYWORDS – enthesitis, seronegative spondyloarthritis, NSAIDs, achillies tendon, Homoeopathy, disability, enthesopathy.
DEFINITION – Entheses are regions where a tendon, ligament, or joint capsule attaches to bone. Disorders of entheses are called enthesopathies and are commonly found in seronegative spondyloarthropathies (where rheumatoid factor is negative),
including AS. The spondyloarthropathies are articular conditions that affect spinal joints as well as peripheral joints in different degrees.
Enthesopathy is unique to the spondyloarthropathies (SpA) and appears as painful localized tenderness at the tibia, the
peripheral patella, and the calcaneal insertion of the Achilles tendon and plantar fascia. Enthesitis is inflammation of the origin and insertion of ligaments, tendons, aponeuroses, annulus fibrosis, or joint capsules and is a characteristic feature of SpA.
Overuse (like repetitive motion), injury (traumatic or from sports) or diseases, such as psoriatic arthritis or ankylosing spondylitis, are the most common causes. People who develop enthesitis may have been seen by a physician for continued bouts of tendinitis, that may either affect one part of the body or multiple areas of the body, before a diagnosis of enthesitis is made.
Pathologic examination of enthesitis demonstrates local inflammation, fibrosis, erosion, and ossification.Bursitis and synovitis may also occur adjacent to the entheses. There are two types of entheses: fibrous and fibrocartilaginous.
Fibrous entheses are found at the attachment of tendon to the metaphysis or diaphysis, and are composed of dense fibrous tissue. They are thought to be of little importance in rheumatic diseases. Fibrocartilaginous entheses are present on epiphyses of long bones and on small bones of the hands and feet. They appear to be more important in inflammatory disease. It includes
the peritoneum, which is continuous with the periosteum; collagen fibers of the tendon or ligament, which insert into the bone; the adjoining fibrocartilage; and bone not covered by periosteum. A wide variety of overuse or sporting injuries might not be inflammatory but instead due to overloading and microinjury or degenerative mechanisms can later lead to enthesitis.
CLINICAL PRESENTATION –
A careful history and a thorough but gentle palpation of entheses may document evidence of past or present inflammation due to any stress or injury at the entheseal site. Enthesitis is diagnosed clinically from the presence of marked localized tenderness or swelling at the entheseal insertion into the bone, Specially lower extremities at insertional sites around the patella, heel (Achillies tendon), and plantar fascial attachments to the heads of the metatarsals. Observation of stance and gait (including walking on the toes and heels), may reveal altered weight bearing as the person avoids pressure on inflamed entheses. The complaint is mostly of chronic orientation with certain acute exacerbations which frequently produces severe pain and may later on develop into resultant disability.
DIAGNOSTICS and TRAETMENT –
MRI is the diagnosis of choice as it provides a better view of the affected site. Also x-rays and usg of the painful site can be done. Physical examination plays a very important role as it is the basic tool to identify the complaint.
DMARDS or biologic drugs are often prescribed by Rheumatologists to lessen the inflammation and retard joint damage caused by the auto-immune conditions if any. Gentle exercise, behavioural modification, an antiinflammatory diet, therapeutic massage, rest and NSAIDs are often helpful for patients with this condition.
HOMOEOPATHIC MEDICINES –
1.Calcarea Arsenica : It is indicated in pain and stiffness near nape of neck. Violent backache , throbbing , drives out of bed . Weariness and lameness of lower limbs.
- Calcarea Carbonica : It is indicated in persons fair, fatty, flabby . Mentally forgetful, confused , having h/o overlifting . Curvature of dorsal vertebra ,weakness of extremities
- Calcarea Phosphorica : While having some similarity with Calcarea Carbonica it has characters of its own . It is indicated in bone diseases ,it presents with soreness in Sacro-iliac symphysis ; stiffness and pain, with coldness and numbness worse in change of weather ,pain in joints and bones.
- Belladona : It stands for suddenness of onset .Joints swollen , inflamed, with severe throbbing pain , joints very hot to touch . Stiff neck, Swelling of glands of neck, pain in nape as if it would break . Pressure on dorsal region most
painful . Lumbago , with pain in hip and thigh.
- Bellis Perennis : Sore bruised feeling in pelvic region . Soreness of abdominal walls and uterus . Joints sore, muscles soreness. Itching on back and flexor of thighs. Wrist feels contracted as from an elastic band around joints . Sprain with great soreness . Railway spine .
- Bryonia Alba : Painful stiffness in nape of neck. Stiches and tearing; worse on least movement. Knees stiff and painful. Every spot is painful on pressure .
- Apis mellifica : This remedy relieves swollen joints with itching and stinging pain , relieved by cold compress.
- Kalmia latifolia: Pain in neck down arm ; in upper three dorsal vertebrae extending to shoulder-blade . Pain down the back as if it would break ; in localized regions of spine ; through shoulders lumber pains of nervous origin.
Pain affects large part of limb. Weakness numbness. Pain along the ulnar nerve , index finger. Tingling and numbness of left arm.
- Nux Vomica : Backache in lumbar region . Burning in spine ; worse , touch . Must sit up in order to turn in bed . Bruised pain below scapulae. Legs numb feels paralyzed ; cramps in calves and soles. Partial paralysis , from overexertion on getting soaked. Cracking in knee joint during motion . Drags his feet when walking . Sensation of loss of power in the in limbs in the morning.
- Rhus Toxicodendron : Pains tearing tendons ligament and fascia .Soreness of condyles of bone . Better by continuous motion. Numbness and formication from overwork .Tenderness of knee joint loss of power in forearm and fingers.
- REFERENCES –
- An enthesis is the point of insertion of a tendon, ligament, fascia or joint capsule to bone. From: Paediatrics and Child Health, 2011
- Clinical features of axial spondyloarthritis Lianne S. Gensler, in Rheumatology (Sixth Edition), 2015
- Structure and Function Ross E. Petty, in Textbook of Pediatric Rheumatology (Seventh Edition), 2016
- https://www.sciencedirect.com/topics/medicine-and-dentistry/enthesis/ Chronic Pain Treatment, Dr. Raj N. Sureja MD, Interventional Pain Management, News and Events, Pain Management, Patient Care / By Ortho OSC
- Kehl AS, Corr M, Weisman MH. Review: Enthesitis: New Insights Into Pathogenesis, Diagnostic Modalities, and Treatment. Arthritis Rheumatol. 2016 Feb;68(2):312-22. doi: 10.1002/art.39458. PMID: 26473401;