ENTHESOPATHY IN PEDORTHICS
The important changeover from attachment of a tendon , ligament , or articular capsule to bone acts has a go-between by two tissues – fibrocartilage and its calcified counterpart . The diffusion of pressure is greatly minimized when tension absorptions are reduced when the connection is permitted to transmit stress equally to the area , rather than become injured by the pressure it is exposed to .
An example of this is with the Achilles tendon ’ s attachment to its corresponding bone , the os calcis . The Achilles tendon fans out at its insertion to the bone , and still expands at its proximal extension as a muscle . This type of broadening will effectively reduce the occurrence of stress and distribute the pressure more widely .
Physically , the enthesis or insertion is comprised of the attachment portion of the tendon ; the attachment portion of the bone which is covered by the periosteum and any other structure , such as bursae , fibrous tissue , adipose tissue and sesamoid bones . The periosteum contributes to a firmer hold to the tendons and ligaments where they affix to the bone . These fibrous structures become built-in at their attachment , and are a direct continuation of the tendonous fibers .
It is good to remember that in the fourth zone , the cartilage layer adjacent to the bone is calcified and known as Yoshida ’ s Zone , which passes into the boney structure . These fibers are not calcified .
The Relationship Between Enthesopathies and Degenerative Disease of Bones and Joints
There is a simultaneous relationship between enthesopathies and degenerative diseases of bones and joints . It becomes an intergral part in rheumatic diseases such as rheumatoid spondylitis . The capacity to elude new bone formation is lacking ; therefore in rheumatoid spondylitis slackening of ligamentous tension occurs , giving a joint laxity . Also , joints do not develop stiffness and ankylosis .
In another condition such as Reizer ’ s Syndrome , a disorder in which insertion of tendons and facia become inflamed verified by bone scans , heel pain occurs in more than 50 % of patients and calcaneal periostitis or erosions may be seen in x-rays . In addition , ‘ sausaging ’ or diffuse swelling of the toes is common and reflects combined articular and soft tissue involvement . Also in this Syndrome , the enthesitis of the calcaneous is at first destructive and erosive . The enthesitis is most often localized to the distal , superior surface of the oscalcis . The anthesis is often symmetrical .
In psoriatic arthritis , the calcaneal enthesitis is also seen ,
A treatment plan should center on a few common goals to improve disorders of posture and gait , and to prevent contractures and eliminate the underlying cause of disease .
but the changes are often asymmetrical with less bone spur formation .
The relationship between enthesis and other associated metabolic enthesopathies are most evident when the enthesis is known as ochronosis . These are deposits of pigment in tendons and their intersections which may include the apatite crystals .
In articular chondrocalcinosis ( pseudogout ), calcium pyrosphosphate dehydrate crystals are found in the cartilaginous structures or articular capsule . In podogra , or urate gout , tophaceous involvement of the Achilles tendon may produce erosive changes in bone .
Enthesopathies are often encountered in hyperparparathyroidism , both primary and secondary to hemodialysis ; in hypoparathyroidism ; osteomalacia , acromegalic arthoropathy and in paraplegic victims .
A treatment plan should center on a few common goals to improve disorders of posture and gait , and to prevent contractures and eliminate the underlying cause of disease . In acute entheopathies , such as gout inflammation or sports related injuries to the Achilles tendon insertion , intermittent and short-term immobility many be necessary in order to avoid development of contractures .
The local application of ice compresses are also beneficial . This should be supported with elevation of the part , rest and oral analgesics for pain and discomfort . For subacute or chronic enthesopathies , warm or hot compresses are effective . This is further supported with physical therapy involving whirlpool and ultrasound in an attempt to improve the local circulation and enhance healing .
Enthesopathies can become chronic , requiring a lifetime of management including rest , medications , gentle exercises , and other tactics to prevent flare-ups and further injuries . Beyond arthritic conditions , it has been verified over the last decade that even diabetics are sufferers of chronic enthesopathies , especially those that affect gait , knee , hip and ankle , which depending on age may benefit from an orthotic device to improve the mobility .
26 Pedorthic Footcare Association www . pedorthics . org