Bones and muscles are held together by tendons and ligaments which allow them to work together to help you move. The place where a tendon or ligament attaches to bone is called an enthesis (plural: entheses). Enthesitis is inflammation of one or more entheses. There are over 100 entheses in your body, and some of the more common spots people experience enthesitis are underneath or on the back of the heels, on the sides of the elbows, and on the outside of the hips.
Enthesitis usually occurs with a group of arthritis types called spondyloarthritis (SpA), including psoriatic arthritis (PsA), axial spondyloarthritis (AxSpA), ankylosing spondylitis (AS), reactive arthritis, and enteropathic arthritis (a type of arthritis that occurs in people with inflammatory bowel disease). Enthesitis is also common in children and youth that live with SpA. People with these types of arthritis may experience pain in the tendons or ligaments due to enthesitis, in addition to painful joints. Around half of all people with PsA and AS will experience enthesitis.
Symptoms & Diagnosis
Having enthesitis can be a sign of active arthritis, but it doesn’t always mean a worsening of your disease. Enthesitis is common in the general population but in patients with axSpA or PsA, it may occur more frequently and be more difficult to control. If you feel your symptoms are progressing or getting worse, consider talking with your doctor about treatment options to reduce or control symptoms.
Symptoms
Symptoms of enthesitis include pain around the entheses. This pain is sometimes accompanied by stiffness and swelling.
The entheses of the lower limbs are more often affected by enthesitis than those of the upper limbs. The most common locations where people experience enthesitis include, underneath or on the back of the heels (achilles tendonitis and plantar fasciitis), on the sides of the elbows (tennis and golfer’s elbow), and on the outside of the hips (trochanteric bursitis). It can also occur in other areas of the body, including fingers, toes, at the back of the head where it meets the neck, and the area where the ribs meet the breastbone.
Enthesitis is also linked to changes in nails, such as pitting or separation from the nail bed, that many people with PsA and AS experience.
Diagnosis
Your doctor will perform a physical examination to diagnose enthesitis. They will note the location of the pain, tenderness, and/or swelling, and will also consider your medical history. Sometimes your doctor may order certain tests, such as an ultrasound or MRI to help confirm the diagnosis. There are no standard lab tests that can detect enthesitis.
Rheumatologists often look for the presence of enthesitis to help confirm the that a patient has a type of SpA and not another type of arthritis that may have similar or overlapping symptoms.
Treatment
Treatment options for enthesitis vary depending on the severity and location of the symptoms. Treatments that are effective for noninflammatory enthesitis such as active rehab and NSAIDs may be considered in patients with axSpA and PsA. Some patients with inflammatory arthritis may have also have enthesitis and treating their arthritis may help the enthesitis. Speak with your doctor to decide what the best treatment option is for you.
Physiotherapy
Many enthesitis flares can be managed with physiotherapy and strengthening exercises that work the muscles as they slowly stretch — like when lowering a weight. This type of movement is called eccentric loading.
Orthotics
Orthotics can be helpful for managing plantar fasciitis in patients with flat feet.
Tennis elbow brace
Patients with tennis and golfer’s elbow may experience some relief with the use of an elbow brace to offload force on the entheses.
Medications
If your pain or symptoms persist, talk with your doctor to determine if medication is right for you.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) help treat inflammation and can be used to treat mild symptoms. Some people cannot take NSAIDs, so it is best to talk to your doctor or a member of your healthcare team about your symptoms and health history before starting any new medications.
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Conventional disease-modifying anti-rheumatic drugs (DMARDs) may be helpful for treating symptoms of arthritis, but there isn’t enough evidence to know if they improve enthesitis.
Apremilast, a phosphodiesterase blocker DMARD that is often used to treat PsA, has also been shown to be effective in treating enthesitis in some people.
Biologics and tsDMARDs
Some biologic drugs used to treat spondyloarthritis seem to improve enthesitis, specifically tumour necrosis factor (TNF), IL17, IL23, IL12/23, and JAK inhibitors.
Corticosteroids
Local corticosteroid injections may be used in certain cases.
Self-Management
Although there is no cure for enthesitis, there are things you can do to help manage the condition. Your active involvement in developing your treatment plan is essential.
If the enthesitis occurs in the foot, elevating the affected foot, or wearing special shoes, shoe inserts, braces or compression socks may help reduce symptoms.
Some people report that use of over-the-counter remedies such as Epsom salt soaks, diclofenac gel, and cannabidiol (CBD) products help relieve symptoms, however there is not enough evidence to know if they work. Heat or cold therapy may also help manage pain from enthesitis.
Heat
Taking a warm shower and using warm packs are ways to help reduce pain and stiffness. It is recommended to always use a protective barrier, such as a towel, between the warm pack and your skin.
Heat is ideal for:
- Relieving pain and stiffness
- Relieving muscle spasms and tightness
- Enhancing range of motion
NOTE: To avoid making symptoms worse, heat should not be applied to an inflamed joint.
Cold
Using a cold pack (commercial, or homemade from crushed ice, ice cubes or a bag of frozen vegetables) can be helpful. It is recommended to always use a protective barrier, such as a towel, between the cold pack and your skin.
Cold is ideal for:
- Swelling
- Decreasing pain
- Constricting blood flow to an inflamed joint
Contributors
This information was last updated May 2025, with expert advice from:
Dr. Jonathan Chan
MD, FRCPC – Rheumatology
Clinical Fellowship in Spondyloarthritis
Clinical Associate Professor, University of British Columbia
Clinical Investigator, Arthritis Research Canada
References:
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5195265/
- https://www.sciencedirect.com/science/article/pii/S0049017217306273
- https://www.sciencedirect.com/topics/medicine-and-dentistry/enthesitis
- https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/physical-effects/enthesitis-and-psa
