Dr. Timothy Young discusses a different kind of bone spur in the foot: Enthesophytes, not your typical bone spur.

Introduction:

There can be confusion when talking about bone spurs in the foot. In general, when one thinks of an arthritic bone spur, that is often an osteophyte. However, there is a different kind of bone spur; this is an enthesophyte. The best way to think of an enthesophyte is calcification of the tendon or ligament at its attachment to the bone. A common example would be a heel spur related to plantar fasciitis or calcification of the Achilles tendon where it attaches to the back of the heel bone. It is important to know, however, that calcification of the Achilles tendon or a plantar calcaneal heel spur, in either case, may not cause any pain or symptoms at all. On the other hand, if there is associated inflammation or degenerative changes, there may be symptoms and pain.

Enthesopathy is another similar term describing this condition. Note that Enthesopathy often occurs in response to a mechanical condition, but there can be more of a systemic inflammatory condition also, such as ankylosing spondylitis or psoriatic arthritis. Some of the autoimmune arthritic conditions may potentially be related to this condition.

Enthesophytes vs. Osteophytes: An Overview

Enthesophytes Defined: Enthesophytes are abnormal bony projections that occur at the attachment points of tendons or ligaments to the bone. These bony outgrowths are the result of the body's response to chronic stress and irritation in these connective tissues.

Osteophytes in Contrast: We have previously discussed osteophytes in our prior blog. Osteophytes are abnormal bony projections that form within joint spaces. Unlike enthesophytes, which are associated with the insertion points of tendons and ligaments, osteophytes develop as a response to joint degeneration and inflammation, often associated with conditions like osteoarthritis. The most common osteophytes in the foot and ankle could include the great toe joint, where bone spurs limit motion and cause an enlargement on the top of the joint. In the ankle, it is often the front of the ankle joint that develops osteophytes that can also limit ankle joint motion.

The Stress Response: Understanding Enthesophyte Formation

Chronic Tendon or Ligament Stress: Enthesophytes are born out of the repetitive stress and strain on tendons and ligaments. This stress can result from various factors, including overuse, improper biomechanics, or inflammatory conditions affecting the connective tissues.

Microtrauma and Inflammation: Microscopic damage to the tendon or ligament can lead to localized inflammation. As the body attempts to repair this damage, the bone responds by forming additional bony tissue at the insertion point – thus, an enthesophyte is born.

Common Locations: Enthesophytes can occur at multiple sites throughout the body. Common examples in the foot include the heel, with two common examples being Achilles enthesophyte and an enthesophyte associated with plantar fasciitis or the most typical heel spur.

Distinguishing Features: Enthesophytes vs. Osteophytes

Location:

Enthesophytes: Develop at the attachment sites of tendons or ligaments to bones.

Osteophytes: Form within joint spaces in response to joint degeneration.

Associations:

Enthesophytes: Linked to chronic tendon or ligament stress and inflammation.

Osteophytes: Associated with joint degeneration and conditions like osteoarthritis.

Clinical Manifestations:

Enthesophytes: May cause localized pain at the attachment sites, especially during movement.

Osteophytes: Can impact joint movement, causing pain, stiffness, and reduced range of motion.

Managing Enthesophytes: It is important to understand that in many cases, it is really because of the enthesopathy that we are treating so for calcification of the Achilles tendon, we often are treating Achilles tendon problems. And for treating a plantar calcaneal spur, we often are treating plantar fasciitis as the primary problem, and the enthesopathy may be a secondary problem.

Conservative Measures:

Rest, activity modification, and gradual return to exercise.

Physical Therapy: Stretching and strengthening exercises.

Anti-Inflammatory Medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage inflammation and pain.

Orthotic Support:

Proper footwear and orthotic devices to alleviate stress on affected areas.

Shockwave Therapy: This is extremely effective at treating Achilles tendon problems and calcific Achilles insertional tendinosis and plantar fasciitis.

Platelet Treatments: Concentrated platelets are injected into the damaged tendon or plantar fascia.

Surgical Procedure Interventions:

Tenex: This is a less invasive type of procedure that can remove damaged tendon and remove some of the calcified portions.

Traditional Surgery: In resistant cases, surgical direct treatment may be considered.

Conclusion:

Enthesophytes may relate to the body's adaptation to the demands placed on tendons and ligaments. This condition may (or may not) cause discomfort, especially in the presence of chronic stress, and may limit exercise. Understanding their distinct nature and differentiating them from osteophytes is crucial for accurate diagnosis and effective management. If you suspect the presence of enthesophytes and experience persistent pain or discomfort, please contact our office for consultation or make an appointment online.