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Living with Psoriatic Arthritis (PsA)

Enthesitis and damage

Does Enthesitis “only” cause pain due to inflammation of the tendon where it connects to the bone or does that inflammation point also get damaged permanently? I would appreciate some good teaching on Enthesitis and what it does in relation to PsA.
Is all pain caused by inflammation and if so, how does it go from minimal to crazy and then calm down again so fast? My thinking is that inflammation is a relatively slow event. Man, I have a lot to learn while waiting for the MTX to kick in.
While waiting, my “go to” relief is in Celebrex and 1000mg Tylenol…sometimes allows me to function close to normal but seem to really pay for the extra activity once it wears off. Thanks

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Here’s the short answer from WebMD. Yes, over time it can indeed lead to damage.

Your other question

Wow! I wish I knew the answer to that one! I woke up this morning with my elbow pretty much screaming at me. That one may have been caused by a bad sleeping position, but I’ve had this happen, even whole body.

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I have swelling in the entheses, synovium, and bone marrow of my ankle and upper mid-foot, all of it can definitely damage the tendons. My podiatrist just put me in a full fiberglass cast to minimize the chances of rupture while we decide what to do (surgery, injections, etc.)

The inflammatory process has so many parts that if any of them go awry and it takes a while to get them back in line it could account for those wild swings in pain? Sometimes I feel like some of the parts are just taking a long lunch, then they finally get back in there and do their job and it suddenly gets better.

These days I attribute almost everything to inflammation. But we’re talking the immune system and all I understand about that is that it’s beyond my understanding.

Clearly we still have systemic inflammation at some level even when the disease is controlled … and the effects can be extremely erratic. That’s why, after feeling fit as a flea all day, I’m now awake in the middle of the night dealing with unpleasant symptoms with my go-to remedy - tea, plus the one I’m less sure of, nurofen.

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So we’ve established enthesitis over time causes damage. The more interesting question to me is why does the pain and even swelling go from 0 to 10 and back to 0 again, sometimes so quickly and other times not quick enough.

The only way that makes sense to me to think about it is that I’ve got abnormal immune system something like a wayward child capable of the most ferocious tantrums. And some of those tantrums are over quickly and some sadly take longer or rage longer. And all pain is initially caused by inflammation in my view and then later by the possible damage that inflammation caused. In PsA it’s not at all a slow process as you’re finding out. It can be lightning quick too.

At the beginning I was fascinated that what was painful and so sore one day wasn’t necessarily painful a week or a month later. And that it seemed the disease literally danced all around my body. Oddly it helped me cope because initially if x was sore one day, I thought it would always be sore. And I was so thankful that wasn’t necessarily the case.

The most frustrating part of PsA to me is learning to pace myself better. And three years down the road, I’m still learning to pace better. That helps with the pay back issue when the painkillers wear off.

Yes, it definitely causes damage! Long term it causes calcification of the enthesis/tendon ie. bone spurs. The extensor tendon of my right arm is growing bone as I type.

Thank you for that excellent illustration, it describes things well!

Thanks…what means are used to determine if damage has begun or happened etc? How long does it take for irreversible damage to occur?

There’s no set time for damage to happen. That depends on too many different factors. So if you’ve had pain for 6 months in your left ankle - you may not have any damage there. However another person could have pain in their left ankle for just a month and does have damage there.

So it’s a perpetual case of watching and seeing. And taking whatever meds you’re prescribed in order to slow down the your process of any damage occuring. It does also mean you have to be untop of things too and become a somewhat assertive patient as well. As in ‘squeaky wheels’ get the oil.

X-rays, scans etc can show damage and of course you ‘feel’ it too.

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I don’t think there is a one size fits all answer @Amos, as Poo says lots of factors affect it. From what docs have said to me, long term inflammation doesn’t even have to be the extreme pain causing variety to start to effect changes. My arm tendon issue was “discovered” by ultrasound when I asked for a steroid injection because I had developed functional problems along with pain and tenderness. I understand that extracorporeal shockwave treatment (same as used to blast kidney and gallstones etc) is being successfully used as an alternative to surgery for bone spurs, when interventional treatment is necessary.

A good example of the pain/changes scale for me is that I discovered last summer I have partial fusion of some of my neck vertebrae … and I would say that I have never had pain in my neck that I would identify with changes/damage on that scale. I had some transient neck pain decades ago; might be that I had PsA all those decades ago even though I only started with symptoms in 2011 that led to a diagnosis in 2012. As you’ll see here on the forum PsA is a slippery and deceitful disease.

I had neuropathy in the bottoms of my feet several years before the actual damage appeared. The burning and stinging were every day for several months before my rheumy finally prescribed nortriptyline, which stopped that pain. It wasn’t until a couple of years after that when I started experiencing pain in my arches and xrays and MRIs showed the cartilage there was eroded and I had bone on bone in several of those joints. The cartilage in my ankle joints is nearly completely eroded, too, and I had never experienced pain in my ankles. Oh, and my back “went out” 6 weeks after I started Enbrel, even though Enbrel was working well and my PsA seemed to be about 90% controlled! All the years of stiffness and pain in my lower back had apparently done more damage than I thought.

My conclusion: if you have pain and inflammation, expect damage…but don’t be too sure there’s no damage where you haven’t had any pain!

All of these answers have been so excellent in helping me see a bigger picture. I’ve never encountered such mystery and unpredictability in my body before. It’s like 2+2=4 or 7 for a while but then it changes to 12! This site does help with some of the known issues as described by those with far more experience than me. I’ve even found that taking an NSAID and Tylenol helps marvellously…sometimes! Same drugs, same body, same disease and they can be very effective or absolutely no help at all. I just took my 8 week dose of 15 mg MTX and will bump up to 20…absolutely no help so far. Or, perhaps I would be way worse if not on it. Have any of you experienced long term remissions?

Sadly this made me smile a little. Define ‘long term’? And define what you mean by ‘remission’? Is that no symptoms of anything or just manageable symptoms?

I’ve done well for up to three months at a time periodically. But haven’t yet managed any longer than that yet. Every time I think I’m doing well, something odd will just fell me. I’ve gone through two inexplicable stress fractures in my pelvis, no idea how they occured. Thankfully they both occured at the same time. Followed swiftly by a gash on my shin taking 7 months to heal (getting infected twice too) and needing to be booted in plastic to shower. That was followed by my DMARD abruptly stopping. 4 months later I start a biologic. 5 months later I suffer persistent diarrhoea for 7 long weeks finally landing up in hospital. It transpired the DMARD didn’t like the biologic so once I stopped the DMARD I was better within 24 hours. I’ve just completely around 3 months feeling pretty marvellous only to be felled by horrendous back pain that had me in tears and unable to do much of anything. That’s finally easing now after 3 rather awful weeks. I just live in the day now. If today is a good day for me that’s brilliant. If it’s not, I’m hopeful tomorrow will be better at least.

You probably won’t find mxt does much until 3 to 6 months. It, like most of the DMARDS, are very slow burners. That’s frustrating initially but you really should find it starts helping eventually. It’s brilliant you’re tolerating it. I couldn’t tolerate it at all.

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I am sorry to hear of the degree of bodily pains that you have had over the years. Your “Take it one day at a time” counsel seems wise. Because all of this started with very mild inverse psoriasis, which is down to a few very small flare ups that I can easily put out, I thought that the arthritis issue would act the same and just fade away like most of my psoriasis. But so far, the weirdness just keeps surprising me. I find it very frustrating as to how to plan my day. I’m still in a bit of denial as I keep thinking, “Its only pain…I can push through it and live a normal life”. To some degree it works but the pain is dampening my ambition. We live on an acreage, heat with wood, maintain a large garden etc…I’m really fighting the urge to say “no” to all of the needs around the place that we love to do.
So, I am hoping for “remission”… one that allows a close to normal life. I sometimes wonder if folks who have been doing very well on their meds and living close to normal don’t share their success stories on this site…they are too busy enjoying a pain free existence? Is this site primarily used by those who are in a real bad way? I guess that’s a tough one to know!

I think there’s a large amount of truth in that. People who are doing fine are too busy just living. But here there are success stories too. Which is lovely to see. And I tend to stick around regardless how I’m doing. :smile:

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My take on the answer to your last two questions is “probably”.

When I was first diagnosed in 2012 I was here every day, usually multiple times a day, because I needed information and support as well as share what I was learning and to help other people. When you’re scared and in pain and wondering what the heck is happening this is a great place to receive and give support. I then became a moderator for this and several other of the Ben’s communities but somewhere along the way I think I just burnt out. I burnt out with all my own issues and just couldn’t find the place within me to reach out and help others like I’d once been able to.

Today (and I mean that in the broad sense) I feel fed up with the whole PsA cr@p-shoot. I’ve got it; it’s not going away, it’s mine for life and I have to get on with living it. Sometimes it’s better and sometimes worse and I’ve had a few medication and infection scares along the way too. The medics are pretty happy with how my biologic seems to be controlling things but do I think I’m living close to a normal life? By the standards of my pre-PsA life the answer is “no” but in terms of my new adapted life then I guess I have to be honest and say “yes” I have a pretty good one but it’s one where I have to take it day-to-day and sometimes moment-to-moment so I try not to dwell on it too much and just be.

My feeling is that most people find some kind of equilibrium eventually.

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Sorry I missed this earlier. The answer to the original question is Yes. Most commonly in the feet. That being said MORE common than damage from enthesitis, in the cases of severe pain is good old fashioned Bursitsis. (the bursa is right next to the entheses) The inflammation just sorta spills over. Its worth exploring as there are some pretty good treatment options for Bursitis that can result in releif in the entire area.You can read more at:

Of interest to me were some numbers (discovered too late for these patients involved-ie: autopsy) - “The authors of the study detected features of degeneration in 76% of cases. Synovial inflammatory changes of SECs were noted in 85% of cases (including 57% of Achilles tendon entheses). Enthesitis of the Achilles tendon was found in 73% of cases”

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A excellent website on the latest info about Enthesitis is this website:
http://www.enthesis.info/

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Here is a outline of PsA damage:
http://enthesis.info/spondyloarthritis/the_pip_in_psa.html

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