Back pain is extremely common. In most cases, it is associated with muscle strain, prolonged sitting, poor posture or a mechanical problem affecting the spine. However, persistent pain in the lower back and sacral region can sometimes indicate a chronic inflammatory condition called ankylosing spondylitis.
Ankylosing spondylitis commonly begins during adolescence or early adulthood. Its first symptoms usually develop gradually, which means they may be attributed to exercise, sedentary work or an uncomfortable sleeping position for a long time.
If your back pain began before the age of 45, has continued for more than three months, becomes worse during rest and improves with movement, a rheumatologist should assess your symptoms.
What is ankylosing spondylitis?
Ankylosing spondylitis is a chronic inflammatory rheumatic disease that primarily affects the spine and the sacroiliac joints connecting the sacrum to the pelvis.
It belongs to a group of conditions known as axial spondyloarthritis. Modern terminology distinguishes between:
- non-radiographic axial spondyloarthritis, when characteristic changes cannot yet be seen on a conventional X-ray;
- radiographic axial spondyloarthritis, also known as ankylosing spondylitis, when changes in the sacroiliac joints are visible on an X-ray.
A person can therefore have typical symptoms and signs of inflammation on magnetic resonance imaging even if an ordinary X-ray does not yet show characteristic changes.
In some patients, persistent uncontrolled inflammation can gradually reduce spinal mobility and lead to new bone formation. The course of the condition varies considerably, and early diagnosis makes it possible to begin appropriate treatment.
Early symptoms of ankylosing spondylitis
Lower-back and sacral pain
One of the most characteristic symptoms is pain that develops gradually in the lower back, sacral region or buttocks. It may feel deep and difficult to pinpoint. Sometimes the pain alternates between the right and left buttock.
Unlike an acute injury, patients are often unable to identify a particular event or moment when the pain began.
Morning stiffness
The back may feel particularly stiff after waking, and the patient may need time to get moving. Stiffness can last longer than 30 minutes and return after prolonged sitting or another period of inactivity.
Pain that becomes worse during rest
Rest does not necessarily relieve inflammatory back pain. Prolonged sitting, lying down or inactivity may make the symptoms worse.
The pain may wake a person during the second half of the night and improve only after getting up, walking or stretching.
Improvement with movement
Many patients notice that walking, exercising or stretching makes them feel better. This differs from many forms of mechanical back pain, in which a particular movement or physical load may aggravate the symptoms.
Fatigue
Chronic inflammation can cause considerable tiredness, low energy and difficulty feeling refreshed even after adequate sleep. Fatigue may be present before a diagnosis is established.
Inflammatory versus mechanical back pain
Mechanical back pain often begins after an injury, physical strain or an awkward movement. It commonly becomes worse with a particular activity and improves with rest.
A combination of the following features may indicate inflammatory back pain:
- symptoms beginning before the age of 45;
- pain lasting longer than three months;
- gradual onset;
- prolonged morning stiffness;
- symptoms becoming worse during rest;
- improvement with movement or exercise;
- pain that wakes the patient during the second half of the night;
- pain in the sacral or buttock region;
- a marked response to anti-inflammatory medication.
No individual feature confirms ankylosing spondylitis. The diagnosis is based on the overall pattern of symptoms, examination findings and test results.
Can the condition affect other parts of the body?
Although ankylosing spondylitis primarily affects the spine, inflammation can occur elsewhere.
Heel pain
Inflammation may develop where a tendon or ligament attaches to a bone. This is called enthesitis. The attachment of the Achilles tendon and the underside of the heel are commonly affected.
Inflammation of other joints
Some patients develop pain and swelling in their hips, knees, ankles or other joints. Hip involvement may have a considerable effect on mobility.
Eye inflammation
Axial spondyloarthritis can be associated with acute anterior uveitis. Warning signs include:
- sudden pain in one eye;
- redness of the eye;
- marked sensitivity to light;
- blurred vision.
These symptoms require urgent assessment by an ophthalmologist.
Psoriasis and inflammatory bowel disease
Conditions in the spondyloarthritis group can be associated with psoriasis, Crohn’s disease and ulcerative colitis. Tell your rheumatologist if you have psoriasis, persistent diarrhoea, blood in your stool, abdominal pain or a family history of these conditions.
Does ankylosing spondylitis affect only men?
No. Axial spondyloarthritis affects both men and women.
Women may have less typical symptoms, may develop radiographic changes more slowly and may experience more symptoms outside the spine. The condition should therefore not be ruled out because of the patient’s sex.
How is ankylosing spondylitis diagnosed?
There is no single test that can conclusively confirm or exclude ankylosing spondylitis in every patient.
During an assessment, the rheumatologist may consider:
- the age at which the symptoms began;
- how long the pain has been present;
- whether movement or rest changes the pain;
- the duration of morning stiffness;
- spinal and joint mobility;
- tenderness where tendons attach to bones;
- a history of psoriasis, eye inflammation or bowel symptoms;
- a family history of related conditions.
Blood tests may include C-reactive protein, erythrocyte sedimentation rate and, in selected cases, an HLA-B27 test.
Normal inflammatory markers do not rule out axial spondyloarthritis. A negative HLA-B27 result does not prove that the condition is absent, while a positive result alone does not establish the diagnosis.
An X-ray may be used to examine the sacroiliac joints. If the symptoms suggest inflammatory disease but the X-ray does not show characteristic changes, the doctor may recommend magnetic resonance imaging.
How is ankylosing spondylitis treated?
Treatment aims to reduce pain and stiffness, control inflammation, maintain spinal mobility and help the patient participate fully in everyday activities.
A treatment plan may include:
- regular, individually appropriate physical activity;
- physiotherapy and posture exercises;
- non-steroidal anti-inflammatory medication when medically appropriate;
- biologic or other targeted medication for active disease;
- stopping smoking;
- regular assessment of disease activity and response to treatment.
Medication is selected by a rheumatologist according to disease activity, other health conditions, previous treatment and individual risks. Long-term self-treatment with anti-inflammatory medication is not recommended.
Regular exercise is a central part of treatment rather than merely an addition to medication.
When should you consult a rheumatologist?
Consider a rheumatology consultation if your back pain:
- began before the age of 45;
- has continued for longer than three months;
- is worse in the morning or after rest;
- improves with movement rather than lying down;
- regularly wakes you during the second half of the night;
- is accompanied by pain in the sacrum, buttocks or heels;
- occurs together with joint swelling, psoriasis, bowel symptoms or recurrent eye inflammation.
An X-ray can appear normal during the early stage of the condition. Persistent symptoms with features of inflammatory back pain should therefore not be ignored.
During a rheumatologist consultation, the doctor will review your symptoms and previous test results and decide whether additional blood tests or diagnostic imaging are required.
Dr. Aleksandra Bukina
To arrange a rheumatologist consultation at Republikas laukuma klīnika in central Riga, call 28002363.
Frequently asked questions
Can ankylosing spondylitis be cured completely?
There is currently no treatment that eliminates the condition completely. Appropriate treatment can nevertheless control inflammation, relieve symptoms and help preserve mobility and quality of life.
Does ankylosing spondylitis always cause the spine to fuse?
No. The course of the disease varies between patients. Not everyone develops extensive structural changes or fusion of parts of the spine.
Do normal blood test results rule out the condition?
No. C-reactive protein and other inflammatory markers may remain within the normal range in some patients. Blood test results must be considered together with the symptoms and imaging findings.
Does a positive HLA-B27 test mean that a person has ankylosing spondylitis?
No. HLA-B27 increases the likelihood of the condition, but many people who carry this genetic marker never develop ankylosing spondylitis.
Which doctor should I see if I suspect ankylosing spondylitis?
A rheumatologist diagnoses and treats ankylosing spondylitis. Sudden eye pain, redness, sensitivity to light or blurred vision require urgent assessment by an ophthalmologist.
