Ankylosing Spondylitis: Symptoms, Diagnosis and Treatment
Healthy spine compared with ankylosing spondylitis, showing sacroiliac and spinal inflammation with possible progressive fusion.
Ankylosing spondylitis is a long-term inflammatory arthritis that mainly affects the sacroiliac joints and spine. It is the radiographic form of a broader condition called axial spondyloarthritis. Symptoms commonly include lower-back or buttock pain, prolonged morning stiffness and discomfort that improves with movement but worsens after rest.
Early medical assessment, appropriate medication and regular individualised exercise may help control inflammation, maintain movement and support participation in work, exercise and daily activities. Ankylosing spondylitis belongs to the broader group of arthritis and rheumatology conditions.
Quick answer
What does ankylosing spondylitis usually feel like?
Symptoms often begin gradually before the age of 45. Back or buttock stiffness may be worse in the morning, after sitting or during the second half of the night. Unlike many common mechanical back-pain patterns, symptoms frequently improve after movement rather than rest.
What is ankylosing spondylitis?
Ankylosing spondylitis, often shortened to AS, is an immune-mediated inflammatory condition. It primarily affects the joints between the pelvis and spine, called the sacroiliac joints, as well as the spinal joints and nearby ligament attachments.
Doctors now commonly use the broader term axial spondyloarthritis. This includes:
- Non-radiographic axial spondyloarthritis: symptoms and other findings may be present before definite structural changes appear on a standard X-ray.
- Radiographic axial spondyloarthritis or ankylosing spondylitis: characteristic sacroiliac-joint changes are visible on X-ray.
Some people also develop symptoms in the hips, shoulders, knees, ankles, rib joints or the places where tendons and ligaments attach to bone. The condition can also occur alongside eye inflammation, psoriasis or inflammatory bowel disease.
What causes ankylosing spondylitis?
The exact cause remains unclear. Genetics and immune-system activity both contribute. Ankylosing spondylitis has a strong association with the HLA-B27 gene, although carrying HLA-B27 does not mean that a person will develop the condition.
Likewise, a negative HLA-B27 result does not rule it out. Diagnosis depends on the overall clinical pattern rather than one gene, blood test or scan.
Symptom recognition
What are the symptoms of ankylosing spondylitis?
Symptoms vary between people. They may develop slowly and fluctuate between quieter periods and symptom flares.
Back and pelvic symptoms
- Lower-back or buttock pain beginning before age 45
- Symptoms lasting longer than three months
- Morning stiffness that takes time to ease
- Pain or stiffness after sitting or resting
- Alternating pain around the buttocks
- Symptoms that improve with movement
- Waking during the second half of the night
Other possible features
- Fatigue or reduced energy
- Hip, shoulder or peripheral-joint pain
- Heel, Achilles tendon or plantar fascia pain
- Rib stiffness or reduced chest expansion
- Current or previous psoriasis
- Persistent inflammatory bowel symptoms
- Current or previous eye inflammation
No single symptom confirms ankylosing spondylitis. However, a combination of these features should prompt medical assessment, particularly when back pain began before age 45.
Seek urgent medical care
Do not ignore a painful red eye
Arrange urgent same-day medical or eye assessment if you develop a painful red eye, marked light sensitivity or blurred vision. These symptoms may indicate acute anterior uveitis, which can occur with axial spondyloarthritis.
How does inflammatory back pain differ from mechanical back pain?
The following patterns may help guide assessment. However, they overlap and cannot confirm a diagnosis by themselves.
Inflammatory pattern
- Often begins gradually before age 45
- Usually persists for more than three months
- Often worsens after rest or inactivity
- Frequently improves after movement
- May disturb sleep later in the night
- Can occur with fatigue, uveitis, psoriasis, bowel disease or enthesitis
Common mechanical pattern
- May begin at any age
- May follow a change in activity, load or position
- Often relates to particular movements or tasks
- May settle when the aggravating load stops
- Sleep disturbance varies
- Usually lacks wider inflammatory features
Important: inflammatory and mechanical symptoms can coexist. A physiotherapist or doctor should assess persistent, unexplained or unusual back pain.
How is ankylosing spondylitis diagnosed?
No single test diagnoses ankylosing spondylitis. A GP or rheumatologist considers your symptom history, age at onset, family history, physical findings, blood tests and imaging together.
Clinical assessment
Your assessment may examine spinal and hip movement, chest expansion, painful tendon attachments, peripheral joints and the pattern of your symptoms. Your clinician may also ask about psoriasis, eye inflammation, bowel symptoms and family history.
Blood tests
Blood tests may include inflammatory markers and HLA-B27 testing. However, inflammatory markers may remain normal, and some people with axial spondyloarthritis do not carry HLA-B27.
Imaging
Sacroiliac-joint X-rays may show structural changes associated with radiographic axial spondyloarthritis. When X-rays do not explain a strongly suggestive symptom pattern, a rheumatologist may consider MRI to look for active inflammation or other relevant findings.
A physiotherapist does not confirm ankylosing spondylitis independently. If your presentation suggests inflammatory back pain, your physiotherapist may recommend GP or rheumatology assessment while helping you manage movement and activity safely.
Long-term management
How is ankylosing spondylitis treated?
Management usually combines medical care, education, regular exercise and support for daily function. Your GP and rheumatologist manage investigations and medication. Physiotherapy may help you maintain movement, posture, strength and confidence with activity.
Confirm the diagnosis and medical plan
Your GP and rheumatologist assess disease activity, organise investigations and discuss suitable medication. Physiotherapy complements this care rather than replacing it.
Understand symptoms and plan for flares
Education can help you distinguish normal exercise responses from a significant flare. Your plan may adjust movement volume, intensity and recovery rather than stopping all activity.
Maintain mobility and breathing movement
Exercises may address spinal rotation, extension, hip mobility, posture and rib-cage movement. The most useful exercises depend on your symptoms, mobility and disease stage.
Build strength and aerobic fitness
Progressive strengthening and aerobic exercise can support physical capacity, bone health, cardiovascular health and participation in valued activities. Loading should progress gradually.
Review and maintain the program
Long-term management works best when the program remains practical. Reviews can address changing symptoms, work demands, sport, confidence, fitness or difficulty maintaining the routine.
How may physiotherapy help ankylosing spondylitis?
Physiotherapy focuses mainly on active management. Your physiotherapist may assess mobility, posture, breathing movement, strength, balance, fitness and the activities that matter most to you.
Movement and mobility
A tailored program may maintain spinal, hip, shoulder and chest movement without forcing painful ranges.
Strength and fitness
Progressive exercise may improve physical capacity for work, walking, recreation, gym training and daily activities.
Flare and load planning
Your plan can include practical adjustments for difficult days while preserving safe movement and avoiding unnecessary inactivity.
Some people find heat, gentle hands-on treatment or soft-tissue techniques temporarily comfortable. These options should support, rather than replace, regular exercise, medical management and an active long-term plan.
PhysioWorks also provides a dedicated rheumatology physiotherapy service for people managing inflammatory joint conditions, stiffness, fatigue and changing exercise tolerance.
What exercises are used for ankylosing spondylitis?
There is no single best exercise for everyone. Exercise selection should account for your symptoms, spinal movement, joint involvement, fitness, medical treatment and other health conditions.
- Gentle spinal and hip mobility exercises
- Posture and spinal-extension exercises where appropriate
- Rib-cage mobility and breathing exercises
- Progressive lower-limb, trunk and upper-body strengthening
- Walking, cycling, swimming or other aerobic activity
- Balance and functional exercises when required
- Activity-specific conditioning for work, recreation or sport
Exercise should remain regular and sustainable. A severe flare, new neurological symptoms, marked shortness of breath, suspected fracture or significant change in general health requires medical or clinical review before progression.
What results can you expect?
Ankylosing spondylitis is a long-term condition, and there is currently no cure. However, treatment can help control inflammation, reduce pain and stiffness, maintain function and lower the risk of complications.
Symptoms may fluctuate. Many people continue to work, exercise and participate in family or recreational activities. Progress is usually measured through movement, function, fitness, sleep, symptom behaviour and confidence rather than pain alone.
Ankylosing Spondylitis FAQs
What is the difference between ankylosing spondylitis and axial spondyloarthritis?
Axial spondyloarthritis is the broader condition affecting the sacroiliac joints and spine. Ankylosing spondylitis is the form where characteristic structural sacroiliac-joint changes are visible on X-ray.
What does inflammatory back pain feel like?
Inflammatory back pain often begins gradually before age 45, lasts longer than three months, worsens after rest and improves with movement. It may also cause prolonged morning stiffness or waking during the second half of the night.
Can physiotherapy help ankylosing spondylitis?
Physiotherapy may help maintain spinal and joint movement, guide regular exercise, improve strength and fitness, support posture and develop practical strategies for symptom flares and daily activities.
What exercises may help ankylosing spondylitis?
Programs commonly include spinal and hip mobility, posture exercises, rib-cage movement, progressive strengthening and aerobic exercise. Exercise selection should match your symptoms, mobility, health and current medical management.
Can ankylosing spondylitis affect the eyes, bowel or skin?
Yes. Axial spondyloarthritis can occur with anterior uveitis, inflammatory bowel disease or psoriasis. A painful red eye, marked light sensitivity or blurred vision requires urgent medical or eye assessment.
When should I speak with my GP or rheumatologist?
Arrange medical assessment when back or buttock pain began before age 45, has lasted longer than three months, regularly disrupts sleep or improves with movement rather than rest. Review is also important when symptoms occur with psoriasis, bowel inflammation, heel pain, swollen joints or eye inflammation.
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References
- Ramiro S, Nikiphorou E, Sepriano A, et al.
ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update.
Ann Rheum Dis. 2023;82(1):19-34. - National Institute for Health and Care Excellence.
Spondyloarthritis in over 16s: diagnosis and management.
NICE guideline NG65. - National Institute for Health and Care Excellence.
Diagnosis of axial spondyloarthritis using imaging.
NICE quality standard QS170. - Ortolan A, Webers C, Sepriano A, et al.
Efficacy and safety of non-pharmacological and non-biological pharmacological treatments in axial spondyloarthritis: a systematic literature review informing the 2022 update of the ASAS-EULAR recommendations.
Ann Rheum Dis. 2023;82(1):142-152. - Boudjani R, Challal S, Semerano L, et al.
Impact of different types of exercise programs on disease activity, function and mobility in ankylosing spondylitis: a systematic review and meta-analysis.
Disabil Rehabil. 2023;45(18):2899-2909. - Luo Y, Zhang L, Liu Y, et al.
Effectiveness of exercise intervention in relieving symptoms of ankylosing spondylitis: a systematic review and network meta-analysis.
PLoS One. 2024;19(5):e0302965. - Sveaas SH, Bilberg A, Berg IJ, et al.
High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis: a multicentre randomised trial of 100 patients.
Br J Sports Med. 2020;54(5):292-297.
