Body Pain and Axial Spondyloarthritis

There are a variety of symptoms associated with spondyloarthritis (SpA). Some are hallmarks of the condition, while others may seem unrelated at first. Knowing the range of possible symptoms can help you in letting your health care provider know about any new symptoms. It can also help in getting you appropriate treatment sooner, rather than waiting until they worsen.

Not everyone will have every symptom, and the frequency and severity of symptoms can vary at different points along the AxSpA spectrum as the condition progresses. Awareness of symptoms can help you get treatment earlier, which can help relieve discomfort or pain and improve quality of life. Enthesitis is a symptom that is characteristic of SpA.

What is enthesitis?

Enthesitis is defined as the inflammation of tendon, ligament, and joint capsule insertions to bones.1 In plain language, it is when the area where tendons and ligaments attach to bones becomes inflamed. Often times this happens in areas that are used in daily activities like sitting, standing, or walking.2 The inflammation causes pain or discomfort in these joint areas called entheses.

Figure 1. A joint without inflammation versus an inflamed joint with enthesitis

A normal joint next to a joint with enthesitis showing red inflammation and swelling.

Why enthesitis occurs

There is no known one cause of enthesitis. Instead, it appears to be caused by a variety of factors. Research has been done that shows that when entheses are repeatedly stressed, an inflammatory reaction is caused.2 This produces proteins called cytokines, as well as other inflammatory cells that go into other tissues.1,2 Bone tissue that comes into contact with these cells acts like it has been injured and needs to repair the bone – and makes new bone.1,2

Infection with microbes may also play a part in enthesitis. Some people with SpA are more susceptible to infections, and these microbes may set off an immune response that leads to inflammation.1

More research needs to be done in this area, but this is a good start to helping provide treatment for enthesitis.

How enthesitis is treated

Treatment for enthesitis has mainly been only nonsteroidal anti-inflammatory drugs (NSAIDs). Using NSAIDs can effectively treat symptoms and may also slow down progression of bone changes in ankylosing spondylitis (AS).1 This makes NSAID use a critical part of AS therapy.1

For those whose enthesitis does not respond to NSAIDs, biologic medications such as TNF (tumor necrosis factor) inhibitors may be used. TNF inhibitors are drugs that are used in treating inflammatory conditions.3 These conditions include inflammatory bowel disease (IBD), AS, juvenile arthritis, rheumatoid or psoriatic arthritis, and psoriasis.3 The drugs target Tumor Necrosis Factor (TNF), which causes inflammation.

In healthy individuals, surplus TNF is usually blocked. For people who have a rheumatic condition, higher levels of TNF in the blood causes inflammation and other symptoms.3 These drugs help control the amount of excess TNF, reduce related symptoms, and help control inflammation.

TNF inhibitors have not been effective in everyone with SpA-related enthesitis, and not all TNF inhibitors have shown to be effective.1 The TNF inhibitors that have been found to be effective include: adalimumab, etanercept, infliximab, and golimumab.1

If you have enthesitis, talk with your doctor about your symptoms and what you’re experiencing. Together you can come up with a treatment plan to help reduce symptoms and ease any discomfort.

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Written by: Jaime Rochelle Herndon | Last reviewed: May 2020