Patient information · Rheumatology
Axial spondyloarthritis
back pain that gets better with exercise, not rest
Axial spondyloarthritis is inflammatory arthritis of the spine and pelvis. It typically begins before 45, and the average delay to diagnosis in the UK is around eight years — because the back pain is assumed to be mechanical, and the one feature that distinguishes it is rarely asked about.
Seek urgent assessment if you have
- a red, painful eye with light sensitivity and blurred vision — this needs same-day eye assessment
- new severe back pain after a fall or injury, particularly with long-standing disease
- numbness in the saddle area, or bladder or bowel changes
- fever with back pain, or feeling systemically unwell
- sudden change in a stable spine, or new neurological symptoms
Acute anterior uveitis occurs in up to a third of people with axial SpA, can threaten sight, and needs treating within hours to days. A fused spine fractures more easily and with less force — any significant new pain after even minor trauma needs imaging.
Five features that distinguish inflammatory back pain
Back pain is inflammatory rather than mechanical if it: began before age 45; came on gradually; is worse with rest and better with exercise; causes morning stiffness lasting over 30 minutes; and wakes you in the second half of the night. Four or more of these should prompt referral. Mechanical back pain does the opposite — better with rest, worse with activity, and it does not wake you at 4am and force you to get up and move around.
Other features
- Alternating buttock pain, from inflammation of the sacroiliac joints
- Enthesitis — pain where tendons attach, classically the heel (Achilles or plantar fascia)
- Dactylitis — a whole finger or toe swollen like a sausage
- Uveitis — recurrent red painful eye
- Psoriasis or a family history of it
- Inflammatory bowel disease, or unexplained bloody diarrhoea
- Good response to anti-inflammatories, which is itself a diagnostic clue
- fatigue, which is often profound and under-recognised
Diagnosis
- HLA-B27 is positive in most people with the condition — but also in around 8% of the healthy UK population, so it supports rather than proves the diagnosis.
- MRI of the sacroiliac joints detects active inflammation years before any change appears on X-ray. This is the key investigation.
- X-rays show established structural change but are normal early on — a normal X-ray does not exclude the condition, and relying on it is a major reason for delay.
- CRP and ESR are raised in only around half of cases, so normal markers do not exclude it either.
- It affects men and women roughly equally, though women are diagnosed later and are more often told they have fibromyalgia.
Treatment
- Daily exercise is the single most important treatment — spinal mobility, stretching, posture and deep breathing work. Specialist physiotherapy makes a substantial difference and should be arranged early.
- Anti-inflammatories, often taken regularly rather than as needed, which reduce both pain and possibly progression.
- Biologic therapies — anti-TNF and IL-17 inhibitors — have transformed outcomes for people not controlled on NSAIDs.
- Steroid injections into sacroiliac joints or entheses for localised problems.
- Conventional DMARDs such as methotrexate work for peripheral joints but not for spinal disease.
- Stop smoking — smoking is associated with faster structural progression and worse outcomes.
Long term
Not everyone progresses to a fused spine, and modern treatment makes that considerably less likely. Cardiovascular risk is raised by the inflammation and should be monitored. Bone density falls even in a stiff spine, so osteoporosis assessment matters. Tell any anaesthetist about a stiff neck before surgery, and inform the DVLA if neck movement is significantly restricted.
Why come to us. Eight years is the average delay, and it happens because nobody asks the five questions. We take a proper history, test HLA-B27, CRP, ESR and full blood count in-house with results explained in the same visit, and arrange MRI of the sacroiliac joints through our CQC-registered partners — not an X-ray that will be normal. We refer to rheumatology with the workup complete, and start specialist physiotherapy straight away. Seven days a week.
The right scan, not an X-ray that comes back normal
HLA-B27 and inflammatory markers in-house, MRI arranged fast.
Tower Bridge Hospital London
97–99 Whitechapel Road, London E1 1DT
WhatsApp 07903 284 189
info@mhwclinic.co.uk
Open Mon–Sat, 9am–7pm (closed Sundays until September)
In an emergency
Call 999, or go to the Royal London Hospital Emergency Department, Whitechapel Road, London E1 1FR.
When we are closed and it is not an emergency
Call NHS 111 or visit 111.nhs.uk.