For years I have been wanting to see more research and more content about enthesitis. It’s a common source of pain for Psoriatic Arthritis and Spondylitis patients but no one ever talks about it. Everything is generalized to be joint pain. An enthesis is “The site where a tendon or ligament inserts into a bone” and “enthesitis occurs when an enthesis becomes inflamed” (Timothy Gower, 2024)
Some of the earliest manifestations of Psoriatic Arthritis in kids is enthesitis particularly in presenting as Achilles tendonitis….so why is it that no doctor has mentioned tendonitis or enthesitis to me since I was a teenager showing mainly tendonitis and enthesitis pain? Is it because there is no treatment, it isn’t studied or are patients and physicians not educated about it enough to remember to talk about it? Its one of those symptoms that makes me feel like a crazy person. Like no my fingers and toes have not swelled up recently and I don’t have any joints sensitive to the touch right now but I have tendonitis flares in my ankles, elbows and wrists and bursitis in my knees.
In a recent editorial, researchers called attention to the fact that we need treatment for all presentations of Psoriatic Arthritis including enthesitis. They stated that enthesitis “is observed in 30% of real-life patients but generally exceeds 60% in randomized clinical trials, representing one of the major contributors to pain and functional disability, ultimately contributing to difficult-to-treat phenotypes of PsA [1]“(Bernardo, 2024). I cannot tell you I heard I feel after reading that. I’m not crazy, enthesitis just was not part of the focus for the revolutionary treatments that hit the market for autoimmune arthritis diseases like Psoriatic Arthritis. In fact in 2022, a literature review stated that “The majority of trials in PsA did not require patients to have enthesitis at study entry since enthesitis was evaluated only as a secondary outcome” (Eder, 2022). A secondary outcome that probably causes 90% of my Psoriatic Disease pain and daily activity disruption. The farther I read into this article, the more validated I felt. The treatments that I have found most effective for my Psoriatic Arthritis (not my Psoriasis) have been shown to be effective for enthesitis. “Treatments with a strong recommendation for use included: TNFi, IL-17i, IL-12/23i, IL-23p19i, PDE4i, and JAKi.” I have had what might have seemed like an irrational obsession with IL-17, 12 & 23 for the last decade because Stelara was so effective for me for so long for both my Psoriasis and Psoriatic Arthritis. So much so that I was able to start playing soccer again, an activity that I had to quit in high school.
I started this research tonight because I was in my feels and wanting to do something productive and for myself and it worked. I feel validated, hopeful and excited to see what the Group for Research and Assessment in Psoriasis and Psoriatic Arthritis (GRAPPA) publishes next and I am thankful that of a group of researchers are now seeing enthesitis as a primary outcome of Psoriatic Arthritis.
References:
Bernardo D’Onofrio, Carlo Selmi, Bending the curve of enthesitis in psoriatic arthritis with Janus kinase inhibition, Rheumatology, Volume 63, Issue 11, November 2024, Pages 2905–2906, https://doi.org/10.1093/rheumatology/keae267
Eder, L., Mathew, A. J., Carron, P., Bertheussen, H., Cañete, J. D., Azem, M., Sedie, A. D., Salvarani, C., Ranza, R., Elliott, A., Turkiewicz, A., de Toledo, R. A., Bukulmez, H., Stoenoiu, M. S., Mandelin, A. M., Koehm, M., Lindsay, C. A., Siegel, E., & Mease, P. J. (2022). Management of enthesitis in patients with PSORIATIC ARTHRITIS: An updated literature review informing the 2021 Grappa Treatment Recommendations. The Journal of Rheumatology, 50(2), 258–264. https://doi.org/10.3899/jrheum.220312
Timothy Gower. (2024). Enthesitis and psoriatic arthritis: Arthritis foundation. Enthesitis and Psoriatic Arthritis | Arthritis Foundation. (n.d.-b). https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/physical-effects/enthesitis-and-psa
Poggenborg, R. P., Eshed, I., Østergaard, M., Sørensen, I. J., Møller, J. M., Madsen, O. R., & Pedersen, S. J. (2015). Enthesitis in patients with psoriatic arthritis, axial spondyloarthritis and healthy subjects assessed by ‘head-to-toe’ whole-body MRI and clinical examination. Annals of the Rheumatic Diseases, 74(5), 823–829. https://doi.org/10.1136/annrheumdis-2013-204239
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