Tuesday, October 4, 2022

What Is Enthesitis Related Arthritis

What Are The Signs & Symptoms Of Enthesitis

QD8 Enthesopathy-related arthritis

Enthesitis-related JIA usually causes symptoms in the low back, knees, ankles, and hips. Symptoms can start when a child is as young as 1 year old.

When the arthritis and enthesitis affect the joints of the low back, it is called juvenile ankylosing spondylitis .

Other problems can include:

Home Remedies For Enthesitis

A physical therapist can give you gentle stretches to do at home to help relieve the pain of enthesitis, Dr. Fields says. In addition, the doctors and patients we talked to suggested:

  • Apply heat or ice to affected areas
  • Maintain a healthy weight. Weight loss can take pressure off the involved areas, Dr. Fields says.
  • Rest and elevate the affected foot. I try to keep the swelling down by icing it, and keeping my leg and foot elevated, Lesley P. told us on Facebook.
  • Wear special shoes. People with plantar fasciitis can benefit from shoe inserts to cushion the heel and may be helped by a consultation with a podiatrist, Dr. Fields says.
  • Wear compression socks, braces, wraps, or even a medical boot.
  • Watch salt intake to control swelling. Salt intake does make a difference, Ruth says.
  • Over-the-counter remedies . I love using Biofreeze on the bone in my foot it helps! Caroline P. told us on Facebook. Other CreakyJoints members recommended Epsom salt soaks, diclofenac gel, magnesium, or CBD products.

Presentations Of Psoriatic Arthritis

Psoriatic arthritis causes swelling, pain and stiffness in your joints and in areas where your tendons and ligaments connect to bone.

Just like psoriasis, PsA can range from mild to severe. Mild PsA is sometimes referred to as oligoarticular, meaning it affects four or fewer joints in the body. More severe PsA is often called polyarticular, meaning it affects five or more joints. But regardless of the severity, psoriatic arthritis can have a profound impact on pain, the ability to do daily tasks and move comfortably.

PsA can involve the peripheral joints or less commonly, the axial skeleton .

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Tendons Ligaments And Achilles Oh My

Given my complex diagnostic journey, it should be no surprise that even my enthesitis cant present itself normally. People predominantly experience it in their heels and the bottom of their feet as opposed to their elbows or other joint locations. For me, it was often at its worst towards the end of my workday when I was exhausted and on stress overload.

In fact, it was so bad that some days I even wondered if I was having a heart attack and experiencing the pain in your arm that is associated with having a heart attack.

Certain Types Of Arthritis Are Prone To Pain Where Tendons And Ligaments Meet Bone Which Is Called Enthesitis Heres How To Deal With It

Juvenile enthesitis

If you have ankylosing spondylitis or psoriatic arthritis, you may be familiar with the pain of enthesitis, an inflammation where tendons and ligaments attach to the bone even if you arent aware it has a name. I didnt know what it was called! Monica D. told us on Facebook. I have pain all the time. Makes it difficult to walk very far.

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S To Detect Sacroiliitis

International League Against Rheumatism criteria define sacroiliitis in children clinically as the presence of tenderness on direct compression over the sacroiliac joint. Other physical examination findings that may indicate sacroiliitis are decreased lumbar flexion or a positive Patricks test . Inflammatory back pain, which is defined as lower back pain that starts insidiously, improves with exercise, and is associated with more than 30 minutes of morning stiffness or alternating buttock pain, may also herald sacroiliitis., In one retrospective study, eleven of 53 children with radiographic findings of sacroiliitis did not have any physical examination abnormalities or a history of inflammatory back pain. The positive and negative predictive values of sacroiliac joint compression in the detection of sacroiliitis in children are unknown.

Enthesitis In Psoriatic Arthritis

Psoriatic arthritis is a form of spondyloarthritis that affects roughly one-third of all people with psoriasis. Enthesitis is a relatively common symptom of psoriatic arthritis. In fact, it is one of the four main signs of psoriatic arthritis. The others include:

  • Peripheral arthritis, which affects large and small joints in the hips, knees, wrists, elbows, feet, ankles
  • Spondylitis, which stems from inflammation of the spinal or sacroiliac joints, or those connecting the sacrum and pelvis
  • Dactylitis, also known as sausage digits, which can cause swelling so severe that the joint can no longer be independently recognized within a finger or toe

All of these manifestations define how and where people experience symptoms of psoriatic arthritis. They also overlap to a certain degree. For example, although doctors refer to dactylitis as a distinct condition associated with PsA, enthesitis in connective tissue usually contributes to the overall swelling. That said, all have distinctive symptoms.

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A Primary Feature Of Spondyloarthritis

If you have seen the words entheses, enthesitis, or enthesopathy in your X-ray or medical reports, the terminology may have been unfamiliar to you. Let’s look at the meaning and also how it relates to various types of arthritis and rheumatic diseases.

  • Enthesis typically refers to the connective tissuewhere tendons, ligaments, or joint capsules attach to bone. Two types of entheses exist: fibrous entheses and fibrocartilaginous entheses. While that is the classic definition, a newer, broader definition suggests that enthesis is more than a simple attachment or insertion siteenthesis functions as a unit which includes adjacent tissues . The unit is referred to as the “enthesis organ complex”.
  • Enthesopathy is any abnormal condition that affects the entheses . Enthesopathy may be due to an inflammatory condition, such as psoriatic arthritis, or a condition related to injury or overload, such as plantar fasciitis.
  • Enthesitis refers to inflammation of the entheses.

How Can Parents Help

Juvenile Idiopathic Arthritis (JIA): Pathology & Clinical Presentation รข Pediatrics | Lecturio

Enthesitis-related JIA usually is a lifelong disease, but treatments can help ease pain, keep kids active, and prevent long-term joint damage. To help your child:

  • Be sure your child takes all medicines exactly as directed.
  • Work with the physical therapist to develop a regular exercise program. This will help keep your childs muscles strong and flexible.
  • Learn all you can about enthesitis-related JIA with your child. Your care team is a great resource. You also can find information and support online at:

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Conditions Associated With Enthesitis

Enthesitis may be linked to inflammatory conditions or it may be mechanically induced by injury. Peripheral enthesitis is characteristic of all of the spondyloarthropathies, including undifferentiated spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and reactive arthritis.

Reactive arthritis is a form of arthritis that results from infection. The swelling of reactive arthritis is often triggered by infection in a more remote body part, such as the urinary tract, intestines or genitals. Typically the joints of the knees, feet, and ankles are targets for inflammation secondary to reactive arthritis. More specifically, enthesitis in people with reactive arthritis usually occurs in the plantar fascia, pelvic bones or Achilles tendon. Reactive arthritis is actually uncommon and usually goes away in most people within a year after onset.

Ankylosing spondylitis is an inflammatory condition that is most prevalent in men. The inflammation of ankylosing spondylitis affects the vertebrae and causes them to fuse. Chronic enthesitis of the tendons and ligaments of the vertebrae is the first step in the eventual fusion of vertebrae, which is the main feature of ankylosing spondylitis. People with ankylosing spondylitis can also experience enthesitis of the costochondral joints, or joints of the ribs. The term plantar aponeurosis refers to the thickened connective tissue that supports the arch of the foot.

Fever As An Initial Manifestation Of Enthesitis

  • Affiliation Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

  • Affiliation Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

  • Affiliation Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

  • Affiliation Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

  • Affiliation Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

  • Affiliation Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

  • Affiliation Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China

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Predominately In White Western European Population

The HLA-B27 gene is found in about 7% of the white western European population with higher and lower rates in other ethnic groups. It tends to be higher in far northern groups such as Inuit and Samis and in certain North American tribes on the Pacific coast and lower in African populations. It is non-existent in Australian Aboriginal populations.

What Causes Spondyloarthritis

Juvenile enthesitis

We dont know what causes spondyloarthritis, but we do know that there is a genetic factor. About 90% of people with spondyloarthritis carry the HLA-B27 gene, a gene that is found in about 7% of the white western European population. The involvement of this gene has been known since 1973 but there is no defining mechanism known by which B27 causes SpA.

Confusingly, the other 10% of people with SpA do not have the HLA-B27 gene, so there must be other factors at play. Researchers have now identified at least twenty genes that have been linked to SpA but their role is not well understood. It is known that the genes ERAP 1 and 2 are closely related to B27, and it may be that it is the interaction of these genes with B27 that causes the disease. It is also known that another gene, that codes for the receptor of IL-23 is involved.

A great deal of genetic research is going on worldwide to identify the genes associated with SpA and the susceptibility of someone, with these genes, developing disease.

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The Development Of Extra

  • 1Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
  • 2Radiology Unit, Meyer Children Hospital of Florence, Florence, Italy
  • 3Department of Pediatrics, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia

Introduction: Enthesitis-related Arthritis is a specific category of juvenile idiopathic arthritis characterized by axial and/or peripheral arthritis, and enthesitis, although other different extra-articular manifestations may encompass its clinical spectrum.

Materials and Methods: In order to examine if ERA-JIA with extra-articular involvement may represent a different entity from ERA without extra-articular involvement, we performed a retrospective, observational, monocentric study, in a cohort of ERA patients followed between 2001 and September 2020 at the Pediatric Rheumatology Unit of Meyer Children Hospital of Florence. We analyzed the demographic, clinical, laboratory and imaging data at the disease onset, as well as after 3, 6, and 12 months follow up.

In our cohort, children diagnosed with ERA-JIA at the onset of disease and then developed extra-articular manifestations show the absence of middle foot involvement and worse prognosis with an early need for the use of biologic agents, and overall low chance to achieve remission.

The Connection With Arthritis

Some kinds of arthritis are autoimmune disorders. This means your body’s immune system makes chemicals that attack and damage your own tissues. This can cause enthesitis.

It’s a common symptom of two kinds of autoimmune arthritis — psoriatic arthritis and ankylosing spondylitis. Psoriatic arthritis, which is common in people with the skin condition psoriasis, can affect your entire body. Ankylosing spondylitis mainly affects your spine.

Enthesitis also happens in about 10% to 20% of children with juvenile idiopathic arthritis, which can affect one or more joints and lasts at least 6 weeks. These children are described as having enthesitis-related arthritis .

Kids with juvenile arthritis often have a family history of inflammatory conditions, like ankylosing spondylitis, psoriatic arthritis, or inflammatory bowel disease. They also have eye redness and pain due to inflammation, along with other arthritis symptoms.

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Papers Of Particular Interest Published Recently Have Been Highlighted As: Of Importance Of Major Importance

  • 1.

    Rosenberg AM, Petty RE. A syndrome of seronegative enthesopathy and arthropathy in children. Arthritis Rheum. 1982 25:10417.

    CAS PubMed Article

  • 2.

    Petty RE et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol. 2004 31:3902.

  • 3.

    Flato B et al. Long-term outcome and prognostic factors in enthesitis-related arthritis: a case-control study. Arthritis Rheum. 2006 54:357382.

    PubMed Article

  • 4.

    Hofer M. Spondylarthropathies in childrenare they different from those in adults? Best Pract Res Clin Rheumatol. 2006 20:31528.

  • PubMed Central PubMed Article

  • 6.

    Ramanathan A, Srinivasalu H, Colbert RA. Update on juvenile spondyloarthritis. Rheum Dis Clin N Am. 2013 39:76788. This is a review of juvenile spondyloarthropathies, including clinical features, genetics and therapeutic options.

  • 8.

    Stoll ML et al. Patients with juvenile psoriatic arthritis comprise two distinct populations. Arthritis Rheum. 2006 54:356472.

    PubMed Article

  • 9.

    Butbul Aviel Y et al. Juvenile psoriatic arthritis : juvenile arthritis with psoriasis? Pediatr Rheumatol Online J. 2013 11:11. A cohort of children with JPsA were examined for unifying clinical features and long term outcomes.

    PubMed Central PubMed Article

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    OShea FD et al. Comparison of clinical and radiographic severity of juvenile-onset versus adult-onset ankylosing spondylitis. Ann Rheum Dis. 2009 68:140712.

    PubMed Article

  • Treatment: How Is Enthesitis

    Juvenile Rheumatoid Arthritis for USMLE

    As there is no cure for arthritis, doctors focus on treating the symptoms associated with the disease. Some medical treatments for the disease include:

    • Non-steroidal anti-inflammatory drugs . These drugs help reduce inflammation, swelling and pain. Many NSAIDs are available over-the-counter and include ibuprofen and naproxen .
    • Corticosteroids. These are powerful anti-inflammatory medicines, such as prednisone, that can significantly reduce inflammation.
    • Biologic therapies. These drugs help treat the underlying inflammation and can be prescribed if NSAIDs or corticosteroids dont work. These help suppress the immune system and prevent damage to the joints.

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    Types Of Arthritis That Cause Enthesitis

    If you have rheumatoid arthritis or osteoarthritis, chances are you wont experience enthesitis, because it generally only occurs with certain types of arthritis called spondyloarthropathies , which include non-radiographic axial spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis , and reactive arthritis .

    Enthesitis is actually one of the hallmark traits of SpA. It is not a feature of rheumatoid arthritis this is one of the ways in which SpA differs from RA, Dr. Appleyard says.

    Doctors arent exactly sure why SpA targets the enthesis, but it may be that a specific inflammatory response occurs in areas under biomechanical stress .

    About half of people with psoriatic arthritis and ankylosing spondylitis have enthesitis, says Dr. Fields. In both psoriatic arthritis and ankylosing spondylitis, the back and under portions of the heel are common sites of enthesitis.

    There are many other areas where enthesitis can occur, he says, including the inner and outer sides of the elbows, the area where the ribs meet the breastbone, the back of the head where it meets the neck, and in the spine in the area closest to the skin.

    Does Psoriatic Arthritis Cause Enthesitis

    Enthesitis is a well-established sign of psoriatic arthritis that affects over a third of people with the condition. However, PsA is not the sole cause of enthesitis.

    People who dont have psoriatic arthritis can also develop enthesitis, typically after they have experienced an injury or repetitive trauma. Tennis elbow , for example, is a common enthesitis-related complaint that occurs after a person overuses their elbow with repetitive movements.

    The main difference between enthesitis caused by mechanical problems and PsA-related enthesis is in how they each heal. Generally speaking, enthesitis related to overuse will fade if a person cares for their injury and avoids the repetitive movement that caused their inflammation. But for a person with PsA, enthesitis is often a chronic problem.

    For reasons doctors dont yet fully understand, people with psoriatic arthritis tend to have a lower threshold for enthesitis development. Mechanical stress, injury, or infection can all trigger long-term inflammation and ultimately lead to full-blown enthesitis. Experts believe enthesitis is better described as an early indicator of psoriatic arthritis, rather than a direct result of the disease.

    There are several risk factors associated with PsA-related enthesitis. Those who have enthesitis in PsA tend to be young, have severe cases of psoriatic arthritis, or have a high body mass index .

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    What Causes Enthesitis

    Enthesitis-related JIA happens when the immune system, which normally attacks germs, mistakenly attacks the joints. This causes inflammation in the joints and other problems in the body.

    Doctors dont know exactly why kids and teens get JIA. Idiopathic means from an unknown cause. It can run in families but often does not. Its likely due to a combination of:

    • genetic causes
    • the way the immune system responds to infection and illness
    • a trigger, such as an infection

    S To Detect Enthesitis

    Enthesitis Related Arthritis

    Enthesitis in children is typically diagnosed by clinical findings including localized pain, tenderness, and swelling. The findings at certain entheses, however, are nonspecific and can also be found in normal children, along with overuse injuries, apophysitis, and fibromyalgia. Multiple instruments have been used in adults to assess the extent and severity of enthesitis in adults, including the Mander Index, a modified Mander Index, the Spondyloarthritis Research Consortium of Canada Enthesitis Index, the Maastricht Ankylosing Spondylitis Enthesitis Score,, the Leeds Enthesitis Index, and the Major Enthesitis Index. The entheses examined with the Spondyloarthritis Research Consortium of Canada, Maastricht Ankylosing Spondylitis Enthesitis Score, Leeds Enthesitis Index, and Major Enthesitis Index are listed in . A standardized enthesitis index for pediatric patients has not yet been developed. In practice, many pediatric rheumatologists examine the lower extremity entheses by applying pressure on each enthesis with the dominant thumb until the nailbed blanches.

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