ARTHRITIS & RHEUMATISM
Vol. 50, No. 10, October 2004, pp 3306–3313
The “Enthesis Organ” Concept
Why Enthesopathies May Not Present as Focal Insertional Disorders
M. Benjamin,1 B. Moriggl,2 E. Brenner,2 P. Emery,3 D. McGonagle,3 and S. Redman1
Objective. The Achilles tendon insertion is asso-
ciated with a complex of adjacent fibrocartilages, a
bursa, and a fat-pad, and is functionally much more
than a focal insertion. This has important implications
for a better understanding of the spondylarthropathies
(SpA). However, the degree to which other insertions
form comparable “enthesis organs” has not been estab-
lished. The aim of this study was to demonstrate the
applicability of the enthesis organ concept to other
insertion sites.
Methods. Both joint-related (articular) and extra-
articular entheses were removed from 28 sites in the
limbs of formalin-fixed cadavers (age at death 70–101
years) that had been donated for anatomic study. The
samples were prepared for paraffin histologic analysis
and sectioned longitudinally. The presence and extent of
enthesis organs was evaluated at each site in serial
sections stained with Masson’s trichrome and toluidine
blue.
Results. Articular enthesis organs were found at
14 entheses, including the attachments of the digital
extensor tendons and collateral ligaments, the cruciate
ligaments, tibialis anterior, the lateral collateral liga-
ment of the knee, and the popliteal tendon. Extraarticu-
lar enthesis organs were seen at 2 sites, the biceps
brachii and patellar tendon insertions. In all enthesis
Supported by Action Medical Research and Search, Hor-
sham, UK. Professor Emery is an ARC Professor of Rheumatology.
Professor McGonagle is an MRC Clinical Scientist.
1
M. Benjamin, PhD, S. Redman, PhD: University of Cardiff,
Cardiff, UK; 2B. Moriggl, MD, PhD, E. Brenner, MD, PhD, MME:
Medical University of Innsbruck, Innsbruck, Austria; 3P. Emery, MA,
MD, FRCP, D. McGonagle, FRCPI: Leeds Hospital Medical School,
Leeds, UK.
Address correspondence and reprint requests to M. Ben-
jamin, PhD, School of Biosciences, Cardiff University, Museum Ave-
nue, Cardiff CF10 3US, UK. E-mail: benjamin@cardiff.ac.uk.
Submitted for publication April 2, 2004; accepted in revised
form June 30, 2004.
3306
DOI 10.1002/art.20566
© 2004, American College of Rheumatology
organs, sesamoid and/or periosteal fibrocartilage was
present in close association with synovium.
Conclusion. The concept of an enthesis organ is of
general significance in understanding attachment sites
and may explain the diverse pathologic changes, includ-
ing synovitis, bursitis, and extracapsular changes, seen
adjacent to tendon/ligament entheses in SpA. These
findings may provide insight into the reason the target
tissues in SpA are apparently so diverse.
The enthesis is the region in which a tendon,
ligament, or joint capsule attaches to bone, and much of
the pathology in the spondylarthropathies (SpA) can be
directly attributed to disease at that site. Although
enthesopathies are traditionally viewed as focal, inser-
tional disorders, findings on magnetic resonance and
ultrasound imaging suggest the presence of more diffuse
changes with involvement of the adjacent bone and soft
tissue. Thus, in SpA, inflammatory changes may occur
some distance from the insertion site (1–4), and lateral
epicondylitis is linked to degenerative changes not only
at the entheses associated with the common extensor
origin, but also in adjacent ligaments (5–8). We believe
such findings are best understood by viewing insertion
sites not merely as focal attachments, but as parts of an
“enthesis organ complex” that may dissipate stress con-
centration at the bony interface away from the attach-
ment site itself (9).
The archetypal enthesis organ is that of the
Achilles tendon, which Canoso has aptly described as
having the “première enthesis” (10). Here, stress is
dissipated away from the osteotendinous junction by
contact between the adjacent parts of the tendon and
bone in a dorsiflexed foot (9–11). The enthesis organ
comprises not only the enthesis itself, but also fibrocar-
tilages in the walls of the adjacent retrocalcaneal bursa,
together with the bursal cavity and its associated
synovium-covered fat-pad (9,11). The fibrocartilages in-
THE “ENTHESIS ORGAN” CONCEPT
Table 1. Entheses examined
Enthesis
Upper limb
Biceps brachii insertion
Extensor pollicis longus insertion
Extensor digitorum communis insertion
Collateral ligament of proximal interphalangeal
joint
Triceps insertion
Abductor pollicis brevis and abductor pollicis
longus insertion
Flexor carpi ulnaris insertion
Flexor digitorum profundus insertion
Lower limb
Tibialis anterior insertion
Patellar tendon insertion
Patellar tendon origin
Quadriceps tendon insertion
Fibularis brevis insertion
Fibularis longus insertion
Popliteal tendon (femoral attachment ⫹ lateral
collateral ligament)
Anterior cruciate ligament (tibial attachment)
Anterior cruciate ligament (femoral attachment)
Posterior cruciate ligament (tibial attachment)
Posterior cruciate ligament (femoral attachment)
Lateral head of gastrocnemius
Iliopsoas insertion
Pes anserinus insertion
Adductor longus origin
Extensor hallucis longus insertion
Flexor hallucis longus insertion
Extensor digitorum longus
* SF ⫽ sesamoid fibrocartilage; PF ⫽ periosteal fibrocartilage.
clude a sesamoid fibrocartilage in the deep part of the
tendon and a periosteal fibrocartilage on the opposing
superior tuberosity of the calcaneus. They replace the
synovial membrane that lines the bursa more proximally,
and it would be difficult to envisage disease of these
3307
Type of
enthesis organ Comments*
Extraarticular SF and PF conspicuous where the area of the enthesis attachment
is small; closely related to synovium
Articular Prominent SF in the deep surface of the tendon; articular
cartilage acts as a PF; closely related to synovium
Articular Prominent SF in the deep surface of the tendon; articular
cartilage acts as a PF; closely related to synovium
Articular SF in the deep surface of the ligament; articular cartilage acts as
a PF; closely related to synovium
None Blends with adjacent fascia as well as attaching to olecranon
Articular The tendon fuses with the joint capsule which contains SF, is
closely related to synovium, and is juxtaposed to articular
cartilage, which acts as a PF
None Continuous with attachment of ligaments to pisiform
Articular The tendon fuses with the volar plate, which is fibrocartilaginous;
articular cartilage acts as a PF for the volar plate; closely
related to synovium
Articular One slip of the tendon contributes to forming an enthesis organ
for the other; closely related to synovium
Extraarticular A PF of variable prominence is present, depending on the shape
of the bone near the enthesis; closely related to synovium and
fat-pad
None Superficial fibers are continuous with those of the quadriceps
tendon; closely related to Hoffa’s fat-pad
None Superficial fibers are continuous with those of the quadriceps
tendon
None The tendon fuses with the joint capsule, which in turn is closely
related to synovium; no SF or PF
None Fat present in abundance near enthesis, but no other evidence of
an enthesis organ; separate tendon slips to medial cuneiform
and first metatarsal bone
Articular Forms a complex enthesis organ; SF sometimes present in deep
surface; articular cartilage acts as a PF; closely related to
synovium
Articular The tibial spine is covered with articular cartilage, which acts as a
PF; No SF; closely related to synovium
None Also attached to the lateral meniscus
Articular No SF, but lies close to the horn of the posterior meniscus, which
acts as a PF; closely related to synovium
None Also attached to the lateral meniscus
None Tendon also arises from the knee joint capsule
None Some fibers extend beyond the lesser trochanter to the adjacent
part of the femur
None Subtendinous bursa present; no SF or PF, but thick periosteum
None Fuses with tendons of rectus abdominis and gracilis
Articular Prominent SF in the deep surface of the tendon; articular
cartilage acts as a PF; closely related to synovium
Articular Fuses with fibrocartilaginous volar plate and articular cartilage
acts as a PF for this; closely related to synovium
Articular SF in the deep surface of the tendon; articular cartilage acts as a
PF; closely related to synovium
structures in SpA without adjacent synovitis, since they
are so intimately linked (9).
While the “enthesis organ” concept is clearly
relevant for understanding Achilles insertional tendi-
nopathies, the extent to which it applies to other attach-
3308 BENJAMIN ET AL

ment sites is less clear. From a clinical perspective, the

changes in SpA may include synovitis, bursitis, and
diffuse, fusiform, synovial joint swelling. Such changes
attest to the fact that the enthesis-related pathology is
more than insertion-point inflammation. The purpose of
this study was to determine the general applicability of
the enthesis organ concept, by evaluating a wide range of
entheses including those within joints, adjacent to joints,
and at extraarticular sites. We demonstrated that inser-
tions at many sites frequently form part of enthesis
organs that are intimately associated with a synovial
cavity and thus with synovial membrane. These findings
may be central to elucidation of the relationship be-
tween enthesitis and synovitis and for recognition of the
diverse clinical presentations of SpA. They thus have
implications with regard to a better understanding of the
disease mechanisms.

MATERIALS AND METHODS

A wide range of entheses from 28 different sites were
obtained from the upper and lower limbs of cadavers (both
sexes; age at death 70–101 years) at the University of Cardiff
and the University of Innsbruck. The cadavers had been
donated for anatomic study (medical histories were not avail-
able) and had been perfused with a solution containing form-
aldehyde and alcohol; details have been reported previously
(11). Between 2 and 11 specimens were examined for each
enthesis. The attachment sites chosen are listed in Table 1. The
rationale for the selection of sites was 1) the inclusion of
“articular” entheses that attached within a synovial joint (e.g.,
the cruciate ligaments [which are entirely intraarticular, yet
extrasynovial] and the popliteal tendon/lateral collateral liga-
ment complex) or replaced part of the joint capsule (e.g.,
digital extensor tendons, interphalangeal joint collateral liga-
ments, and the insertional tendons of tibialis anterior and
fibularis brevis) and were thus intimately juxtaposed with its
synovium, 2) the inclusion of extraarticular entheses that were
close to joints and associated with subtendinous bursae (e.g.,
the pes anserinus and biceps brachii insertional tendons), and
3) the inclusion of entheses from regions in which periostitis
occurs.
In sampling the entheses, 2 fine saw cuts were made
into the bone, parallel to the long axis of the tendon, and 2
further cuts were made at right angles to the long axis,
proximal and distal to the enthesis itself. Because of the size of
the patellar tendon enthesis, only the central third of the
attachment site was sampled. In accordance with our previ-
ously described protocol (12), all specimens were further fixed
for at least 1 week in 10% neutral buffered formol saline
before being decalcified in 5% nitric acid, dehydrated with
graded alcohol, cleared with chloroform, and embedded in
58oC paraffin wax. Longitudinal sections of the enthesis and
adjacent structures were cut at 8 ␮m, at 1-mm intervals
throughout the block.
At each sample point, 16 sections were collected and
mounted on 8 slides. Adjacent slides were stained with tolu-
idine blue (to highlight the presence of fibrocartilage by its
metachromasia) and Masson’s trichrome (to illustrate the
Figure 1. The articular enthesis organ of the popliteal tendon (PT)
and the lateral collateral ligament (LCL). a, Note the complete
continuity of the tendon and ligament entheses (arrows). F ⫽ femur.
Bar ⫽ 2 mm. b, An integral part of the enthesis organ is the popliteal
groove of the femur, which is covered with articular cartilage (AC).
The popliteal tendon bends over the groove, and there is an interven-
ing fold of synovial tissue (arrow), which is particularly prominent in
this specimen. The enthesis itself lies just out of the picture, to the
right. Bar ⫽ 2 mm. c, In some specimens, a sesamoid fibrocartilage is
present in the tendon opposite the groove. Here it shows evidence of
mucoid degeneration (arrow). Bar ⫽ 100 ␮m. d, Evidence of cartilage
differentiation (arrows) in the synovial fold associated with the
enthesis organ. Bar ⫽ 50 ␮m. (Masson’s trichrome–stained in a, b, and
d; toluidine blue–stained in c.)
general architecture of the whole enthesis organ in the context
of neighboring structures).
RESULTS
Enthesis organs can be broadly classified as joint
related (hereinafter called “articular”) or extraarticular,
according to whether the enthesis lies internal or exter-
nal to the capsule of a synovial joint. We found that
many entheses formed part of an enthesis organ—some
simple, but others complex (see Table 1). In articular
enthesis organs, the synovial membrane with which the
enthesis is associated was a joint cavity. In extraarticular
enthesis organs, it was that of a subtendinous bursa.
Articular enthesis organs. The lateral collateral
ligament and the popliteal tendon were shown to con-
tribute to the formation of one of the most elaborate of
articular enthesis organs (Figure 1). Their entheses were
directly continuous with one another (Figure 1a), and
THE “ENTHESIS ORGAN” CONCEPT
Figure 2. The articular enthesis organ of the insertional tendon of the
tibialis anterior. a, The region where the tendon splits into a metatarsal
(MT) and a cuneiform (C) slip. The enthesis fibrocartilage (EF) of the
latter “doubles” as a periosteal fibrocartilage for the former. Note also
that there is a bursa between the 2 slips (arrow) and that the deep
surface of the tendon has a sesamoid fibrocartilage (SF) in the region
indicated. Bar ⫽ 2 mm. b, Immediately adjacent to the enthesis of the
cuneiform slip (not shown), there is a small bony elevation on the
medial cuneiform (MC) that is covered with a thick periosteal fibro-
cartilage (arrow). The metatarsal slip of the tendon also passes over
this tubercle (as well as over the cuneiform enthesis itself; see a) and
fuses with the joint capsule (JC) to form a single enthesis (E). Bar ⫽
2 mm. c, A prominent and highly vascular synovium (S) protrudes from
the undersurface of the capsule (CAP) into the joint cavity. AC ⫽
articular cartilage at the base of the first metatarsal bone. Bar ⫽ 500
␮m. (Toluidine blue–stained in a; Masson’s trichrome–stained in b and
c.)
the adjacent tendon pressed against the cartilage-lined,
popliteal groove on the femur (Figure 1b). Occasionally,
there was a hint of a sesamoid fibrocartilage on the deep
aspect of the tendon within the popliteal groove (Figure
1c). There could also be a synovial, meniscoid fold in the
interval between tendon and bone (Figure 1b). Such
folds occasionally showed slight evidence of fibrocarti-
lage differentiation (Figure 1d). Although part of the
tendon was lined with synovium, this was absent where
the tendon was in contact with the groove. However,
detached fragments of synovium may be present in the
joint cavity.
Another complex articular enthesis organ was
that of the tibialis anterior (Figure 2). The tendon lay in
a furrow on the medial side of the medial cuneiform,
3309
where it normally bifurcated into 2 slips—a deeper
cuneiform slip and a more superficial, metatarsal slip
(Figure 2a). At such attachments, the enthesis fibrocar-
tilage of the cuneiform slip also served as a periosteal
fibrocartilage for the metatarsal slip—this latter slip
passed over the former. Indeed, adjacent to the cunei-
form attachment site, the enthesis fibrocartilage was
directly continuous with a periosteal cartilage/
fibrocartilage covering a small bony elevation (Figure
Figure 3. Macroscopic views of the articular enthesis organs associ-
ated with digital tendons and ligaments. a, Extensor pollicis longus:
sagittal section of the interphalangeal joint of the thumb. The enthesis
organ consists of the enthesis (E) itself (at the base of the distal
phalanx [DP]), a sesamoid fibrocartilage (SF) near the deep surface of
the tendon, articular cartilage (AC) on the head of the proximal
phalanx (PP), and the intervening joint cavity (asterisk). Note the
unusual presence of a sesamoid bone (arrow) within the tendon and
the fold of synovial membrane (SM) extending into the joint cavity.
Bar ⫽ 1 mm. b, Extensor digitorum communis: sagittal section of the
distal interphalangeal joint of a finger. The enthesis organ consists of
the enthesis itself (at the base of the distal phalanx), sesamoid
fibrocartilage in the deep surface of the extensor tendon, articular
cartilage on the head of the intermediate phalanx (IP), and the
intervening joint cavity (asterisk). Bar ⫽ 1 mm. c, Collateral ligament
(CL): coronal section of the proximal interphalangeal joint of a finger.
The enthesis organ consists of the enthesis (at the base of the
intermediate phalanx), a sesamoid fibrocartilage at the deep surface of
the collateral ligament, and a thin layer of articular cartilage which has
extended around the side of the proximal phalanx from the joint
surface. Bar ⫽ 1 mm. d, Collateral ligament: higher-magnification view
of the boxed region in c, where the sesamoid fibrocartilage in the
collateral ligament lies adjacent to articular cartilage on the side of the
proximal phalanx. There is evidence of degeneration in the sesamoid
fibrocartilage (arrow). Bar ⫽ 100 ␮m. (Masson’s trichrome–stained.)
3310 BENJAMIN ET AL

enthesis, a sesamoid fibrocartilage can be a prominent

feature of the joint capsule. Stress can thus be dissipated
from the tendinous to the capsular enthesis (and vice

Figure 4. Macroscopic views of the articular enthesis organ of the

anterior cruciate ligament (tibial enthesis). Note how the ligament
bends over the “tibial spine” (TS) that is covered with articular
cartilage (AC). EF ⫽ enthesis fibrocartilage. Bar ⫽ 3 mm (Masson’s
trichrome–stained).

2b). As a consequence of this complex arrangement, the

deep aspect of the metatarsal slip showed some evidence
of sesamoid fibrocartilage differentiation where it
passed over the cuneiform enthesis (Figure 2a). Distal to
that attachment site, the metatarsal slip replaced the
joint capsule and thus contacted the cuneiform–
metatarsal joint cavity directly. In this region, meniscoid
synovial folds protruded into the joint space from the
deep surface of the tendon (Figures 2b and c). Occa-
sionally, the joint cavity extended between the 2 tendon
slips as a bursal space (Figure 2a), and in some speci-
mens, a bursa (not lined by synovium) extended into the
narrow interval between the cuneiform slip and the
bone; in others the region was filled with vascular,
adipose tissue.
Where a tendon merged with a joint capsule,
there was often a fairly simple articular enthesis organ.
This consisted of the enthesis itself, a sesamoid fibrocar-
tilage in the tendon adjacent to the attachment site,
articular fibrocartilage covering a neighboring bone, and
a joint cavity that allowed movement between sesamoid
and articular fibrocartilages—the latter being function-
ally equivalent to periosteal fibrocartilage typical of that
seen in the Achilles enthesis organ. Such a definition
covers the enthesis organs of the digital extensor ten-
dons (Figures 3a and b) and the collateral ligaments of
the interphalangeal joints (Figures 3c and d). However,
there may also be a meniscoid synovial fold extending
into the joint cavity from the deep surface of the
tendons, immediately distal to the sesamoid fibrocarti-
lage (Figures 3a and b). In all such tendons, analogous to
the retrocalcaneal bursa in the Achilles region, synovium
was absent from the opposing surfaces of tendon and
bone where these contact one another. A related type of
enthesis organ is that where tendons reinforced, rather
than replaced, joint capsules. This was exemplified by
the insertion of abductor pollicis longus. Near this
Figure 5. Macroscopic views of the extraarticular enthesis organs at
the insertions of biceps brachii and patellar tendons and at the
insertion of the pes anserinus. a, Biceps brachii. The tendon enthesis
(E) is associated with sesamoid fibrocartilage (SF) and periosteal
fibrocartilage (PF). These are separated by a bursa (B), which is only
partly lined with synovium (S). A synovial membrane is absent from
the region of the periosteal and sesamoid fibrocartilages. ST ⫽
subsynovial tissue; RT ⫽ radial tuberosity. b, Biceps brachii: low-power
view of an attachment site where the periosteal fibrocartilage is
tenuously linked to the adjacent tendon by strands of tissue (arrows)
crossing the bursa. The comparatively small area over which the
tendon is attached to the bone suggests that the periosteal fibrocarti-
lage is the result of a partial tear at the enthesis itself. Note the
presence of skeletal muscle fibers (MF) in the subsynovial tissue
associated with the bursa. c, Patellar tendon. A small periosteal
fibrocartilage covers the tibial tuberosity (TT) immediately proximal to
the enthesis, and a bursa intervenes between the tendon and the bone.
Except in the region of the periosteal fibrocartilage, the bursa is lined
with synovium, beneath which there is a substantial quantity of fatty
and highly vascular subsynovial tissue. d, Pes anserinus. Although a
prominent bursa intervenes between the tendon and the tibial metaph-
ysis (TM) immediately adjacent to the enthesis, there is no periosteal
or sesamoid fibrocartilage and thus no enthesis organ. Nevertheless,
the periosteum (P) is thickened. Bars ⫽ 2 mm. (Toluidine blue–stained
in a, c, and d; Masson’s trichrome–stained in b.)
THE “ENTHESIS ORGAN” CONCEPT
Figure 6. Detail of the enthesis organs/entheses shown in Figure 5. a,
Biceps brachii: periosteal fibrocartilage (PF) on the radial tuberosity
(RT). Note the presence of large fibrocartilage cells (arrows). b,
Patellar tendon. Periosteal fibrocartilage on the tibial tuberosity (TT)
directly lines the deep infrapatellar bursa (B), without any covering
layer of synovium. Arrows indicate fibrocartilage cells. c, Pes anserinus.
The thick periosteum covering the surface of the tibia is purely fibrous
(no fibrocartilage cells), contains numerous blood vessels (BV), and is
covered with a synovial membrane (SM). Bars ⫽ 100 ␮m. (Toluidine
blue–stained in a; Masson’s trichrome–stained in b and c.)
versa) by the continuity of the attachment sites. The
relationship between enthesis and synovium is main-
tained because the latter lines the inside of the joint
capsule.
The tibial attachment of the anterior cruciate
ligament also formed part of a simple articular enthesis
organ (Figure 4). It consisted of the enthesis itself, an
articular cartilage/fibrocartilage that covered the lateral
tubercle of the intercondylar eminence of the tibia
(“tibial spine”), and the intervening cavity of the knee
joint. There was no sesamoid fibrocartilage in the liga-
ment where it passes over the tibial spine, but neither
was there a synovial membrane covering the ligament in
this region.
Extraarticular enthesis organs. Extraarticular
enthesis organs were exemplified by those associated
with the biceps brachii and patellar insertional tendons
(Figures 5a–c). A subtendinous bursa occupied the
insertional angle between the tendon and the bone, and
there was periosteal fibrocartilage of variable thickness
near the attachment sites (Figures 6a and b). Although
some fat was visible in association with both the biceps
3311
and the patellar tendon entheses (Figures 5a and c),
much of Hoffa’s fat-pad lay proximal to the level at
which the specimens were removed from the cadavers
for histologic processing. Despite the presence of a
subtendinous bursa and a thick periosteum adjacent to
the pes anserinus enthesis, no enthesis organ was
present at this site (Figures 5d and 6c). There was no
cartilage differentiation within the periosteum, and
blood vessels were conspicuous (Figure 6c). Where both
periosteal and sesamoid fibrocartilages were prominent
at the insertion of the biceps brachii tendon, they largely
replaced the synovial membrane of the intervening bursa
in this region (Figure 6b). In the pes anserinus tendon,
where neither fibrocartilage was present, the synovium
was still visible (Figure 6c). At the insertion of biceps
brachii, the fatty subsynovial tissue occasionally con-
tained a small number of skeletal muscle fibers, together
with associated “microtendons” (Figure 5b).
Sesamoid fibrocartilage was restricted to biceps
brachii–and then only to specimens in which the perios-
teal fibrocartilage was also conspicuous (Figure 5a).
Cadavers in which sesamoid and periosteal fibrocarti-
lages were most prominent were those with a small area
of tendon–bone attachment.
DISCUSSION
The Achilles insertion is a common site of disease
in SpA and has rightly been described as the “première
enthesis” (10). It forms part of a complex enthesis organ
that comprises not only the insertion itself, but also
adjacent tendon and bone fibrocartilage, together with a
fat-pad, bursa, and synovium. The purpose of the
present work was to investigate the extent to which other
enthesis organs exist at diverse articular and extraarticu-
lar sites. We have shown that the concept of an “enthesis
organ” can be applied to many (but not all) tendon and
ligament attachments, and we thus argue that the con-
cept is central to understanding of the spondylarthropa-
thies. If stress is dissipated away from a bony insertion
because of the existence of an enthesis organ, this can
explain why pathologic changes are seen adjacent to
entheses as well as at them, why subtendinous bursae are
often affected in the disease (1,2,4,13), and why bursitis
can mimic enthesitis (14). It also illuminates the obser-
vation that periostitis is a common feature of SpA
(15)—fibrocartilaginous periostea are a typical feature
of many enthesis organs. Finally, the complexity of
enthesis organs that are intimately associated with a
synovial cavity may have implications regarding the
mechanisms of synovitis in SpA.
3312
We have described enthesis organs as being
articular or extraarticular. All have in common the
presence of sesamoid and/or periosteal cartilage or
fibrocartilage juxtaposed to a synovial cavity and thus
close to a synovial membrane. This either lines the joint
cavity or forms part of a subtendinous bursa at the
attachment site. Articular enthesis organs include those
where the tendon/ligament fuses with a joint capsule
(e.g., digital extensor tendons) or attaches inside a joint
cavity (e.g., the tibial attachment of the anterior cruciate
ligament and the insertion of popliteus). The presence of
elaborate enthesis organs in direct association with syno-
vial cavities, especially in joints such as the knee, enables
better understanding of the anatomic basis of entheseal-
related diseases, including SpA. We have shown, for
example, that the femoral enthesis of the lateral collat-
eral ligament merges imperceptibly with that of the
popliteal tendon. This was also evident in the magnetic
resonance imaging studies reported by Recondo et al
(16). Consequently, the 2 structures, together with the
associated synovium, form an enthesis organ as complex
as that of the tibialis posterior (12). Evidently, stress
could be dissipated between the ligament and the ten-
don enthesis, and thus what may seem to be a pathologic
process restricted to an extrasynovial structure (the
lateral collateral ligament enthesis) could affect the
inside of the joint as well.
We have reported here that cartilage-covered,
bony pulleys lie immediately adjacent to many entheses
and often contribute to the formation of enthesis organs.
Either the enthesis itself lies in a shallow depression
below the level of the adjacent bone (i.e., so that the
adjacent bone acts as a pulley) or there is a small bony
protuberance next to the attachment site. The former is
exemplified by the insertion of popliteus, and the latter
by the tibial spine (intercondylar eminence) that contrib-
utes to the tibial enthesis organ of the anterior cruciate
ligament, the radial tuberosity near the insertion of
biceps brachii, and the unnamed tubercle near the
attachment of the tibialis anterior. All such pulleys
dissipate stress concentration so that the risk of wear
and tear at entheses is reduced.
It has been proposed that the fundamental dif-
ference between rheumatoid arthritis and SpA is that
synovitis in the former is primarily an immunologically
mediated event, whereas in the latter it is secondary to
liberation of proinflammatory mediators from sites of
enthesitis. However, this hypothesis was proposed at a
time when the enthesis organ concept had not yet been
developed, and it was difficult to explain how focal
insertional inflammation caused synovitis. Our results
BENJAMIN ET AL
highlight the contribution of synovium to many enthesis
organs, and we thus suggest that synovitis would be an
anticipated consequence of enthesis organ inflamma-
tion. This applies to both articular and extraarticular
enthesis organs. This is especially the case since the
synovium, unlike the enthesis, contains macrophages.
Like the Achilles enthesis organ, those described here in
association with the insertions of the biceps brachii and
patellar tendons lack a synovial lining in part of the
bursa. This is not surprising since the tendon presses
against the bone, and compression would occlude syno-
vial vessels. It is exactly for this reason that synovium is
absent over articular cartilage and at functional entheses
(wrap-around regions of tendons [9]). Indeed, the local
absence of synovium reinforces the similarities between
many subtendinous bursae and typical synovial joints
(9,10). Consequently, deep infrapatellar bursitis and
bicipital bursitis may involve fibrocartilage degeneration
in the bursal walls, as well as synovitis.
In conclusion, this study shows that the concept
of the enthesis organ is not unique to the Achilles
insertion, but is more general: enthesis organs are
present at many articular and extraarticular sites. The
intimate relationship between enthesis organs and syno-
vial cavities and the presence of enthesis organ compo-
nents in joint capsules may have important implications
for understanding the clinical pattern of SpA, including
synovitis and extracapsular changes. It is important to
acknowledge, however, that entheses do not always form
parts of archetypal enthesis organs like that of the
Achilles tendon, and this probably reflects local biome-
chanical factors that influence stress dissipation. Signif-
icantly, however, stress dissipation away from a single
focused attachment site is virtually universal, because
most tendons and ligaments fuse with adjacent struc-
tures or attach at more than one bony point.
ACKNOWLEDGMENT
We are grateful to E. Richter for technical assistance.
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