Inflammatory back pain and spondylitis (spondyloarthritis)

What are these conditions?

Spondyloarthritis (SpA) is the name for a group of inflammatory conditions that mostly affect the spine and the joints of the pelvis (sacroiliac joints) and sometimes other joints and the places where tendons attach to bone. On this page we explain three forms.

Ankylosing spondylitis (AS). The NHS describes it as a long-term condition that inflames the spine and can affect other parts of the body too. Changes in the spine are visible on an X-ray.

Non-radiographic axial spondyloarthritis. The NHS writes that this is a similar form that is not visible on an X-ray but is sometimes shown on an MRI.

Psoriatic arthritis. The NHS describes it as a long-term condition in which the joints become painful, swollen and stiff. Some people with psoriasis (a skin condition) develop it, sometimes years after the skin condition.

The NHS writes that ankylosing spondylitis usually starts in the teens and young adulthood, and gives the start of symptoms as between ages 18 and 40.

Symptoms

Inflammatory back pain differs from ordinary back pain. According to the NHS, in ankylosing spondylitis:

• Back pain and stiffness are the main symptom and appear slowly over months or years.
• It gets better with activity and does not get better with rest.
• It is worse in the morning and at night and sometimes wakes you from sleep.
• There may also be pain in the buttock area.

Other symptoms according to the NHS:

• Pain and swelling in other joints such as the hips and knees.
• Inflammation where tendons attach to bone (enthesitis), especially at the back of the heel and under the heel.
• Tiredness.
• Eye inflammation (iritis or anterior uveitis), which makes the eye red and swollen.
• An association with psoriasis or inflammatory bowel disease.

Psoriatic arthritis according to the NHS: pain, swelling and stiffness in one or more joints, swelling of a whole finger or toe, nail changes (tiny pits and discolouration), tiredness, and symptoms that are usually worse in the morning and better with movement.

Who should see a doctor?

The NHS recommends seeing a doctor if you have persistent symptoms, and, if the doctor suspects this condition, referring you to a rheumatologist. The Spondylitis Association regards back pain that has lasted more than three months and began before age 45 as worth looking into.

If you have psoriasis and a joint that keeps hurting, or you do not have psoriasis but have a joint that “keeps coming back”, the NHS says to see a doctor.

How is it assessed?

The NHS writes that it starts with a doctor, who asks about your symptoms, when they began and how long they last. The tests:

• Blood tests for inflammation. The NHS says a normal result does not rule out the condition.
• X-ray of the spine and pelvis to look for inflammation of the sacroiliac joints.
• MRI if an X-ray does not make the diagnosis clear.
• HLA-B27, a genetic test that can help but is not definitive.
• For psoriatic arthritis: blood tests, X-ray, ultrasound or MRI and sometimes a check of the joint fluid.

The NHS says the diagnosis is sometimes difficult because the disease progresses slowly and there is no definitive test; confirming it can take years.

What does treatment look like in general?

There is no cure, but the NHS says treatment can reduce symptoms and may slow the stiffening of the spine. Treatment is usually a combination:

• Exercise and physiotherapy, which are the foundation of treatment: for posture, spinal movement and reducing stiffness. The NHS says swimming and sport are usually fine, but some daily stretching and exercise is also important.
• Anti-inflammatory medicines (NSAIDs) are usually the first choice.
• Biologic medicines (such as TNF inhibitors and some others) when NSAIDs and exercise are not enough. The NHS says that if there is no marked improvement after at least three months, the medicine may be changed.
• Steroid injections into a joint in some cases, with a limit on how many times.
• Disease-modifying medicines (DMARDs) such as sulfasalazine and methotrexate are effective only for joints outside the spine.
• Surgery is rare.

For psoriatic arthritis, the NHS describes treatment as medicine-based: NSAIDs for mild symptoms, steroid injections into a joint, DMARDs for moderate to severe cases (which may take a few months to work and must be continued despite being slow to work) and biologic medicines.

Do not stop or change medicines without your doctor’s advice.

What can you do?

• Take exercise and stretching seriously and plan the programme with a physiotherapist or rheumatologist. The NHS says to stop straight away if you get pain or feel unwell during exercise.
• In psoriatic arthritis, the NHS recommends low-impact exercise, losing extra weight, stopping smoking and avoiding herbal medicines (without advice).
• Talk to your doctor about alcohol if you are taking medicine.
• Note your symptoms: the time pain gets worse, the effect of rest and movement, and your family history.

When to get help urgently

• A red, painful eye that is sensitive to light, or blurred vision. The NHS says these symptoms need urgent assessment. Go to an eye doctor or an eye emergency department the same day. If you suddenly cannot see, call 115 (Iran’s emergency number) or go to the emergency department.
• Back pain with weakness or numbness in the legs, numbness in the genital or anal area, or problems controlling urine and stool. The NHS says this needs an immediate emergency call or a trip to hospital. Call 115 and do not drive yourself.
• One joint suddenly hot, swollen and very painful, with or without a fever. Contact a doctor or the emergency department the same day.

See the full list in the guide “When should I call urgently?”